Creating a culture of spiritual care

A multidisciplinary team of medical and spiritual care researchers recently made three significant findings: (1) spiritual care needs to be incorporated into care for patients with serious illness; (2) spiritual care education needs to be integrated into the training of interdisciplinary teams caring for persons with serious illness; and (3) include specialty spiritual care practitioners in the care of patients with serious illness.

A general manager asked one of my chaplaincy colleagues about her vision for integrating pastoral care into their facility.  This inquiry is such a brilliant, open-ended question that opens up so many avenues.  Where might we begin?

In healthcare, it has been a long-standing tradition for the chaplain to take care of the spiritual and eternal needs of the patient’s soul while the doctor took care of the patient’s physical needs.  During the twentieth century, there was a complete separation of the roles of faith and medicine.   Physician Paul Tournier challenged this view of separation.  In his private practice, he forged a new type of medicine, which he called “the medicine of the person. ” The medicine of the person integrated both physical and spiritual health.  In the 1960s, palliative care was developed, and with it came a new idea of spiritual care or general pastoral care in medicine. This was an alternative to the traditional model of religious care, which was based solely on a person’s faith and denomination.

Tournier’s influence made its way into the medical systems through various avenues, of which palliative care was at the forefront.  Cicely Saunders, the doctor who founded the modern concept of palliative care, talked about the idea of “total pain” and the need to address a patient’s medical, psychological, social, and spiritual needs all at once.  Saunders herself was an evangelical Christian who recognised that everyone has a spiritual nature – each patient and every member of staff.  In her hospital, a chapel for Christian worship, was available for quite reflection for all, and spiritual care of a general nature was the role of every staff member and no patient should have their spiritual needs go unmet.

Fig 1. Generalist-Specialist x Broad-Narrow Spiritual Care Matrix

Saunders’ biopsychosocial-spiritual framework gave rise to the current generalist–specialist spiritual care model.  In this model, all staff are responsible for spiritual care at a general level which is expressed through holistic care, and concern for aspects of the patient’s well-being including their spiritual/religious dimension which is usually expressed through compassionate presence.  Compassionate presence is the ability of all staff members to be deeply present to the patients in their whole being with a concern about their whole life –­ family, faith, losses, griefs, hopes and cares.

In Saunders’ model spiritual care is integrated into the facility.  All staff receive training in primary spiritual care which includes training in understanding what might be necessary to the patients beyond their medical care, being a safe self-aware person, who is comfortable in their own skin and religious and spiritual beliefs who is able to create space for other to speak about the things pressing most closely on their heart.  Such a system might also include volunteers and pastoral carers who have been trained in general spiritual care and who have time to visit with patients hearing their perspectives.

In the generalist–specialist model, there are also specialist spiritual care practitioners who may be trained narrowly within one religious tradition and others who have been trained more broadly in aspects of personal formation, within which there are levels of expertise: foundational, advanced and expert.  The spiritual care practitioners who work to help scaffold people through times of change and spiritual adjustment have trained to a professional level.  Various training pathways exist in fields of spiritual direction, pastoral counselling, clinical pastoral education, and philosophical therapies that work with people’s reality.  These spiritual care practitioners provide spiritual care to a wide range of patients across the service, including patients who might describe themselves as spiritual but not religious and others who consider themselves to be neither religious nor spiritual.  In this system, there are also specific religious visitors who visit people of their own denomination or religion, who visit and pray, conduct rituals, offer blessings, or read sacred texts.  The distinctions here, are often described as ward-based visiting and faith-based visiting.  A comprehensive spiritual care service provides both.

The research team stressed the importance of adequate spiritual care training for all staff (including any volunteers and pastoral carers in a facility who have contact with patients with serious and life-limiting illnesses), as well as referral channels and access to specialist-level trained religious and spiritual care practitioners.

A multidisciplinary team of medical and spiritual care researchers recently conducted a meta-analysis scanning thousands of academic papers that focused on spirituality and medicine.  They then focused in on 371 papers concerning spirituality in serious illness and health and identified implications for patient care and health outcomes.  The team made three significant findings: (1) spiritual care needs to be incorporated into care for patients with serious illness; (2) spiritual care education needs to be integrated into the training of interdisciplinary teams caring for persons with serious illness; and (3) include speciality spiritual care practitioners in the care of patients with serious illness.

The research team stressed the importance of adequate spiritual care training for all staff (including any volunteers and pastoral carers in a facility who have contact with patients with serious and life-limiting illnesses), as well as referral channels and access to specialist-level trained religious and spiritual care practitioners.

In order to more fully appreciate the finding of this review, it might help to think of spiritual care in its broadest sense, as a 2×2 matrix where spiritual care is offered both at generalist and specialist levels through both broad and narrow expressions of spiritual and religious care, where all quadrants are needed to meet the ongoing spiritual needs of patients.  There is also overlap where narrow religious care often incorporates broad general spiritual care, and many specialist religious practitioners are also certified in broad specialist spiritual care. It is also possible that people hold different positions in the matrix depending on the role a carer is performing at a particular time for example, a nurse who may also be trained in a specific religious tradition who might also provided narrow-generalist care if needed.  

A vital function of an integrated matrix for a health facility would be to describe the scope of spiritual practice for each section, which clearly outlines the skills and capabilities, as well as the limitations of practice for each quadrant of the matrix.

Fig 1. Generalist-Specialist x Broad-Narrow Spiritual Care Matrix is drawn from my research in The Nature of Religious and Spiritual Needs in Palliative Care Patients, Carers, and Families and How They Can Be Addressed from a Specialist Spiritual Care Perspective

Relating Soul to Spirit

Staff who feel comfortable with their own spirituality have been shown to be most at ease talking with patients about what really matters to them in the areas of religion or spirituality.

