Spiritual Care as an Integrative Practice with Common Factors Theory

“People don’t care how much you know until they know how much you care.”
– John Maxwell

There are a lot of different kinds of Psychotherapy out there. Some modalities have been subjected to careful empirical study; some have long histories of clinical practice backing them up; and some live on the fringes of mainstream practice – either due to the biases and fashions that plague any shared human pursuit, or because the modality is indeed a bit wacky.  In choosing a therapy, different people make different choices for a variety of reasons. Sometimes it is because they feel a given modality is particularly apt for addressing a particular condition, but more often it is because a given modality is well suited to their own personality, and “makes sense” to them as individually.

My own practice, which includes both work in a hospital setting and work in private practice, is rooted in the CPE training that informs hospital Spiritual Care Providers (aka chaplains*).

[*Labels are in flux right now, particularly in Canada.  Personally I only use ‘chaplain’ for faith-based care, i.e. the chaplain mediates between a person and a tradition, or works with people in the context of their shared tradition. Conversely, I use ‘Spiritual Care Provider’ for a clinically trained professional who facilitates a person’s meaning making and coping on that person’s own terms (irrespective of similarities or differences in belief). This tidy split is not typical, especially in the U.S., rural regions, and geriatric environments, but I find it useful.  Along the same lines, I would also love to see CPE change from Clinical Pastoral Education to Clinical Psycho-spiritual Education, since the shepherding metaphor is not strongly present outside of Christianity.  However, there are a wide variety of opinions in the profession regarding labels, and mine should not be seen as wholly representative nor wholly unique.]

The practice of Spiritual Care overlaps with various other modalities including, but not limited to emotion-focused, acceptance and commitment, narrative, and story therapies; and often has a Rogerian tone. This overlap is enhanced because the training itself encourages exploring other psychotherapeutic modalities and personality theories.

As an Integrative Psychotherapy (though it may not be clearly named as such) Spiritual Care relies heavily on facilitating the client’s awareness of their own emotions, their own story, and the beliefs and assumptions they have around their story with an emphasis on finding or developing meaning, purpose, and connection with what is significant or sacred to them.  As my clinical supervisor often says, “The spiritual care journey can involve three key elements: Self-awareness, Understanding personal beliefs, Purpose and meaning.” and “Emotions don’t lie. A client’s fear is real, even if a particular belief behind it may not be. We try to help clients unpack those emotions and underlying factors; we give them permission to talk about things.”

Also, since no two people hold exactly the same things as significant or sacred, or exactly the same perception of those things, CPE trained Spiritual Care Providers facilitate a process of discovery and affirmation rather than religious authority. And while we are are all trained to comfort and facilitate individuals and families through times of grief, trauma, and shock; this supportive role is complemented by insight-oriented roles that popular depictions of our profession have often failed to represent.
[Again, this is part of the reason why the language and labels are in flux, since a Spiritual Care Provider is a clinician whose practice should not be confused with a visit from a “friendly vicar”.]

How is a Spiritual Care Provider defined?
The Scope of Practice for Spiritual Care Providers in Canada states: “Spiritual Care and Counselling Specialists seek to improve the quality of life for individuals and groups experiencing spiritual, moral and existential distress related to changes in health, maturation, ability, and life circumstances.  They utilize a holistic, relational approach to assess the nature and extent of the concerns; collaboratively develop a plan of care; provide therapeutic interventions to promote, maintain, and restore health and/or palliate illness and injury; and evaluate the implementation of the plan of care to ensure its efficacy and adequacy.”

And, in Ontario, where Spiritual Care is included in the controlled act of Psychotherapy, we should also add, “In the course of engaging in the practice of psychotherapy, a member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration, to treat, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning.” (See Psychotherapy Act, 2007, section 4)

As an Integrative Psychotherapy, Spiritual Care relies not only on techniques which happen to be present in various other psychotherapeutic modalities; it relies heavily on Common Factors Theory (though it may not be clearly named as such).  Common Factors are not the assumptions, techniques, and ‘tricks of the trade’ of this or that particular modality, Common Factors are personal and relational. They consist of the working alliance; that is the bond between participants; shared goal for client; agreement on tasks/process; etc. “Except for the initial severity of the client, there is no other variable that has been assessed early in therapy that predicts final outcome better than alliance.” However we only see verification of this fact in more recent studies since previous measures tend to focus on procedure not person of the therapist. (B. Wampold, The Basics of Psychotherapy: An Introduction to Theory and Practice, 2007, p95-102) I think it is important to note that these Common Factors – i.e. the working alliance, shared goals, and agreement regarding the task or process; along with the maintenance of health boundaries as well as safe and effective use of self – are clearly articulated in the definition of Spiritual Care Scope found in the Scope of Practice quoted above, and are also laid out in the Competencies of the profession, found elsewhere in the same document.

