Spiritual Sensitivity in Caritas Services: Why and How to Work with the Spiritual Dimension of the Life Situation of Clients

In a society where traditional churches have lost their monopoly on defi ning the conditions of human spiritual life, Caritas facility workers, as well as workers in other church-operated helping organisations, can feel baffl ed as to how they are to fulfi l the postulate of a holistic approach to the life situation of their clients and patients, not confound the concepts of spirituality and religion, and make use of their professional competences framework also with respect to the spiritual dimension of the life of the service recipients. This paper presents practical incentives to this end. First it legitimates the eff ort of Caritas workers to incorporate work with the spiritual dimension of their clients by means of reference to discourses conducted in practical theology, healthcare and social work. Then it presents a processual model of the preparation and practice of Caritas workers, comprising fi ve phases: (1.) mastering the concepts of spirituality and religion, (2.) mastering the concept of spiritual needs, (3.) acknowledging and accepting own spiritual support system, (4.) mastering the concept of spiritual assessment, and (5.) mastering a spectrum of possible spiritually sensitive interventions. The individual phases of the model are interpreted and illustrated by means of reference to the sphere of healthcare and social work.


2017
Nursing, 5 social work 6 and pastoral theology 7 already have a greater or lesser set of publications at their disposal. But in all cases the texts are concerned with a partial aspect, for example, the content of spiritual needs, measuring the fulfi lment of spiritual needs, or a typology of interventions. But no model is off ered that would help the personnel of Caritas facilities to incorporate the issue of spirituality into a line of mutually linked practical steps in preparing for practice and actually beginning practice. Th e mutual interconnection of the individual parts of the model and the author's eff ort to provide incentives for direct practice on the one hand justifi es this paper's extent, while on the other hand the paper's content in no way claims to exhaust the issue.

Why? Reductive Caritas practice?
At the level of mediated experience, I can rely on repeated reports by students of our faculty, who in the course of their professional practice in Caritas facilities more oft en than not encounter a systematic concept of, for example, work with the spiritual needs of users. Th is experience has been fragmentarily confi rmed by the investigation carried out by a Masters thesis research project under my supervision among eight clients of the fi eld service of one Caritas in Moravia who, upon having carried out so-called spiritual assessment, expressed a certain disappointment: 'I would like the workers to help me also in this [spiritual] sphere' , or, 'I am glad to be able to talk to someone about the spiritual things, in the centre there is no one to talk to about this' . 8 At the level of personal experience, I can point out the breadth of interest with which the off er of further education in this issue is met among employees of Caritas services, who are literally starving for any practical methodological support. Unfortunately, we still do not have empirical data, making it possible to test the generalisation of these partial signals from Caritas facilities. But it is possible to point out other signals from the common milieu of social services, pointing in the same direction. Th e absence of integrating the spiritual level of the life situations of social services recipients can also be inferred from the thesis of another Masters student of mine, who tested the usability of spiritual assessment in a set of eight elderly clients in a classical residential facility. She evaluated the acceptation of this kind of work with clients as follows: ' All participants expressed a more than 7 2017 positive attitude to using spiritual assessment, noting that they would appreciate if someone asked them about their faith and their needs in this sphere more oft en. ' 9 Th e results of qualitative research realised with twenty clients of two residential facilities for the elderly in South Bohemia by Věra Suchomelová are even more telling. 10 Th e fi ndings of her research have uncovered a situation which cannot be regarded as anything but a 'trap' , the victims of which are both the social/healthcare personnel and the pastoral workers, if they take part in the provided service at all, and, of course, ultimately the elderly persons themselves. For the personnel erroneously reduce caring for spiritual needs to liturgical situations and contact with a specialised professional -an ordained minister or pastoral assistant. But the clients do not regard such specialised professionals as spiritual conversation partners, with whom they could share life diffi culties and existential topics of their life situation, since the pastoral agenda consisted only of Mass, the Eucharist and the Rosary. 11