Have you ever wondered how the language of soul care and spiritual care relate to each other? The soul is a concept that arises from Scripture. Spiritual care and spirituality have been described as travelling terms, around which over the last fifty years has grown a consensus definition related to a person’s meaning, beliefs, purpose, belonging and rituals. As is common in most chaplaincies, there is a need to be bi-lingual, across different domains as has its own lexicon of terms and areas of interest. However, while overlapping, as shown in the following figure, the terms soul and spirit are not synonymous.

Figure 1. The relationship between the soul and the Biopsychosocial-spiritual model

From a Biblical perspective, all people not only have souls but are souls, each being a mysterious combination of dust and breath first described in the book of Genesis (Gen 2:7). Perhaps the most confusing aspect of the soul is around the word breath or spirit. The confusion has arisen because breath (or spirit or wind) which is used in a general or universal sense as above, is a ‘small s‘ spirit as distinct from the more specific ‘capital S‘ Spirit which refers to the redemptive work of the person work and indwelling of the Holy Spirit, which relates quite specifically to Christian faith.   

In Scripture, the term soul is not a particularly religious word but rather speaks to the unity or totality of the human person, as in the way the marriage ceremony speaks of “all that I am and all that I have”. At its simplest, the soul is dust of the earth animated by the inspiration (or inbreathing) of the breath of God and reminds us that people, like all of creation, are enlivened, animated and sustained by the Creator God. However, it is only human souls, or beings, that are said to bear the image of God, which makes the all encompassing created nature of each soul even more valuable.

The biopsychosocial-spiritual model seeks to describe parts of the unity and totality that make up a person and seeks to honour the dignity of each person.

From a health perspective, working with the biopsychosocial-spiritual model, all people are said to have physical, mental, social and spiritual aspects of personhood or existence. In this regard, we can see that the biopsychosocial-spiritual model of the human person seeks to describe parts of the unity and totality that make up a person and seeks to honour the dignity of each person and tends toward to the Biblical concept of the soul.

In the medical model, the biological aspect of a person refers to their physical health; the psychological aspect refers to emotional and mental health; the social aspect refers to the larger social and cultural systems within which a person is embedded. The spiritual health refers to a person’s non-material aspects of being – including their relationships, values, beliefs, hopes and possibilities. It is this non-material aspect which corresponds most closely to the breath or animating or inspiring aspects of the soul.  

From a soul care perspective, in Christian ministry, we are expressing a holistic concern for people through radical hospitality, compassion, love and care. From a health and spiritual care perspective, there is particular concern for a person’s non-material needs, especially the way in which a person is making sense of their reality and the changes happening about them; this includes people’s religious and spiritual beliefs. This is crucial because a patient for whom religion is important, their faith may well be providing the interpretive grid over all that is happening. For example a Christians patient may well be viewing every aspect of their physicality, psychology and social relationships through the lens of their personal beliefs and the interactive presence of indwelling of the Holy Spirit in their lives.  

From a spiritual care perspective, all staff are expected to provide general spiritual care as they care holistically for their patients. They are encouraged to provide a compassionate presence expressing concern for their health, social and emotional well-being as well as those less tangible things such as their deep beliefs, motivations and the way in which they envision their future. Staff are encouraged to identify patients who are expressing needs in any of these areas and refer on to specialists, psychologists, social workers or spiritual care practitioners or chaplains.

Staff who feel comfortable with their own spirituality have been shown to be those most at ease when talking with patients about what really matters to them in the areas of religion or spirituality. If the patient’s spiritual care needs are connected to a particular faith or religion, it is important to connect that patient to a chaplain who can most closely meet that person’s needs.

The simplicity of soul care

The focus of all soul care is the human soul. At its simplest, the human soul comprises the dust of the material earth and the relational breath of God in a single unity, the person.

Philosopher Michael Polanyi said we know more than we can tell; others have observed an analogy that we say more than we know. This saying perhaps applies nowhere more accurately than when it comes to soul care. When chaplains, pastoral and spiritual care practitioners describe their ministry or role, they might say they provide pastoral care or spiritual care. When pressed to expand upon this, they might explain they provide presence or ‘just’ being there or creating space for another, offering prayer, or accompanying others through grief or crisis. Polanyi was speaking about tacit knowledge; there are things we know and understand well, yet at the same time, we struggle to find the right words to explain and describe them. We also use words like presence, space, and accompaniment, which seem precisely right, yet we might also struggle to ‘show our workings’ to explain how these words capture whole worlds of meaning for us and the people we care for.

There is a lack of words attached to soul care disciplines. There is an inability of religious and spiritual care providers to give a clear account of the interventions they bring to their role. This lack leads to increasingly reductionistic descriptions of soul care, described as non-proselytising, a listening ear, presence, and non-directive counselling. Such lists, as any soul care provider knows, represent minimum competencies rather than the full range and extent of the art of religious and spiritual soul care. One prestigious medical journal described professional chaplains as using “many interventions, such as empathic listening, religious rituals, and prayer.” If chaplains and other soul carers cannot tell their stories and make explicit what is implicit, others will write their stories for them and determine their role.

In contrast to implicit understandings, explicit knowledge is fully revealed or clearly expressed, carefully developed, and avoids vagueness and ambiguity. Explicit knowledge explained meanings and intent and leaves nothing implied. What can be missed is that explicit does not mean complicated, There can be a stripped-down simplicity if we know the central core ideas. Einstein suggested that everything should be made as simple as possible, but not simpler – could this be true too of soul care which lies beneath much of chaplaincy, religious, pastoral and spiritual care?