In journeying with a client, in creating a therapeutic space for their story, their emotions, their assumptions about themselves and the world, benefit comes in what could be loosely likened to what Hinduism calls Darshan: the sacred moment of truly seeing and being seen. And while s/he is certainly no deity or guru, a good clinician can help co-create the right environment and circumstance for clients to experience themselves more deeply.

Postscript:
If this has left you wondering about “What Spirituality?” or “Where’s the Spirituality in this?”, I’d invite you to look at my previous blog post, An Introduction to Spirituality.

Grit, Resilience, and Balance

It’s not glittery memes and “positivity porn” that helps a person achieve their goals; it’s grit.
Angela Lee Duckworth says, “Grit is passion and perseverance for very long-term goals. Grit is having stamina. Grit is sticking with your future, day in, day out, not just for the week, not just for the month, but for years, and working really hard to make that future a reality. Grit is living life like it’s a marathon, not a sprint.”

.

Here are three articles about resilience, grit and balance from folks who get things done when the going gets rough.

A Navy SEAL Explains 8 Secrets To Grit And Resilience

US Navy SEALS conquer fear using four simple steps

Mindfulness-based stress reduction finds a place in the military

What is the difference between Psychotherapy and Coaching?

Sometimes, there seems to be a bit of confusion between Psychotherapy and Coaching, and depending on the professional, their practice, and even where they practice, there may actually be different degrees of overlap.

That said, here is a quick chart of general difference distinguishing Psychotherapy and Coaching (there are likely more and some exception may apply):

Psychotherapy

Coaching

·        About addressing disturbance or
dysfunction as well as enhancing function
·        Solely about enhancing function
·        Inner work / Awareness oriented
(though action may be an outcome)
·        Outer work / Action oriented
·        Addresses underlying concerns ·        Addresses external concerns only
·        Brings unconscious material to
consciousness
·        Only works with conscious mind
·        Enhance insight and self-awareness ·        Clarify goals and enhance motivation
·        Focused on past, present, and future ·        Primarily focused on present and future
·        Focused on personal outcomes ·        Focused on concrete worldly outcomes
·        Focus on whole person ·        Acknowledges whole person but focuses
on specific tasks or activities
·        May have an educational component,
but no advice-giving.
·        May have a mentoring or consulting
elements, depending on the client’s goals
and the coach’s expertise.
·        In some places, like Ontario,
Psychotherapy is a legally regulated
profession overseen by a professional
college. (Check your local laws.)
·        Coaching is an unregulated profession,
though various organizations do exist to
provide the option of training,
certification, and oversight.

And here are some of the ways they are similar:

  • Each has a variety of sub-specialties based on certain theories or techniques.
  • Each has many practitioners who use integrated approaches rather being limited to a given sub-specialty’s theory.
  • Both may involve insights, or shifts in meaning-making, albeit in different ways.
  • Both may involve ‘homework’; not everything occurs in the session.
  • You, as the client, must do ‘the Work’ – just like a physiotherapist can facilitate certain exercises, but can’t do them for you; a psychotherapist and/or coach can facilitate certain processes, but what the client gets out of the process is related to what she or he puts into the process.
  • Both hinge on the openness and trust of the client/practitioner relationship; so finding a ‘good fit’ is vital to the success of the work.

So, if your challenge is an addiction, trauma or PTSD, anxiety, depression, bereavement, the natural stresses that go with certain transitions in life, or the deep work of understanding yourself better, you may require a psychotherapist.

However, if you’re looking to enhance performance or meet certain personal or career goals, you may want a coach.

I am both a registered Psychotherapist as well as a certified Coach.  In my own practice aspects of either service can come into play depending on the client and the client’s needs.  However, even here, it is very important to clearly identify what scope of practice is being leveraged. This keeps the work transparent and maximizes the clients opportunity and agency in our work together.

An Introduction to Spirituality

“There are no things, only processes.”
~ David Bohm (physicist) ~

There are many definitions of Spirituality, even in the clinical discipline of Spiritual Care, but the most popular all seem to express similar ideas.  Two leading writers on the matter express themselves this way:

“Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose, and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred”[1]

“Distinct from religion, which is the search for significance through the sacred”.[2]Spirituality “has to do with however people think, feel, act, or interrelate in their effort to find, conserve, and if necessary, transform the sacred in their lives.”[3]

Or, in my own words: Spirituality is first and foremost relational. Spirituality is the willful and loving exercise of that part of us which participates most deeply in Existence. Spirituality is the process of striving toward Being, Acting, and Knowing, from a stance of authentic Connectedness, Meaning, Value (moral, aesthetic, or otherwise), Purpose, and Becoming.