Th eoretical prerequisites
In his paper about the discourses of professionality and spirituality in social work, Jan Kaňák proposed to distinguish fi ve types of their correlation, 12 whereby he recommends that authors publishing in this fi eld always clarify 13 • what professional and spiritual discourse means for them • from which discourse they enter the topic • which of the types of correlation they want to develop.
From the point of view of the discourse of professionality these requirements can be met only analogically, because the discourse of professionality in Caritas services is not identical with the discourse of professionality in social work, since it is not in fact a separate profession, but a specifi c and broad-spectral sphere of helping practice and helping professions. If within this professional spectrum I choose social work as the reference point, then the reasoning of this study coincides most with the model of spiritually sensitive social work, which strives also for a refl exive coping with life and of the clients' social functioning. 14 A recurrent theme of this type of discourse of spirituality in social work is the need to recognise the client's system of orientation in life, i.e., what the client, and not primarily the worker or organisation, regards as important for functioning and coping and then to mobilise these fi ndings and integrate them into an intervention. Th e way in which the discourse of spirituality is anchored in the nursing setting will be briefl y discussed later. Th ere is no doubt that Caritas facilities cannot give up the responsibility to off er a Christian, or even Catholic cultivation of the clients' spiritual dispositions and by means of, for example, sacramental tools, open up space for the Spirit of God to act in human hearts. For only where the Holy Spirit can act in a human being do natural spiritual dispositions reach their fi nal ends. Of course, such supernatural action of the Spirit of God on a human spirit has natural prerequisites, which 9 © Marie SCHREIEROVÁ, Koncept duchovního posouzení podle Davida R. Hodge   must be respected and also cultivated in the sense of the scholastic principle gratia supponit naturam, i.e., grace presupposes nature. In that which follows, I want to focus precisely on this anthropological 'fi rst layer' and further to outline a set of several tools which -having been mastered by some Caritas workers -could bring about a new level of their service to human beings. 15 In this alignment the presented model is compatible with the holistic conception of Caritas practice.

Th e holistic conception of Caritas practice
Within the theoretical conceptualisation of Caritas practice, as it is developed by 'Caritaswissenschaft ' on a scale unparalleled worldwide, in the public declarations of the profi le of individual Caritas facilities, which an external observer can easily fi nd in websites under the heading 'Who we are' or 'What we off er' , or in the basic document (Leitbild, Kodex), it is regarded as standard that Caritas practice wants to, and ought to, react to human needs at all their levels, including the spiritual ones. Pompey and Roß implicitly formulate this postulate when they tie together Caritas practice with a 'multidimensional conception of the human being' , 16 which, according to them, leads to a critical attitude towards various 'reductive perspectives and models' . 17 Haslinger specifi es his requirement for an integral conception of the human being in Caritas practice as a response to all of his needs: bodily, psychological, social and spiritual. 18 None of the authors, however, off ers practical incentives, proposals or instructions for fulfi lling the requirement. Th e postulate of the holistic conception of Caritas practice also nonproblematically correlates with the theory applied in Catholic social ethics, or Catholic social teaching. Th ere the theory of needs is correlated with the conception of integral human development, as outlined by the encyclical Populorum progressio and updated by the encyclical Caritas in veritate. According to the latter, integral human development 'concerns the whole of the person in every single dimension' . 19 Th e paradigm of integral human development and not merely of a holistic attitude to human needs seems to me to accord strongly with a further type of discourse correlation, as distinguished by Kaňák: spiritually oriented social work, which opens up space for the 'spiritual transformation of clients' . 20 Th e reasoning and tools developed in this paper can therefore be also partially understood in light of this type of relationship between professional and spiritual discourse. 15 Th is maxim can be used in the sense that God's saving action regarding the human being (grace) does not exclude and does not abolish the natural laws of human nature established by God, as we know them in light of the fi ndings in psychology, sociology, biology, etc. Th e grace of a functional, successful relationship of a human being to oneself, to others, to the created world and to God wants to build on the natural foundations with which the human being is endowed and not to avoid or suppress them. In this sense, the vital religious relationship of the human being to God the Father, through Jesus Christ in Holy Spirit, as Christians formulate it, has its natural spiritual prerequisites, which this paper wants to help to clarify. Cf

