Praying With Patients — Exploring the Social Work Challenges
By Scott Janssen, MA, MSW, LCSW
Social Work Today
Vol. 20 No. 4 P. 20

After wrestling with the many concerns preventing his agreeing to a patient’s request to pray with him, this social worker found ways to approach prayer that comforted patients and ensured he wasn’t violating his professional ethics.

Few moments as a hospice social worker have unsettled me more than the night I made an on-call visit with Cliff after his wife Reba died. With many family members in the home, I was there to provide a listening ear, assess for concerns, and respond to questions such as how to tell the grandchildren.

By the time the funeral home staff arrived I was facilitating group storytelling about Reba’s life and expressions of love and gratitude. When the funeral team asked if they could remove her body, Cliff winced, words caught in his throat. Finally he asked if we could have a prayer “before you take her away?”

We circled Reba’s hospital bed holding hands, waiting for someone—anyone—to speak, but no one did. That’s when Cliff threw me into a state of near panic.

“Scott,” he said, squeezing my hand, “Would you lead us in a word of prayer?”

Until then I’d always redirected requests by patients or caregivers asking me to pray with them. My social work training discouraged prayer with patients. It was a red flag that boundaries could be violated or that a social worker was pushing a personal agenda not consistent with good therapeutic relationships.

I saw the pain in Cliff’s eyes. He was placing trust in me, a stranger, to speak words that might bring comfort amidst a world that had just been shattered.

Swallowing hard, preparing to take the plunge, I knew I’d have to wing it.

Research
I was aware that some social workers prayed with patients, but I wasn’t one of them. Turns out, there may be quite a few. A study by Michael Sheridan, PhD, (2010) found that “a substantial percentage” of social workers surveyed “report praying for (55%) or praying/meditating with their clients (33%).”

Sheridan places this finding in the context of a growing emphasis on spiritually sensitive social work practice. Proponents of this approach see it as a way of “enhancing the profession’s commitment to holistic and culturally relevant practice through expansion of the traditional bio-psycho-social-cultural framework to include the spiritual dimension.”

Edward Canda, MSW, PhD, and Leola Furman, MSW, PhD, (2019) argue that: “Attending to spirituality can help us put clients’ challenges and goals within the context of their deepest meanings and aspirations. Since social workers are committed to a whole-person-in-environment perspective, we need to take a holistic bio-psycho-social-spiritual-ecological view. On a pragmatic level, by considering the religious and spiritual facets of clients’ lives, we may identify strengths and resources that are important for coping, resilience, and optimal development.”

According to Ann Callahan, PhD, LCSW, (2019) social workers can cultivate this kind of practice regardless of whether a patient identifies as spiritual or religious. In the case of a patient who identifies as having no such beliefs, a spiritually sensitive practice might focus on issues of life purpose or “the healing power of meaningful relationships.”

By the time I met Cliff I’d already developed a spiritually sensitive practice. Issues around terminal illness had often intersected patients’ spiritual beliefs, especially when they were chewing on big questions about life’s meaning and the nature of death. Communities of faith had often rallied around patients and families, providing support, performing sacred rituals, and affirming shared spiritual narratives about the way the world works.

I’d learned to take a broad and inclusive view when defining the “spiritual dimension” of patients’ lives and recognized its power to help them access strengths, engage social support, and make sense of adversity. But praying with patients had always been out of bounds.

Research suggests, however, that diverse expressions of prayer—including practices such as devotional meditation, spiritual mantras, affirmations, and visualization—can be a useful resource for people struggling with physical health challenges (Ai et al., 2007; Gall & Cornblat, 2002). Prayer can also have a positive impact on those facing depression, anxiety, posttraumatic stress, or major life changes (Ai, Tice, Peterson, & Huang, 2005; Van Hook & Rivera, 2004; Hussain & Cochrane, 2003; Patterson, King, Ball, Whittington, & Perkins, 2003; Miller, Fletcher, & Kabat-Zinn, 1995).

Personal Considerations
My objections to using prayer included personal discomfort, boundaries around my role as a social worker, and lack of training. Praying was part of the chaplain’s role, not mine. Since my social work education had discouraged prayer, I didn’t have a clue about how to generate prayers that reflected a patient’s beliefs while leveraging opportunities within that belief system for psychological healing and enhanced well-being.