Whatever qualities we list in our definitions (meaning, values, etc.), they are used in the service of Connectedness.  This is part of why Spiritual Care appeals to me most; in moments of crisis, Spiritual Care has our Connectedness as its primary concern – Connectedness with Self, Society, Nature, the Divine, Existence, the present moment, and all the things that create, sustain, and positively transform our inner and outer world.

The function or process whereby we apprehend and respond to our connectedness, is what Jung called the individuation, and what Rogers called the actualizing tendency; and though not named, it would be the impulse that informs movement in Mazlow’s (1954) hierarchy of self-actualization, and Erikson’s (1963) stages of ego integrity. Regardless of what it is called, the ability to extend the self into the world, and model the world within ourselves, is a spiritual process.

For me personally, I find connection and meaning in the experience of Nature (which is reflected in the Self) and the contemplation of my sacred stories (which reflects the Self). I will focus here on Nature.  In the cycles of the day, the month, the year, and the cycles of all things, life, growth, death, decay, regeneration, and rebirth are continually evident. The dis-corporation and reintegration of the elements forms an endless round and nothing essential is lost, though the forms may be radically altered.  “As any good gardener knows, it is the processes of decay that sustain the fertility of the soil. All growth arises from death.”[4]  And while our own intimate losses evoke feelings of fear, anger, or sadness, this same cycle also sustains all existence. We need only walk into a garden or forest to observe the cycle in process.  The seasonal holidays many pagans celebrate, honours this round; as do our sacred stories like that of Dionysus dying and being reborn; or Persephone going to the underworld and returning; or Brighid being captured by, and freed from, the Cailleach.[5]  I find the concreteness of these natural and archetypal expressions very powerful; and so in addressing disconnection and meaninglessness in others, I am listening for whatever it may be that will orient them, in the same way that Nature and sacred story orient me.  I am listening for their Mystery.

Beyond understanding our place within Nature, I also understand us as being in some way reflections of that Whole.  Different traditions acknowledge and express our connectedness in different ways.  Abrahamic religions speak of being made in the image of God.[6]  Marcus Aurelius Antoninus (121-180 CE) expressed it this way:

“Our universal Nature is the Nature that pervades all existence, and everything
that now exists has a kinship to all other things that will come into existence.
This Universal Nature is called Truth and is the original creator of all truths.”[7]

Norse, and Vedic creation stories speak of the universe being made from dismembering the person of a primordial giant, god, or man. Celtic and Vedic creation stories also speak of the inverse; the first human being made by gathering together parts of the universe.[8]  And, beyond my source cultures, similar views are proposed by Jung:

“There are indications that physical energy and psychic energy may be two aspects of one and the same underlying reality. If this turns out to be the case, then the world of matter will appear as, so to speak, a mirror-image of the world of spirit or of the psyche, and vice versa.”[9]

There is no room here to fully explore these sacred stories in these related source cultures, or the esoteric-sounding statement of Jung, but in this understanding, the person and existence are microcosm and macrocosm, so our being and Being itself, are depicted in a sort of fractal, self-similar pattern – we are each part of All, we are each reflections of All, and in some way, we are each All itself.  For me, this theme affirms the existential importance of the human person: each person is not just a living human document – which accords well with my appreciation of story – I also strive to respect each individual (including myself) as a microcosm of Existence itself, with all the beauty, power, danger, and potential thereof in each of us.  Such notions are not just elaborate itellectual constructs, they are palpable, sensual symbols of our Connectedness, which hopefully evoke a way of being in the world and a way of acting toward ourselves, each other, and all that is around us.   This fractal/reflecting quality is a call to engage the world directly; we can live from the outside in, and just be a product of our circumstances, or we can live from the inside out and transform the world around us.

So, just as my individual practice is inspired by the practices of the therapeutae and the anam cara,[10] my existential understanding of personhood is informed by this primordial trans-cultural creation myth.  This is also why Jungian theory is so influential to me; it has an explicitly Spiritual component, and (in my reading of it at least) can even be viewed as expressing the microcosm/macrocosm view of the human person that plays such an important role in my faith (particularly in Jung’s understanding of the Self, mandalas, synchronicity, and other instances where inner and outer realities are implicitly or explicitly described as reflecting each other).

With this in mind, I will explore the connection between Spirituality and psychology as it informs my practice, focusing on both Jung, and Rogers.

The Jungian ‘analytical psychology’ often incorporates the broad spectrum of human spiritual experience, including the mythology and folklore of ancient and indigenous religions, to gain a deeper understanding of the human psyche.  It is also a branch of psychology that acknowledges spirituality as a necessary component of our over all well-being.

“[Jung] had established these two facts:

1. The human psyche has an autochthonous spiritual function.

2. No patient in the second half of life has been cured without that patient
finding an approach to this spiritual function.