Findings concerning the positive eff ects of spirituality and religiosity on health and social functioning
In answering the question of why the sphere of the spirituality of service recipients ought to be integrated into Caritas services, one must not neglect the change in climate that has taken place in healthcare and social work in recent decades with respect to the concepts of spirituality and religiosity. In the sphere of medical and nursing research, enormous interest in spirituality/religiosity and their impact on health appeared in the 1980s and especially the 1990s. Even the World Health Organisation (further only WHO), despite the present defi nition of health, which mentions only its physical, mental and social components, 21 introduced the domain of spirituality into the official tool of evaluating quality of life WHOQOL. 22 In 1995, WHO also acknowledged providing spiritual support as an essential part of palliative care. 23 WHO is also hosting a debate concerning the so-called 4th dimension of health and tools for measuring it have already been developed. 24 Th e best illustration of the medical interest in the role of spirituality/religiosity is the Handbook of Religion and Health by the American professor of psychiatry Harald G. Koenig and his colleagues. In the fi rst edition, Koenig and his colleagues summarised the results of more than a thousand research studies, which have shown a greater or lesser correlation with various spheres of bodily and mental health. 25 In the second edition of 2012, the Handbook (in more than 1200 pages) identifi ed over three thousand studies. 26

2017
• a lower smoking rate • a higher experienced control over own bodily and mental state • a lower depression rate • higher self-esteem • lower blood pressure • a lower death rate following a heart operation • a higher average lifespan • a higher ability to cope with stress.
In the sphere of social work, the situation is similar. Up to the 1980s, spirituality and religion were a neglected topic, which some authors ascribe to 'the deep-rooted, historical antipathy towards religion amongst social work in Western societies' . 28

Processual model of spiritual sensitivity in Caritas services
I propose to cultivate the discourse of spirituality in Caritas services so that it contains fi ve partial concepts, which ought to be incorporated into the competency equipment of individual workers in direct practice with clients in the order indicated in Figure 1. Authors writing in healthcare about the concept of spiritual needs focus mostly on the technical level of the competence of nurses and physicians. Only exceptionally do they refl ect upon the prerequisites on the individual level of the workers, 33 and they mention the standard of culture in the organisation most in the form of complaints about the unprepared state of the hospital environment. 34 Authors from social work, on the other hand, place signifi cant emphasis on the organisational factors of spiritually sensitive practice. 35 Within this distinction between the individual and the organisational level of spiritually sensitive Caritas practice, the model presented below takes into account only the individual level of professional competence. In introducing the individual components of spiritually sensitive practice to the reader, authors mostly begin with a clarifi cation of the concepts of spirituality and religion (religiosity) in the main current of discourse in the helping professions, especially in social work and nursing. 36 Th is helps to prevent confusion between the two concepts, the resulting limitation of perspective for evaluating the client's life situation, and also facilitates a better orientation in the worker's own spiritual story. Th en the workers can be introduced to several models of conceptualising the spiritual and religious needs of clients from diff erent target groups, to whom the particular Caritas facility off ers services. A broader spectrum of models and their contents can decrease the risk that workers miss relevant signals and information from the client. Aft er this step, at the latest, workers must be provided with suitable stimuli and space for self-experience focused on recognising and accepting their own spiritual system, of which they can be more or less aware. However, it 33 Daniel Sulmasy requests that a physician takes the following steps: start paying attention, fi rst, to signals coming directly from the patient, second, to the physician-patient relationship, third, to the spiritual lesson implied by the patient's situation also for him, fourth, to his own spirituality and the way how it aff ects his care of patients, and fi ft h, to start fi nding out the patient's spiritual story, cf. Daniel would be just as possible to associate this phase with the fi rst step. 37 In any case, self-orientation in this dimension of their own life not only increases the workers' empathic sensitivity to the clients, but also helps to prevent situations of counter-transfer, or even manipulation with the client. Only aft er this preparatory phase is it possible to theoretically and practically master the skill of spiritually evaluating the client's situation, which -according to the chosen perspective -leads to the detection of unfulfi lled needs, or of resources on which the client can rely again. Based on such assessment, it is possible to propose, carry out and evaluate suitable interventions. Th e Caritas worker will be better able to consider and select these based on an overview of the spectrum of interventions reported on by professional literature.

