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Relational Spirituality
By Ann M. Callahan, PhD, LCSW
February 2017

Social workers must understand the meaning of spirituality to be spiritually sensitive. Relational spirituality pertains to the experience of relationships that enhance life meaning. The therapeutic relationship can inform a client's worldview and sustain a social worker's capacity to care.

It is Monday morning and the first face I see is Sue looking back at me. There she sits in a wheelchair covered with a blanket and a huge smile. As I enter the nursing home, Sue welcomes me. We talk for a moment to usher in my day as a clinical social worker. Sue greets everyone who enters from her station in the lobby. If you want to find someone—staff or client—Sue will gladly help. Today Sue is wearing a pink cowboy hat decorated with metal studs that form a cross on the front. Each day, Sue carefully selects which hat to wear based on her outfit. Over the years, people have given Sue hats, which she proudly displays on the walls in her room. Sue is also an artist and has numerous sketch pads and art supplies she uses when she is not enjoying activities such as bingo with the other clients. Later in the afternoon, when I search for Sue, she is in her bed watching television. Sue gracefully allows for my intrusion to have a psychotherapy session. Based on previous sessions, Sue will focus on significant relationships.

Stereotypes of nursing homes suggest a scary place where suffering begins and life ends, but my work in nursing homes suggests a different place. Nursing homes are a place for rehabilitation until discharge to home, while for others chronic illness demands a commitment to long term care. In the process, nursing homes provide an instant community that is invested in a client's care. People in this community include clients as well as staff, family members, and friends. Each nursing home operates differently, but all nursing homes consist of relationship networks that inform life meaning. For clients such as Sue, nursing homes can provide opportunities for self-discovery, to develop new relationships, and have "bucket list" experiences.

Relationships that emerge as part of nursing home care help clients not only survive but in some cases also thrive. Life becomes defined by activities of daily living where clients engage in tasks structured around the clock: nursing shifts, activities schedules, therapy sessions, and anticipated visits. Relationships with certified nursing assistants enable clients to bathe, put clothes on, and brush their teeth. Relationships with nurses enable clients to take their medications and receive additional health care as per medical necessity. Relationships with family and friends help clients feel connected to the outside world. This daily routine tames fears inspired by the unpredictable nature of life.

As a clinical social worker, my job is to engage clients in a therapeutic relationship. I attend to significant relationships and develop interventions to help clients strengthen relationships with what matters to them most. Significant relationships can be determined by the way clients treat themselves, the people for whom they care, and how they engage with their environment. Social workers who are sensitive to the spiritual importance of relationships allow clients the opportunity to explore how relationships nurture them spiritually. Relational spirituality is defined by the experience of meaningful, life enhancing relationships (Faver, 2004; Canda & Furman, 2010). Relationships across levels have the potential to enhance life meaning.

Micro Level: Intrapersonal Relationships
Intrapersonal relationships are defined by internal processes that inform one's relationship with the self. Clients may engage in, e.g., prayer/meditation, crafts, reading, watching television, using the computer, spending time alone, or exercising. Although these activities may vary in degree of importance, they can provide clients a way to channel energy toward self-care. Based on my experience with Sue, prayer helped Sue manage anxiety when she would leave her room to go into the dining room. Sue's efforts to go into the dining room seemed to build self-confidence that was more powerful than fear. Conversely, I was sensitive to the fact that Sue still needed some time alone to grieve for the loss of her husband.

Mezzo Level: Interpersonal Relationships
Interpersonal relationships with someone or something else, like a companion animal, provide additional opportunities for meaningful connections. Interpersonal relationships may occur one-on-one or in groups with other clients, staff, and visitors. At a minimum, most clients rely on staff to help them with personal care. Sue was paralyzed with only partial use of one arm, so she relied extensively on staff for mobility. She needed assistance in getting out of bed, changing her clothes, and using the bathroom. Other clients, including Sue's roommate, could attend to her needs, but appreciated staff who checked on her. Being sensitive to Sue's need for others, I worked to help Sue increase her trust in the ability of others to help her with personal care.