The focus of all soul care is the human soul. At its simplest, the human soul comprises the dust of the material earth and the relational breath of God in a single unity, the person. The soul (dust and breath) facilitates a person’s relationships within themselves, with others, their environment, history and their creator. The soul is intimately connected with health, well-being, flourishing, meaning and purpose and belonging. How a person engages with reality, ultimate meaning, the transcendentals of truth, beauty and goodness and the darker sides of life, including sin, suffering, death and evil are facilitated by the soul.

Soul care works across explicit beliefs and values, experiences and implicit understandings, different perspectives and most importantly, their relationships and connections.

Soul care is concerned with people within themselves and their spiritual web of relationships. Soul care works across explicit beliefs, deep values, experiences, implicit understandings and different perspectives. Most importantly, the care focuses on their relationships and connections. Following this, soul care’s attention is on possibilities and how people can adjust to changing realities through various interventions and modalities. These work with a person’s vertical and horizontal web of relationships, both in the religious and the everyday spheres. Soul care is not an isolated task but works in community with other services including religious congregations, psychologists and social workers, who attend to mental and emotional illness and social needs, as well as legal and judicial services.

Soul care focuses on the person and the things in their heart and mind. The tasks of soul care perhaps could be most simply described as interventions that help people adjust to new realities employing a range of theories and practices from religious and secular wisdom traditions.

Lifelines of the soul

Transformative listening requires certain qualities of strength, endurance and discipline to master. And, in many cases, it may require the acknowledgement of failure and a renewed dedication to becoming available again and again, even in the course of a single conversation.

In Australia, we have traditionally had a high level of volunteerism demonstrated through sporting clubs, service clubs, parents and friends’ associations, hospital auxiliaries, conservation societies, churches and faith-based organisations. There have always been people who have generously visited people in hospitals, and prisons and provided support to people before the courts, offering what has been traditionally called pastoral care or volunteer chaplaincy. While few would challenge the generosity of the people who offer to these ministries, there remains a need to closely review the correlation between the needs of the recipients and the personal attributes, skills, knowledge and experience of the volunteer both to honour the gift of the volunteer and the needs and the expectations of the recipients.

We know from studies in the UK, that patients value chaplaincy that allows them to speak about what is really on their mind. In fact, when asked to list what they value, the patients values being able to speak of what was on their mind ahead of the chaplain being a good listener or valuing their religious or spiritual beliefs, because listening and valuing the patient for themselves are prerequisites for creating the type of space and trust necessary to allow one to share the things that a deep within their soul. A study from Victoria showed that patients believe the faith affiliation of the spiritual care team member is important but not as important as other attributes such as kindness, listening skills and a nonjudgmental attitude. This leads us to conclude that a listening presence that enables to other to speak what is on their soul, is the minimum requirement for anyone, whether, employed or volunteering in the chaplaincy or soul care sector.

We also know that transformative listening provides a space for reflection that transcends polite or social levels of conversation. Conversations which help people transcend their current circumstances happen only in a space of deep trust, connection and attunement. We also need to add to this the extenuating circumstances which lead people to be speaking with a chaplaincy or spiritual care volunteer. Such circumstances, as the need to be in residential care, hospitals, prisons, before the courts, living with a disability, or having experienced a natural disaster will include at the very least, loss and grief. We need to be mindful as well that this loss and grief is often combined with shock, trauma, or ongoing disability giving rise to suffering at multiple levels of reality, physical, emotional, social and spiritual.

I wish to ask, what are the minimum standards that would equip a person to safely ministry in this space? There are several short courses offered that aim to train a person for volunteer chaplaincy, companions or listeners in various roles in residential care, hospital, and disaster settings. Some organisations assume theological, social work or counselling qualifications have met the basic requirements and require no additional training for spiritual care. Some courses for volunteers are a week-long intensive, others are ten weeks of 2–3-hour long seminars. Others have a learn-on-the-job approach. I wish to suggest that none of these approaches provides adequate training for guiding a spiritual conversation, safety for working one-to-one with vulnerable individuals, or adequate supervision and follow-up once the volunteer has been placed.

Telephone counselling services work with many of the same sensibilities as volunteer chaplains. Both services are working with vulnerable people to provide an opportunity to speak about what is worrying them or uppermost in their minds. In both services, there is a need for self-aware people to have the ability to self-reflect and are settled and stable within themselves. Secondly, the person needs to have the ability to connect and attune in a safe and bounded way, and thirdly, they need to have the necessary skills and knowledge to minister within the limits of their role.

It could be that we seriously underestimate the extent to which a good conversation represents a lifeline to those we listen to.

It might be that some may say that chaplaincy or spiritual care volunteers are just there for a friendly chat or to provide a listening ear, but such an attitude belies the point that like so many activities that appear effortless, good listeners are formed arriving at a state of unconscious competence through training and practice. It could be that we seriously underestimate the extent to which a good conversation represents a lifeline to those we listen to. There are some who temperamentally and spiritually are good listeners, but why would we not seek to extend their gifts for their sake and the people they listen to?

For these reasons, I wish to suggest that we look towards the training of telephone counsellors to provide a minimum framework for training and supervising volunteer chaplains or spiritual carers. Below is a modified version of one such telephone counselling service, Lifeline, who train volunteers in three stages:

Stage one: 3 months

Initial training takes place over 12 weeks, including 12 consecutive face-to-face group training sessions once per week for 3 hours; in addition, there are approximately 1–3 hours per week of independent e-learning to be completed.

Stage two: 2 months

Supervised visiting includes visiting with a chaplain and then being observed by a chaplain. The 3-hour face-to-face sessions during this time are Value-Based Reflective Practice Groups (VBRP), which allow participants to reflect on their individual progress. It provides opportunities for learners to practice new skills and gain constructive feedback. Successful completion of this stage leads to an invitation to stage three.