Mastering the concepts of spirituality and religiosity
To consider the possibilities of working with the spiritual dimension of the client's situation, it is necessary to understand the basic notions and concepts. In the discourse of the helping professions, such as nursing and social work, the last two decades have brought the conviction that it is useful to distinguish between the notions of spirituality and religiosity. 38 Although authors do not agree on a unifi ed defi nition, the diff erences in defi ning the two concepts are not dramatic. Kaňák serves to introduce the reader to the issue. 39 An example of distinguishing between the two concepts can be the renowned publication on social work Spiritual Diversity in Social Work Practice: Spirituality refers to a universal and fundamental human quality involving the search for a sense of meaning, purpose, morality, well-being, and profundity in relationships with ourselves, others, and ultimate reality, however understood. 40 Religion is an institutionalized (i.e. systematic) pattern of values, beliefs, symbols, behaviours, and experiences that are oriented toward spiritual concerns, shared by a community, and transmitted over time in traditions. 41 A similar defi nition is found in other authors in social work 42 or medicine. 43 Th e authors mostly agree in conceiving religiosity as a part of spirituality, which is mostly manifested in a religious way, albeit many prefer to express it by their relationship to nature, music, art, sport, to a certain philosophical current, or to friends and family, i.e., in a non-religious and secular way. 44 Th e phase of distinguishing between the concepts of spirituality and religiosity can help to pre-

2017
vent situations of conceptual confusion of the two concepts, when the client's religious/church membership, if it is actively ascertained at all, is used to infer information about the client's spiritual preferences, wishes, needs and resources.

Mastering the concept of spiritual needs
Caritas workers must be introduced to models of spiritual needs, as they have been distinguished, based on empirical investigations among diff erent target groups of the helping professions. Examples are listed in Tables 1-4. Th eir common feature is that they eff ectively illustrate the breadth of what patients and clients themselves regard as spiritual needs compared to the traditional indicators, such as receiving Sacraments or a visit by the hospital chaplain. Of course, it is not merely a matter of memorising the published schemata. Th e worker will gain a higher competence by becoming familiar with the characteristics of the individual partial needs, illustrations of situations, and the statements, based on which they were recorded, and interrelating these with his own experience of contact with clients. An important principle of the pedagogy of spiritual needs is the awareness that in a particular patient one must expect an individual constellation of needs. Consequently, not every patient experiences all needs. Familiarity with a broader spectrum of published models thus serves especially to stimulate imagination and sensitivity to the client's individual situation. 45

Recognising and accepting one's own spiritual support system
Authors in nursing and social work point out that before a worker starts attending to the spiritual needs or assessment of others, he must become sensitive to his own spiritual system and fi nd his way around it, 55 since 'understanding and claiming our own spirituality can prepare us to help our clients discover, understand, and affi rm their own spirituality' . 56 It also makes it possible to avoid risks that would disrupt the relationship of trust with the client: superfi ciality, the appearance of merely fulfi lling an obligation, spiritual counter-transfer, proselytising, condemnation, and bias. 57 Similarly, Svatošová warns that a person 'who is not aware of his own spiritual needs, does not want to be concerned with them, and pays no attention to them' will not be able to recognise this attitude in clients. As soon as the client notices that, he 'withdraws and keeps a distance. He changes the conversation topic, is silent or otherwise manifests a lack of interest in continuing the conversation. ' 58 On the way to this competency, sometimes called 'spiritual competency' by authors in social work 59 , one can use a number of practical instruments of spiritual self-assessment. A number of more or less formal instruments to this purpose are available in the literature. To illustrate I will present the set of questions according to Govier: 60