There were other objections. Was it ethical to pray within the context of religious or spiritual beliefs that I didn’t share? Would it mean appearing at times to validate viewpoints I found objectionable? For example, many patients conceptualize the transcendent as an anthropomorphic God of male gender. This is inconsistent with my spiritual beliefs for which the primacy of humans over other living beings and of men over women is problematic.

What about patients who believe in a God of vengeance? Not only would praying to this understanding of the transcendent violate personal beliefs, it might reinforce the kind of distress I’d often seen in patients who believed their illness was a divine punishment or who worried they were going to be cast into a realm of eternal suffering after they died.

I couldn’t ethically pray to this particular God, but praying to one abundant in love and forgiveness might stand in opposition to a patient’s beliefs or preferences. This could create conflict and undermine trust. It might also risk attempting to impose alternate beliefs on a patient rather than accepting the personal validity of their own.

Then there was the matter of what to pray for. At times patients or family members had asked me to pray that God cure cancer or restore a patient’s body to full functioning. Could I pray for something I considered unrealistic?

Our profession’s Code of Ethics is clear when it comes to advocacy for cultural diversity, inclusion, and social justice. Would it be ethical to pray using a patient’s religious framework if that framework is at odds with, even hurtful to, other family members who held different beliefs? The gay son, for example, who feels stigmatized by his mother’s fundamentalist Christianity, or the daughter whose belief in nature as a transcendent force has been ridiculed by her family.

Until Cliff squeezed my hand, these objections had created an intractable boundary. That moment changed my practice. I began reflecting on whether there might be situations in which offering a prayer might be ethically defensible and clinically useful. Situations where prayer might help a patient better cope with the challenges of illness or facilitate psychological or interpersonal healing, without blurring my role as social worker.

Sheridan argues that social workers who employ prayer with clients should “critically review their use of spiritually based interventions and discern what factors they employ in making such practice decisions.”

What follows are a few rules of thumb which have come to inform my practice decisions about prayer. I make no claims that these are or should be valid for most social workers. They were developed working with patients who are dying. As such there may be issues related to populations served or agency policies that make prayer a nonstarter in other settings or clinical contexts.

Suggestions With a Social Work Perspective
The first criterion is that I never initiate an offer of prayer. I allow it to come from a patient or caregiver. This has three useful functions. The first is that an unprompted request generally denotes the consent of the person for whom the prayer is being said, and consent is essential. The second is that allowing the patient initiate a request confirms that prayer is important to them, consistent with their wishes, and likely to be clinically useful. The third advantage is that it reduces the likelihood that I might push prayer in a way that shuts down conversation, makes inaccurate assumptions, or confuses a personal agenda for that of the patient.

It is acceptable, even necessary, to say no. I decline requests in cases where I have insufficient understanding of a person’s spiritual perspective to feel confident that I can do so respectfully. I also decline requests which seem driven by an agenda not shared by the patient or others involved. For example, a caregiver who asks me to pray that a patient “accept Jesus” before he or she dies. In some cases there may be psychiatric issues such as hyperreligious fixations, compulsions, or delusions that preclude the use of prayer.

I try to decline requests in ways that soften the potential that a patient will feel rejected. For example, I might invite patients to reflect on what they are currently praying for. I might ask if they have a particular prayer, sacred song, story, or text that speaks to them and invite a reflection on why. Such shifts can turn requests that have been declined into opportunities to process and share. In some instances, by using such refocusing I don’t even have to explicitly decline the request.

Canda and Furman emphasize the importance of establishing relationships of trust, empathy, and respect prior to engaging in interventions or therapeutic processing that explicitly focus on spiritual or theological content. Unless there is a relationship of trust and attunement, as well as an understanding of a patient’s spiritual and/or religious beliefs—its values, language, imagery, and practices—I tend to decline requests for prayer. There may be exceptions such as in crisis situations such as Cliff’s request but these exceptions are rare.

A final rule of thumb is that I must believe, based on observation and assessment, that there is a good probability that a prayer will bring comfort and not cause or reinforce distress. When these criteria are met, I generally agree to offer a prayer.

How do you meld language, metaphors, and images from a patient’s spiritual worldview with their stated end-of-life goals to create a prayer that enhances psychological, emotional, and spiritual wellbeing?