It might be assumed that, after such findings, theologians would have flocked to Jung’s consulting room; but this has not happened…. [T]hey might have at least been glad that an experimentally proved theologia naturalis exists.”[11]

Despite, or perhaps due to, its emphasis on the profound interrelatedness of religion and psychology, Jungian ‘analytical psychology’ draws criticism from both certain psychological schools of thought and certain Christian schools of thought.  In failing to take sides, both sides find analytical psychology suspect.  The fact that spirituality is endorsed at all, draws fire from secular or reductionist psychologies; and the breadth of spirituality endorsed draws fire from any version of religion where ideological entrenchment and ‘one-true-way’ thinking is normative.  Some Christian theologians commenting on Jung “have [even] argued that he should not have ventured into theology in the way that he did.”[12] In the negative responses of both secular/atheistic and narrowly Christian commentaries, the violation of self-imposed boundaries is predictably followed by a defensive response– often with the energised emotionality that would indicate a neurotic trigger.[13]  Other thinkers have benefited from a more synergistic relationship between analytical psychology and Christianity, though serious explorations of other expressions of religion are usually left out of that line of enquiry.  Good examples are to be found in Psychology for Christian Ministry, by Watts et al.,[14]  Personally, I find spirituality and psychology to be simply different approaches to the same meaning-making endeavour, and I see no reason why they can not inform and enrich each other.

Alongside the often abstract theories of Jung, Rogers’ practical and concrete theory also informs my understanding of Spirituality and my practice.  Rogers’ entire theory is based upon the “actualizing tendency”, which serves as the built-in motivation present in every living thing to develop as much of its potential as possible and to make the very best of its existence. Rogersapplies this actualizing tendency to all living creatures.  He compares humans, actualizing their potentials by creating and manipulating society and culture, to animals and plants coevolving or exploiting particular niches in ecosystems. Rogerseven went so far as to systematically and rationally apply this understanding to ecosystems themselves.  The universal applicability of the actualizing tendency to all living beings, and even systems of living beings, is scientifically and spiritually compelling.  It is in harmony with evolutionary principles as currently understood in the life sciences, with the essential goodness of life, and with the previously mentioned connection between person and existence.  I see the actualizing tendency as a functional definition for Spirituality, constrained by the empirical nature of the field in whichRogersworked.

Despite the constraints placed on Rogerian language and shattered by Jungian language; I see these descriptions as pointing to the same thing Spiritual Care Providers describe when we say that, “[b]y spiritual, we mean the fundamental capacity to have faith, to make meaning, to create community and culture, to long for and practice love, peace, and justice, and to be oriented toward wholeness.”[15]

Taken together, my faith, spirituality, and psychology all invite me to remember that each of us is a special part of something larger than ourselves, and in that remembering – regardless of the language we use to describe it – that something draws us toward Being, Acting, and Knowing from a stance of authentic Connectedness, Meaning, Values, Purpose, and Becoming… toward well-being.


[1] Puchalski, 2010, p. 25.

Puchalski et. al. 2009 p.885-904.

[2] Pargament, 1997, p.3

[3] Pargament, 1999, p.12

[4] Starhawk, 1997. p3-4.

[5] Brighid is a goddess of fire who fosters life; a midwife, healer, mourner poetess, craftsperson, and warrior, who governs the hearth, home, hostels, and hospitals – though in this story she is the vitality of nature.  The Cailleach (lit. ‘veiled one’ or ‘hag’) is a monstrous goddess of winter, darkness, chaos, in-between times/place, and the limiting powers of nature, but also a source of fertility and (when engaged correctly) an upholder of kingship, justice and truth)

[6] Genesis 1:26-27

[7] Marcus Aurelius 2006 p.89.

[8]Lincoln 1991 p167-84

[9] Marie-Louise von Franz, 1975. p.236

[10]Soul Friend’. In early Irish monasticism, the anam cara was a monk, nun, or priest who formed a personal relationship with another individual, listened to their private confessions, provided them with spiritual advice, and finally performed last rites upon their death. Some suggest the anam cara may have ancient pagan origins, citing its resemblance to the Hindu Acharya (Vedic/Celtic similarities being quite common); others suggest it likely emerged from a Christian context, anam cara being a translation of the Greek ‘psykhikos philos’, who fulfilled a similar role. The anam cara is strong pastoral image for me in my practice.

[11] Meier, 1989, p.127

[12] Watt, et al. 2008. p 294.

[13] Hollis 1996, p.9-10  Triggering will be discussed in more detail in the section on Spiritual Distress.

[14] Watt, et al. 2008 pp. 295-298.

[15] Bueckert and Schipani, 2006, p3.