Stage three: 6–12 months

The probationary period consists of visiting one-half day (3.5 hours) per week, supervision and mandatory professional development. On the successful completion of this final stage, the volunteer is a trained volunteer of the ministry, who should continue to receive supervision and continuing education.

This training model has flexibility where the initial three months could be conducted on or off-site, allowing for resource sharing between sites. The e-learning material should include both general approaches to soul care and spiritual care (transformative listening, limits, boundaries, cross-cultural competencies, trauma informed care etc.) and context specific training (dementia, men’s sheds, hospitals etc.). Stage two involves a closely supervised volunteer placement with further group supervision and stage three is a closely supervised probationary period.

Photo by Antoine Barrès on Unsplash

Soul Care Literature

Because of the heightened affective state around illness, uses the psalms, prayers, Christian poetry, and metaphorical language help communicate directly into the soul in this affective space

I was recently asked what guidelines we used in selecting Christian literature that was suitable for hospital patients. My ideas have been shaped by Christian patients who told us what they liked or had found helpful. We also knew what literature patients and families had selected themselves, and there was a high degree of agreement. It was one of those situations where I had to give words to implicitly held ideas.

The most commonly requested and chosen Christian literature are booklets containing a single Gospel, New Testaments containing Psalms and Proverbs, and complete Bibles. Many people take pocket copies with small print, but many others request large or giant print or easy English translations. There is also a need for a simple handbook to the Bible to assist new Bible readers.

Begin where the person is, not where we would like them to be – working from the real, not the ideal.

In addition, to Bibles, many patients choose other literature, and based on the patients’ selections, below are some considerations we attend to when selecting printed material for patients. A further crucial concern is that illness affects people’s ability to concentrate and form new abstract concepts but often opens people to deeper affective and emotional perspectives on realities.

Literature that speaks to patients and their families:

  • Places them in conversation with God through thoughtful words – allows them to notice, wonder and discover things about the triune God.
  • Begins where the person is, not where we would like them to be – working from the real, not the ideal.
  • Uses easy English, good sized font and pictures or illustrations designed for adults rather than teens or children.
  • Holds to Christian/scriptural theological perspectives that are agreed upon by most denominations.
  • Uses the first and second person I-Thou rather than third-person and addresses the reader as you rather than them, they, this person or that.
  • When speaking about God, talks to God, or of God, as if he is standing right next to a person longing that they might come to him, rather than distantly about God.
  • Because of the heightened affective state around illness, uses the psalms, prayers, Christian poetry, and metaphorical language help communicate directly into the soul in this affective space.
  • Uses gentle and gracious language that can accommodate the depth of suffering, helplessness, meaninglessness, pain and angst of a severe illness, leaving a door open for God’s transforming life in the situation.  
  • Avoids offering answers without hearing the questions – this is particularly the danger with evangelist tracts – they are written for a general audience. They are not designed to attend to the specific needs of the other, attune to their situation and accompany them on their journey through suffering and death.
  • Seeks to build up, not to tear down – connect people to God’s love rather than trying to convince them of their sinfulness and or for forgiveness. Offers of God’s forgiveness make little sense if someone has no concept of the triune God, and this requires a scaffold to build between a person’s understanding and the obstacle between them and knowing God, which is highly individual.
  • Locate sin and redemption within the broader category of God’s good but broken creation.
  • In Christ, there is forgiveness that takes sin as far away as the east is from the west.
  • Bears witness to the faithful presence of God and his desire that all who are heavily laden might come to him.

Photo by Rod Long on Unsplash

A Worked Example of Spiritual Care

In the background, a chaplain or soul carer carries many narrative patterns: encoded variously in melody and harmony, themes and variations, rhythms, textures tones and timbre.

One of the significant challenges with ministries such as chaplaincy, pastoral care, spiritual care is defining what soul care is and explaining what it looks like. A colleague and I were talking about this a few days ago, and he asked, “Well, for example, what would spiritual care look like if you were visiting a man who was a victim of a shark attack and had lost both feet?”

As a chaplain, I would meet such a patient on a regular ward round as I regularly visit some intensive care units and several surgical wards. I usually choose not to know the patient’s medical diagnosis before I visit for the first time as it tells you very little about the person or the relationship they have with their diagnosis. I also meet patients following a referral or a specific request for a visit from a chaplain. If the medical staff requests the visit, usually, the request is accompanied by a brief description of the patient’s medical condition.

All soul care begins with an offer to listen or attend to the other and be willing to attune to the matters on their soul and accompany them into their story, initially asking only questions that help the other clarify their thoughts or feelings. As we listen deeply to another, we also listen to ourselves while subconsciously being held within our more extensive webs of meaning. The sensitivity and stability of a more comprehensive web of meaning allow us to enter another person’s story and help bear the weight of their griefs and sorrows without merging them with our own or dissolving ours into theirs.

The carer’s attitude is crucial; it is not enough to be a safe person but to have the ability to engender a feeling of safety within the other that enables enough trust to share what is uppermost on their mind or troubling them in their heart. The skills to connect and listen deeply needs to be developed and honed. Deep listening helps bring forth the metaphors and words of feeling necessary to communicate that which is on the heart or mind.

In the background, a chaplain or soul carer carries many narrative patterns: encoded variously in melody and harmony, themes and variations, rhythms, textures tones and timbre. These narrative threads, in turn, resonate with themes from theology, philosophy, psychology, sociology, literature. They present as accounts of trauma, PTSD, grief and loss, abandonment, isolation, enmeshed or well-differentiated relationships, supportive community, physical, mental and emotional states and spirituality. Spirituality is also seen in feelings and beliefs around justice, guilt, shame and forgiveness, and existential experiences often beyond our control. Narrative threads of spirituality appear through all these themes, expressed through religious observance, practices, habits and the things in which they find peace.