Mastering the concept of spiritual assessment: how to detect spiritual needs and resources
Probably the fi rst tools for detecting spiritual needs were designed in connection with the nursing concept of spiritual distress. In 1982, O'Brien presented a scheme of the seven components of spiritual distress, 64 its manifestations, and questions eliciting its detection posed to the patient. 65 One of the newest tools of this kind was published by a team of Swiss physicians and elaborates on a set of spiritual needs identifi ed in geriatric patients. 66 Czech and foreign literature off ers a number of quantitative structured tools for detecting the spiritual needs of patients; of the foreign ones, let me cite, for example, the 29-item 'Spiritual Needs Survey' , 67 the 17-item 'Spiritual Needs Inventory' for patients in palliative care, 68 the 20-item 'Spiritual Self-Assessment Index for Older Adults' 69 or the 19-item 'Spiritual needs questionnaire' -SpNQ. 70 Th e setting of oncological patients gave rise to the Czech tool 'Patient Needs Assessment in Palliative Care' -PNAP, which also contains six items from the domain of spiritual needs. 71 But the healthcare community evidently perceives the limits of using such questionnaire tools, which consist in their tendency to objectivise that which is essentially relational, in the capacity of grasping only abstract characteristics of persons, and at the risk of insensitivity to the patient's personal sphere of life. 72 Th at is why the authors also recommend using suitable open questions. In Czech literature, a set of questions by authors from the palliative setting has been available for a long time: 73 • Has this disease changed your priorities in any way -for example the places, things and life questions that are important to you? • Has the disease aff ected your family and other relationships? 7 2017

• Has the disease changed your view of yourself? • Has the disease changed your view of life? • If so, which priorities are most important for you? • What is your greatest wish or desire in this phase of life?
Th e distrust towards the overly normative character of questionnaire tools in the sphere of healthcare is shared by the sphere of social work, where the issue of detecting spiritual needs is standardly treated as spiritual assessment and where the aspect of working with the resources and capacities of clients has been asserted since the 1990s. Th is new perspective also ideally resonates with the discourse of Caritas practice, where authors defend the principal orientation towards the resources and competences of clients: Since diakonia sees every human being as equipped with positive life resources, it assumes that all who are affl icted with problems possess, at least in principle, a competence of their own to overcome them. At the same time, it does not overlook the fact that these resources and the resulting competence can be strongly limited for various reasons. 74 Th e theory, on which the concept of spiritual assessment in social work relies, states that the social worker's task is to identify the client's system of orientation in life, i.e., what the client uses to understand life and fi nd his way around it. Each kind of spirituality and religiosity represents such an orientation system. 75 In situations of stress and diffi cult life problems the client's orientation system gains importance. 76 Spirituality (if it is sound) can therefore become an important part of the resources on which the client can, or even must (in the sense of subsidiarity) rely. But oft en problems overwhelm the client so much that he overlooks his resources and does not appreciate them. 77 It is therefore important that the social worker gains access to the client's orientation system and helps him to rely on it again. To do that the social worker must carry out a spiritual assessment with the client. Authors distinguish between several types of spiritual assessment, albeit they do not agree on the labels they give to them. Commonly mentioned are two pairs: introductory (short)detailed and implicitexplicit. Th e goal of introductory assessment is to fi nd out to what extent the client's spiritual system supports him. Based on information gained from such assessment the worker can estimate what eff ect the client's spirituality could have on providing the service, i.e., whether the spiritual convictions he holds can work as a barrier or as an advantage, 78 and whether it would be suitable to follow up with a more detailed conversation, because the client signals that spirituality plays an important part for him, or whether it will be better not to burden the client with any more, because it is not of much relevance to him. 79 Th e situation of fi rst contact with the client, when his spiritual interests are expressed, whether verbally or non-verbally, and it is already appropriate to react adequately, can be regarded as a certain kind of preliminary assessment. Dudley mentions two scenarios to illustrate. In the fi rst one Also classifi ed under the type of short, yet explicit assessment is a set of questions labelled MIM-BRA 84 by its authors. As in the case of the preceding model, its advantage is that it does not create pressure, is intended for time-limited situations of working with the client when it is necessary to fi nd out quickly whether spirituality is important and relevant for his situation, and then to decide whether the worker will address this resource with the client directly, or whether he will pass it over to another worker: 85 I am interested to know what is most meaningful and important in your life which might be relevant to our work together. Please feel free to respond or not respond to the following questions in any way that makes sense to you. For the purposes of detailed and explicit assessment, the authors off er a broad range of tools, which help to structure the conversation, 88 or make use of elements of visualisation. Hodge has developed and published fi ve such tools in all: 89 • spiritual history -a verbal description of the client's spiritual story • spiritual life map -comprises the same but makes use of a pictorial format and is therefore suitable for artistically skilled and reserved clients • spiritual genogram -maps the development of spirituality across at least three generations and is appropriate where the wider family plays an important role in the client's situation • spiritual ecomap -represents the client's present, his existential bonds to key spiritual variables in his milieu and is therefore more suitable for clients who fi nd little interest in looking back at the past • spiritual ecogram -combines the advantages of the traditional genogram and an ecomap and allows the social worker to inquire into the relationships between past and present infl uences.
• Spiritual needs are always fulfi lled in the context of a relationship. Th erefore, the starting point and prerequisite is the forming of a helping relationship with its classical parameters (so-called common factors), such as empathy, genuineness, unconditional acceptance, warmth, etc. 91 A helping relationship with such parameters already is implicitly spiritual. 92