Macro Level: Transpersonal Relationships
Transpersonal relationships with the environment or higher power provide another way through which relationships can enhance life meaning. The quality of transpersonal relationships can be indicated by interior decorating, enjoying the natural environment, and trips outside the nursing home. Sue decorated her room with her hat collection and artistic creations. Sue also enjoyed sitting in her favorite place in the lobby. There Sue felt she was part of the milieu, while others would come and go.

Bird feeders as well as flowering bushes surrounded the building. Being sensitive to the need to feel connected to something bigger, I encouraged Sue to look out her window to enjoy the changing seasons and to go on outings arranged by activities staff.

Practice Implications
The social work relationship entails helping clients navigate life experiences. This involves drawing from client strengths to respond to daily challenges. Efficacy rests in the social worker's capacity to create a therapeutic relationship that is life enhancing. It is within this context that clients have increased opportunity for other meaningful, life-enhancing relationships, some of which necessitate client-centered interventions to inspire change. The change process varies relative to how relationships on the micro, mezzo, and macro levels inform life meaning. Potential for success is further relative to professional expertise (Hodge, 2016). The need to convey the value of the therapeutic relationship remains as long as there is social work to do.

Therapeutic conditions that a client experiences as spiritually sensitive provide a foundation for relational spirituality. Spiritually sensitive practice means social workers are sensitive to a client's need for meaningful, life enhancing relationships and that social workers have the capacity to recognize how a therapeutic relationship can help clients experience significant relationships as life enhancing. Based on Buber's (1970) theory of dialogue, "I-Thou" communication validates a client's human dignity and worth and recognizes that all clients deserve respect. "I-Thou" communication provides a way to impart spiritual sensitivity throughout the provision of care.

For example, generalist qualities such as collaboration, cohesion, empathy, goal consensus, positive regard, affirmation, congruence, and genuineness significantly influence treatment outcomes (Norcross, 2012). These relational qualities also provide a foundation for advanced psychotherapeutic interventions such as client-centered and existential therapy as well as dignity therapy and relational social work. So, as with generalist interventions, spiritual sensitivity can be conveyed through advanced generalist and clinical interventions. Congruent with the concept of relational spirituality, spiritual sensitivity requires the professional capacity to facilitate relationships that enhance life meaning, starting with the therapeutic relationship.

Final Thoughts
Relational spirituality has the potential to manifest through the practice of spiritually sensitive social work. In my practice, this means helping clients like Sue discover ways to more fully engage in significant relationships across the micro, mezzo, and macro levels. The therapeutic process provides clients a way to identify what they need to make their relationships more meaningful, and, ultimately, a means for transcending difficulties. Since relational processes create the core of a therapeutic encounter, the social work relationship itself has the potential to enhance life meaning. It is the client's perception of enhanced life meaning that defines relational spirituality, but in the process of providing spiritually sensitive care, social workers have the potential to change themselves.

Author's note: This article is based on some of the research done for the author's book Spirituality and Hospice Social Work, Columbia University Press.

— Ann M. Callahan, PhD, LCSW, teaches social work at the University of Tennessee, Knoxville and is a clinical social worker for MedOptions Behavioral Health Services. She has more than 20 years of social work related experience. Callahan specializes in spiritually sensitive hospice and palliative social work.

References
Buber, M. (1970). I and thou. (W. Kaufmann, Trans.). New York, NY: Touchstone.

Canda, E., & Furman, L. (2010). Spiritual diversity in social work practice: The heart of helping. 2nd ed. New York, NY: Free Press.

Faver, C. A. (2004). Relational spirituality and social caregiving. Social Work, 49(2), 241-249.

Hodge, D. R. (2016). Spiritual competence: What it is, why it is necessary, and how to develop it. Journal of Ethnic and Cultural Diversity in Social Work, 1-16. doi: 10.1080/15313204.2016.1228093.

Norcross, J. C. (Ed.). (2012). Evidence-based therapy relationships. Retrieved from http://www.nrepp.samhsa.gov/pdfs/Norcross_evidence-based_therapy_relationships.pdf.

Resources
Callahan, A. M. (2017a). Spirituality and hospice social work. New York, NY: Columbia University Press.

Callahan, A. M. (2017b, February). Therapeutic relationship as a spiritual resource. Webinar for the North American Association of Christians in Social Work. Retrieved from http://www.nacsw.org/.