As a chaplain listens with an open-handed curiosity to a person’s story, some aspects will resonate with one or more of the patterns mentioned above. These inklings cause us to notice certain things and wonder if the other is also aware of a link in their story. A point comes where we might respond to ask how something felt or how it seemed to them as we help them form connections from the things they have shared.

To place these carefully chosen reflections, we need to understand what we are hearing and our sense-making frameworks for linking and locating the expressed ideas and impressions.

I wish to return to the hospitalised patient suffering from a shark bite. If the patient had requested a chaplain to visit him, and after greetings, I enquire how I could help him. If I had met him in a surgical ward, I would have explained I was a chaplain doing a ward round and wondering how his hospital stay was going and if anything was on his mind or troubling him or he would like to chat?

A conversation with the patient could go as many different ways as there are people. But suppose I merged this patient who was bitten by a shark with a patient Joshua (identifying details changed for privacy). He was a road cyclist training for an international event when hit by a truck and suffered extensive damage to his legs, requiring amputation of one. In that case, I think it may provide a plausible possible encounter.

I met Joshua two and half weeks after his accident. He began speaking about his accident. He viewed himself as a survivor rather than a victim despite the truck driver being in the wrong. He expressed that he was looking forward to beginning rehab and moving some muscles again. Yet, as he spoke, it became more evident that the loses and griefs he was facing were huge. He was a schoolteacher and was grateful that the school understood and provided him with a leave of absence for an extended period and was eligible for third party insurance to cover many of his costs. As he continued, he then mentioned that he had been married for two years to his childhood girlfriend, and she was also an elite athlete. While she was amazing with the whole accident thing, he had gnawing insecurity voicing a fear that she might not want to live the rest of her life with a disabled person.

Joshua was not religious. He had a philosophical approach to life where he didn’t have a special pass to avoid tragedy. Joshua could not see anything he would have or could have done differently on the day of the accident as he followed his regular training routine.

I commented that he seemed to be carrying a very heavy load and was bearing many losses. He nodded and wiped away a tear with the heel of his hand. After a bit, he said, yeah, some days it’s all too much, then smiled and thanked me for listening. I replied, thank you for sharing; you certainly are going through a lot. I will keep you in my thoughts and prayers.

Following a chaplaincy visit, a chaplain reviews the visit through a spiritual assessment tool. One such tool is a simple and effective assessment developed by two nurses, Highfield and Cassons. It reviews the patient’s meaning and belief, their need to give love and receive love and their hopes and creativity which broadly corresponds to a description of a person’s faith, loves and hopes.
I prefer to review the conversation using a framework of religious, moral, spiritual and existential concerns and the web of relationships in each domain. After listening to Joshua and reflecting on the conversation, my initial spiritual assessment was this.

Joshua was not religious, but his accident disrupted his patterns and habits and separated him from his training and work community. Morally, Joshua was not asking questions of justice around the accident but seemed to be attempting to absorb the impact within himself through the frame of ‘life happens.’ At this early stage, he was not dwelling on the deep wrong that had been committed against him, nor the severe assault against his person and body.

Spiritually, Joshua was experiencing disruption to all areas of his life that filled him up, his relationship with his wife, body, sport, and training teams expressed through absence and grief. Existentially, in an instant, he had lost his leg, his health, his work, his sport, yet he demonstrates a genuine desire to transcend his current sufferings.

As a chaplain, I was in internal prayer for Joshua and prayed that my visit would be helpful to him at this time. I endeavoured to accompany him, staying with his story and going at the same speed he was going. I drew on the stable and secure framework I have around me, working out of the depth of my faith, skills, and training to accompany and scaffold Joshua in his experiences.

Prayer and Soul Care

The practice of prayer is perhaps the most future-orientated and therefore hopeful soul care practice of all, linking the present to eternity.  

Pastoral theologian Eduard Thurneysen contended that there was no proper soul care without prayer. In many ways, the act of soul care is a lived prayer seeking as it does to bring hope into despair, light into the darkness, life into existence and grace to futility.

Prayer is tangible and hopeful. Desires expressed in prayer give voice to the hopes and longings of the future.

Thurneysen, a Chrisitan pastor, viewed his ministry of visiting with parishioners as an act of hospitality. His soul so extended into listening that it assumed the form of intercessory prayer. He drew upon Philippians 1:3-6: “Whenever I think of you, I offer to God my prayer and thanksgiving for you.”1 He describes a “full listening… without a single word passing our lips.” The type of hospitality that he spoke of accepts the speaker as they are and draws them into a kind of solidarity – neighbourly love – flowing out of the spiritual life in Christ back towards God-given life.

Thurneysen’s understanding of prayer in soul care had three aspects. Firstly, “it is a prayer for myself as a pastor, for purification and illumination of my spirit, a prayer that I may become the true instrument of the Spirit of God.” Secondly, it is a “prayer for my neighbour; it is intercession.” The third form is prayer with the other. Thurneysen noted that wisdom was required as to whether or not this third act of common or shared prayer was appropriate. Thurneysen explained that for God to be at work in this context was a work of his own free grace. In a sense, it is an act of daring on the pastoral carer’s part even to take initiative in the process of prayer. In Thurneysen’s words, “The circumstances will decide from case to case whether I may and ought to pray with another person.”3

Caring for another involves being wisely attuned to what might be taking place for themselves, the other, and the working of the Holy Spirit through the soul care process. “Prayer is therefore always a step that leads beyond all boundaries into the realm of eternity. For it is actually talking with God, really God, really being heard by God and listening to God. Hence prayer is the final destination of every way, the deliverance from every distress, the fulfilment of every petition.”4 From a human perspective, the carer facilitates a conversation between the other and the Heavenly Father in prayer, depending upon the Holy Spirit, in the name of Christ Jesus.5

Through prayer and faith, the soul carer foresees hope and a possible future through love and forgiveness through the power of a love that bears all things, suffers all things, believes all things. Thurneysen felt strongly that neither prayer nor hope were practices to be employed simply for therapeutic ends. Instead, these arise from the Christian faith and are anchored deeply in Christ within the soul of the carer.  Prayer in this context is not a therapeutic practice but a radical act of hospitality whereby the horizons of the present have been opened out and are inviting the inbreaking work of the Heavenly Father.