Mastering a spectrum of possible interventions
Th e foreign literature on social work presents a rich resource of information on what procedures and interventions are used by social workers, both at the level of direct work with the client (micro) and at the level of working with organisations and communities (macro). 93 Th anks to the careful analysis of Jan Kaňák, several dozen of these are available to Czech readers and Caritas workers 94 so I will not elaborate on them here. Introducing the options aims to weaken possible prejudices concerning the incompatibility of spiritually based and spiritually oriented procedures with the professional mandate, and further to stimulate creativity and refl ection on which of the procedures would be applicable in the individual situation of the worker's mandate and the client's life situation. For healthcare-based Caritas workers, it will, without doubt, be more useful to point out the possibilities of procedures corresponding to their competences. In this respect, one must not omit the study realised by Roberta Cavendish and colleagues. 95 Of a total of 404 nurses, 18% (97) reported using 34 types of 'spiritual care activities' with the patients and themselves. Th e investigators then matched the reported activities with the categories (labels) and activities described in the 'Nursing Interventions Classifi cation' -NIC. 96 Of the ten detected categories 97 I will cite activities of the fi rst two for illustration: 98 Facilitating

Conclusion
A brief look into the discourses of social work and healthcare, i.e., the two reference fi elds on which the contemporary practice of Caritas services relies, has shown enormous interest in investigating and integrating the concept of spiritual needs and associated concepts, such as spiritual distress, spiritual resources, spiritual (self-)assessment, etc. In the sense of the theological premise 'gratia supponit naturam' , a healthy Caritas practice can, and in fact to some extent and form must, rely on these fi ndings and competences, must employ them, begin to critically refl ect upon them, and further publish the results of the experience. Only then can it hold of Caritas services, in an analogy to medicine, that they are provided 'lege artis' . With respect to the spiritual needs and resources of service recipients in Caritas facilities it is not legitimate to choose the strategy of creating taboos or of passing the buck and hastily delegating to clergy, chaplains, pastoral workers and other subjects of exclusive competences. So far, practical theology has not provided Caritas workers with incentives for realising services in such a quality that would also integrate the spiritual dimension of the life situation of the recipients. Th e presented model of subsequent steps in the preparation and practice of Caritas personnel wants to pay off that debt in part. Many aspects standardly associated with elements of the presented model have not been treated at all, or only marginally (ethical rules for assessment and interventions, evaluation of interventions, etc.), and require further refl ection, as well as the organisational setting, which can eff ectively stunt, or facilitate, the application of spiritually sensitive Caritas practice.