For this reason, prayer must not be forced, manipulated or coerced by the soul carer. There is a complexity in the offering of prayer in soul care practice, and the practitioner must be alert to the possiblity of overreach when taking an initiative that may only belongs to God. Yet, prayer might be the very means to shift ordinary conversation beyond the breach into a truly divine-inspired soul conversation. 

The soul carer is an agent of hope; there is no hope left even when humanly speaking. Such longings and prayers present the other with a glimpse of the eternal horizon of significance from which the soul carer ministers. Thurneysen believed, therefore, these qualities of wisdom, hope and prayer and needed to be cultivated. No matter how effective listening is, it can never “replace the decisive act of prayer.”6  Prayerfulness of the soul carer for the other is of such importance that it could almost be equated with soul care. In fact, as Thureysen expressed it, “The practice of soul care and prayer are actually one and the same. Soul care is prayer.”7

The attitude of prayer can move a conversation from the horizontal plane of human concerns to the vertical dimension of the inbreaking of the Word.

1 Eduard Thurneysen, (1946) Theology of Pastoral Care, 128, 197
2 Ibid, 195.
3 Ibid, 198
4 Ibid, 197
5 Ibid, 197
6 Ibid, 190
7 Ibid, 190
Image by Couleur Pixabay

Soul Care of the Spiritual Self 

The soul of every person comprises a multilayered, interconnected web of beliefs, values, experiences, emotions and relationships held together through a spiritual web with overlapping religious, moral, spiritual and existential dimensions. 

A soul care conversation is an intermingling of hospitalities. The soul carer offers the hospitality of soul to attend to another’s soul. If the offer is accepted, the other extends hospitality by inviting the carer into their spiritual home.

The spiritual home is a metaphor for our spiritual self, comprising a constellation of spiritual connections.1 Or, as Louis Nieuwenhuizen explains, “The spiritual self is not separate from the physical, psychological or social self; it is simply a natural, interconnecting dimension.

This concept is supported by an ever-expanding body of literature supporting the “idea of multiple complex connections between the psychological, physical and spiritual components of individuals.”2 The soul is an embodied and encultured entity that embraces the whole person and the whole of life. Spirituality of the soul focuses mainly on how a person makes sense of life or finds meaning in life and death. The soul of every person comprises a multilayered, interconnected web of beliefs, values, experiences, emotions and relationships held together through a spiritual web with overlapping religious, moral, spiritual and existential dimensions. We might consider the religious, moral, spiritual and existential dimensions of the spiritual as distinct yet interconnected domains within the concept of sense-making or spirituality.

These interconnected domains form the most profound and fundamental components of the spiritual self and cohere around the individual’s core beliefs.3 Soul care works within the multifaceted spirituality of an individual’s spiritual self. Each domain of spiritual the spiritual self represents a different dimension of the self and approaches questions around meaning, purpose and belonging from a different perceptive.

For the purposes of soul care and facilitating spiritual wholeness, or spiritual health, it is possible to think of the spiritual self as a spiritual home and the different domains as rooms or spaces. This spiritual home has four rooms or areas: religious, moral, existential, and spiritual. The spiritual home has a verandah or porch for the chatter that passes the time of day on the weather, other people or other things of a social or general nature. Not everyone who visits a spiritual house is invited to enter the spiritual home. To cross the threshold, one entered through a door that was opened for the inside.

The religious space within the spiritual home contains the personal and social connections and practices clearly defined by objective aspects of religion – such as shared beliefs and traditions, habits, patterns, liturgy, rituals, rites of passage, symbols and signs. Now, many people might be thinking about the people who identify themselves as spiritual or not religious. Philosopher James A K Smith observed, that to be human is to follow a set of cultural liturgies. We might find these rituals in malls, stadiums and universities, and these habits and liturgies, are shaped and in turn, shape what we love or desire.4

Symptoms of religious distress are exhibited through disbelief, dismay, a loss of faith or trust, or a sense that there is nothing behind the drama and theatre of the belief system. The believer has become disillusioned, believing that the rituals do not represent any larger reality, the signs do not signify anything more substantial, and the symbols are merely hollow trinkets. Yet, even in disbelief and loss of faith, there are other sets of liturgies and rites of passage such as the burning of books, desecration of sacred things, or the removal of wedding rings or the formal desacralisation of religious property or items. 

The moral space contains the person’s internal compass, guided by their deeply held corresponding philosophical values, ethics and morality. Their moral space will be directed by their sense of fairness, justice, good and evil, ideas of retribution, forgiveness and grace. The overlap between religious and moral spaces will depend on how religious beliefs form and influence a person’s moral intent. Symptoms of moral distress arise when there is an inner conflict between one’s own values and what one is required to do or witness. Soul care will witness and attend to the other’s inability to reconcile their morality events with their belief about what should have happened.

The existential space relates to the experienced reality of when stuff happens. Our Existential spirituality is a closely related relationship with the external world through our body and mind and our physical and cognitive responses to the existence, and how we make sense of events and find meaning through the events. Philosopher Martin Heidegger coined a term to describe our experience of these events, and he called this our thrown-ness into life. This thrown-ness may be positive, negative or neutral, but is mainly beyond an individual’s control and includes birth and death, ethnicity and nationality, disease and heath, war or peace, poverty or prosperity. Existence includes all events of life and things that matter. These events include genetics, history, environment, culture, family and shared spaces. Our response to existential events is variously described as resilience, thriving or despondency, fatalism, survival or acceptance. Symptoms of existential distress include suffering, pain, anxiety, pain, loss, grief and soul care provided focused attention and awareness of the expressed losses and suffering.  

 The spiritual space relates to inwardness, subjectivity, and personal experiences that connect people to something beyond themselves. This space is experienced as a state of creativity, flow state or being in the zone where perceptions of focus and time are experienced differently. Spiritual experiences and practices include prayer, meditation, yoga, scripture reading, connectedness to nature, gratitude, thankfulness, sport, dance, and music. These are times we are functioning in a non-self-conscious way from our heart or soul. It could be said we are performing out of our spiritual self, not mediated through a persona.

In this state, we can be others who also are also relating as their selves and find harmony or symmetry felt as being on the “same wavelength” “in tune with” or “in step with.” Symptoms of spiritual distress exhibit disharmony, discordance, disproportion and may be exhibited variously as guilt, shame, fear, depression, being overwhelmed or feeling trapped.

Spiritual health is evident when a person’s spiritual self can predominantly participate in their regular liturgies, process, and grow through life’s challenges. They have a moral framework that can accommodate sin and tragedy and find comfort and peace even in trying circumstances, as described in Psalm 18. Conversely, Psalm 137 describes people experiencing religious, moral, spiritual and existential spiritual distress. Psalms 42 and 43 describe someone held by fragile threads of grace that hold in the face of distress. In the 23rd Psalm, we observe the spiritual health of someone who can place their religious, moral, existential and spiritual distress in the shepherd’s care and is restored to spiritual health even in the face of physical death.

Central to the Christian faith is the belief that the spirit of Christ dwells within the spiritual home of the believer, (Eph 3:17; James 4:5) experienced as the peace of Christ which passes all understanding (Phil 4:4-7).

1 Louis Nieuwenhuizen, “Lived Experience of Hospital Patients and Its Integration into Theory,” Chaplaincy Today Vol 24. No 2. p3.
ibid p4.
3 ibid p4.
4 Cultural liturgies” is a term coined by philosopher James K. A. Smith. The term refers to communal habits and patterns of worship seen in all human cultures.

The Existential Frame of Soul Care

This is not an easy place to sit. We are easily assailed by an overwhelming desire to restore that which was lost; to fill voids with solutions, and fix things up to stem the tide of our own overwhelming fear and anxiety – if this tragedy could befall one person it could befall anyone.

The alien landscape of suffering is a world that exists on the other side of a tissue-thin membrane. We are separated from this world of seemingly ‘untouchables’ by gossamer-thin fibres of favourable circumstances that isolate the wounded from the walking. Those who suffer are caught in this nightmare world: even in sleep, the craved for escape eludes them. In this alien world time warps ― it enters slow motion― people’s lips move soundlessly. This lonely and isolated landscape can be torturous solitary confinement.

When we sit awhile in the landscape of another’s existential crisis we begin to attend to their pain and attune to their utterances of loss. However, this is not an easy place to sit. We are easily assailed by an overwhelming desire to restore that which was lost; to fill voids with solutions, and fix things up to stem the tide of our own overwhelming fear and anxiety – if this tragedy could befall one person it could befall anyone. We are forced to choose a vantage point, for there is no view from nowhere. We might choose to soar above the situation, theorising and categorising: retreating into our systematic and biblical theology to understand this loss in the sweep of all of creation and redemption. Or we might observe events from a psychological or medical perspective trying to situate events within structure and frameworks of mental and physical health and disease orientating us to find a solution to the current distress.

These different viewpoints map onto Frame’s triperspectival framework. Each theological viewpoint is a different type of lens on reality. The Normative lens captures an overview of reality capturing themes and patterns. From this normative lens are principles, doctrines, typologies and the salient turning points of salvation history are seen theologically from the divine viewpoint. The Situational lens is a long lens that captures what can be observed and described from history, nature, culture, society, psychology ― the books of Ecclesiastes and Proverbs provide examples and the situational lens on reality. The Existential lens is limited to the depth of field to which a particular person in a particular place and circumstance can see. The Book of Job (excluding the divine speeches) provides a salient example of the Existential lens.

The normative and situational lens serve to orientate and stabilise the soul carer. These lenses provide anchor points from which the carer can descent down into the existential suffering of another. By differentiating between the purposes of the lens of Scripture, the carer avoids using Bible as a book of solutions or oughts, shoulds, and musts for people who in the present time are unable to will themselves to climb up on to the first rung. Psalm 137 poignantly captures feelings of the desolation of such a people, the exiles who are sitting, weeping and remembering.  For the exiles, perceptions of reality are shaken. They need to find new categories to process the experience, this takes time.

Many of the psalms of lamentation and Psalm 88 in particular paint a harrowing picture of a person who feels desolate, destitute and utterly abandoned by God. The sufferer is unable to come out to us we must enter into the alien landscape. For a sufferer undergoing a Psalm 88 experience, we also must descend into the dark regions below, sustained by the normative and situational knowledge that God is not absent even in Sheol or the pit, or beneath the overwhelming waves. We sit beside, we weep with those who weep, we pray, we wait and stay in the present, enduring how it is now for the sufferer.

It is an act of grace to stand with the sufferer and share their existential lens limiting our vista to their vista, trying to see things from their perspective – below where they are – not from God’s global perspective.  To feel the events from their perspective – beside – this is not a time for putting things into perspective.  Severe trauma and stress place a person in a continual present: the only starting point. We must stay beside the sufferer and ‘be now‘ in their present, being careful not to run ahead of them or pull them back, it is a dance where we must learn the sufferer’s dance steps.    

Only by being in their present is there any possibility of scaffolding them into the future. There are times for remembering the past and times for looking forward and providing a reason to go on, but not at the expense of denying someone the opportunity to express the pain they are feeling now, today. 

Once we are able to abide in the landscape, we have to learn to stand with the sufferer and allow our eyes to adjust to the surrounding darkness we also can accompany them. If we listen carefully we might hear the predawn birdsong as we wait for the predawn light, a thread of hope of a home where there is no more crying, no more pain – a quiet whisper; a plea that there must be more to life than this. We enter the chaos as one of Christ’s people and stand with the sufferer and turn our face towards the light.

Some of the content of this post was first published as “The Alien Landscape of Suffering,” by Kate Bradford, edited by Margaret Wesley, Loss and Discovery: Responding to Grief with the Compassion of Christ and the Skills of All God’s People.  (Wipf & Stock Publishers) 2013. pp 166 -174.
Frame and Poythress Triperspectivalism
Image by Bertsz from Pixabay 

Perspectives in Soul Care

Grief and loss are experienced as anguish within the soul, they are not as dilemmas to be solved.   

Loss and its accompanying grief fragment and shatter our reality. Familiar paths of life and meaning are ruptured or dissolved by a rising tide of events we have little control over. Soul care, at its best, is a ministry that provides a balm to the seeping wounds of grief. It scaffolds and holds the sufferer through the unfamiliar tangle of grief when the familiar paths are overgrown, moving only at the pace that the sufferer can manage.

Yet, anyone who has spent much time with people grieving the loss of someone they love will have heard on more than one occasion examples of people’s rather clumsy attempts at words of comfort. These attempts might include phrases such as “they’re in a better place,” or “you’ll be fine,” or “stay strong.” They may offer explanations: “everything happens for a reason,” or suggestions that the sufferer sees things from a different perspective that begins with “at least you still/or can …” Sentiments such as these very often require a commitment to an image or idea that further burdens the sufferer.

Similar attempts to quote the Bible or express a biblical sentiment place similar burdens on the sufferer.

  • There are several verses so repeatedly misapplied they bear outlining them here.
    • God is faithful. He will not allow you to be tested beyond your ability (1 Cor 10:13)
    • Do not be anxious about anything (Phi 4:6)
    • God intended this suffering for good to accomplish his work (Gen 50:20)
    • Give thanks in all circumstances, for this is God’s will for you in Christ Jesus. (1 Thes 5:18)
    • The Lord gives, the Lord takes away, blessed be the Lord (Job 1:21)
    • And we know that for those who love God, all things work together for good. (Rom 8:28)
    • We may plan all we want, but it is still the Lord’s plan that will reign. (Proverbs 19:21)

The critical issue is, will this verse resonate with the sufferer in the midst of their present suffering? Are they able physically and mentally to integrate this concept into their world now, or does it simply become another overlay that prevents genuine integration? Such verses were written for a specific context and are a helpful but generalised touchstone of faith. There are inherent dangers in applying extracted and globalised wisdom to highly specific local situations which risk exacerbating and intensifying the sufferer’s grief. As with the words of Job’s comforters, these attempts minimise, or worse still, deny the reality of the suffering of the bereaved. In a previous post, we observed that suffering is nuanced, and context always matters. To this, we could add another truism – grief and loss are experienced as anguish within the soul, not as dilemmas to be solved.   

There are many reasons why these words further injure the bereaved. Such causes include misunderstanding the nature of the losses that people grieve, poor skills at communicating sympathy and compassion, and a lack of differentiation between the comforter’s unease and the care needed for the sufferer, leading to an unfortunate consequence that their own discomfort is inadvertently projected onto the sufferer.

Their actions exhibit a faulty theology, such as the theology of Job’s comforters for which they God critiqued them, “You have not spoken truly about me, as my servant Job has.” (Job 43:8)  

John Frame’s Triperspectival ethical model offers a framework that helps avoid the failure of Job’s friends. Frame contends that errors in interpretation stem from misunderstanding our finitude and not sufficiently grasping our limited perspective and that we do not see reality from a Divine perspective. Frame’s triperspectival ethic accentuates three perspectives from which events can be viewed: 1) a normative perspective where events can be understood from a divine vantage point; 2) a situational perspective from the point-of-view of information and that which can be gained by observation, and 3) an existential perceptive which represents the internal experience of the people involved in the event under observation.  

If we consider the verses listed above, they tend towards a normative viewpoint, where all the intertwining threads of existence can be seen from above across time. Similarly, we might consider the sufferer’s limited perspective on events they are experiencing, yet, seeing only through a glass darkly viewed from below, shrouded in mist. If the carer assumes a theological perspective above, it distances the carer from the sufferer rather than moving towards them. The ministry becomes commentary rather than sympathy.  Comfort, intercession and accompaniment are lost while the other passes alone through their valley of the shadow of death.  

There are rich streams of comfort through Scripture that speak into shadowy and fragmentary experiences of pain, loss, suffering, and evil. Scriptures that are written from the view below, verses that intercede for broken hearts and crushed souls. Frame’s Triperspectival model provides an integrated theological framework for making sense of God and reality and provides a well-defined explanation for why the above comments fail to offer the comfort the carer intended.

A critical task of pastoral theology is to cultivate the ability to act appropriately at particular times. This includes understanding why some pastoral interventions help in some circumstances but cause harm in other contexts and identifying the multiple variables in a situation. Theology, in essence, is wisdom, a sense-making framework from the standpoint of Scripture.

To be continued in the next post The Existential Frame of Soul Care

Edited for clarification 10/11/2021
A Primer on Triperspectivalism by John Frame and Vern Poythress
Photo by Nong Vang on Unsplash

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