In some cases, this may simply mean reading a sacred text, poem, or parable from a patient’s spiritual tradition. Often, though, it means constructing the kind of extemporaneous prayer for which Cliff had been asking.

Over time I’ve developed a loose template for this, which I offer in case it’s of any value to other social workers pondering these questions.

Frameworks for Prayer
I typically start by asking a patient what they want me to pray for. This often leads to a discussion of issues on their mind and helps home in on specific concerns such as being free from physical pain or coming to terms with anger. If a patient asks for something that seems problematic, a conversation can then be had that alters or modifies expectations. For example, if a patient wants me to pray that an estranged family member suddenly appear and apologize for years of hurtful behavior, we might explore how such expectations could set a patient up for disappointment or impede opportunities to forgive or let go of worry.

I usually begin a prayer with an invocation of the transcendent, however a patient understands it. This may mean using the word God but could also mean calling on the power of love, nature, or universal energy. For patients who understand this presence primarily as loving and beneficent I emphasize these and related qualities. For those who understand it as judging, dangerous, or punitive I leave such qualities out.

I then find something to affirm and/or for which to express gratitude. This might mean thanking the transcendent presence for giving strength or bearing witness as a patient struggles. It may mean gratitude for the patient’s life and how they have positively impacted others. It could mean acknowledging the labors of loved ones providing care or gratitude for something simple which a patient has mentioned—the feel of sunlight on their cheek as it enters the window or the power of happy memories during a time of sadness.

Once this safe frame has been established, I name one or more of the moment’s challenges such as distress associated with physical illness, painful emotions, troubling thoughts, or fear of death. These challenges often include something specific with which a patient is struggling such as a belief that his life has been a failure or anxiety for a life partner’s financial safety after the patient dies. Challenges sometimes include traumatic material such as history of interpersonal violence, combat, or abuse.

Acknowledging struggles with events such as trauma, moral pain, or shame in the context of a prayer can help create a vision of using what time remains in a way that repairs hurt or reflects deeper hopes and intentions but caution needs to be taken. Such material can also activate intense emotions and defenses that may be better addressed in a different context.

Once challenges have been named, I ask the transcendent force to guide things in a direction that lessens suffering and increases a sense of peace for all concerned. Often I flavor this vision with specifics related to a particular patient such as reducing depression, finding words to say goodbye, retaining the ability to laugh, or having a peaceful death.

I’m careful not to simply ask for transpersonal assistance but to use language in a way that helps a patient connect with inner wisdom and strength. For example, rather than asking God to take away someone’s anxiety I might ask that a patient better connect with and trust their inner strength, wisdom, and courage.

If a patient is ready to die and wondering why they are still here I might pray that they develop deep patience and better notice small moments of meaning and connection as they emerge during the long days of illness.

The goal is to create a safe context for speaking about the challenges, fears, and hopes in a way that connects a patient with an external source of spiritual comfort and engages their ability to cope internally and hold fast to areas of meaning, peace, and compassion.

End-of-Life Social Work
Decisions about whether to use prayer in the context of end-of-life social work practice should not be made lightly. Nor should they be influenced by personal agendas. Potential ethical perils abound, but so do clinical opportunities to better serve our patients and their families.

If responding positively to a patient’s request for a prayer violates a hospice social worker’s understanding of clinical or ethical norms, they should not use it. On the other hand, if social workers find themselves actively searching for opportunities to use prayer, this may suggest that a personal agenda is interfering with clinical practice. In such cases prayer should not be used until sufficient mindfulness has been developed and peer consultation or clinical supervision has been sought.

Ensuring that we are not pushing prayer, have obtained freely given consent, and that we are honoring a patient’s spiritual beliefs and values is essential. When these factors align and when a social worker is able to generate a prayer that speaks to a client’s situation and honors their strengths, choices, and therapeutic goals, prayer can be a powerful addition to clinical practice.

— Scott Janssen, MA, MSW, LCSW, is a hospice social worker with UNC Health Care Hospice, and a member of the National Hospice and Palliative Care Organization’s trauma-informed care work group.

References
Ai, A., Peterson, C., Tice, T., Huang, B., Rodgers, W., & Bolling, S. (2007). The influence of prayer coping on mental health among cardiac surgery patients: The role of optimism and acute distress. Journal of Health Psychology, 12(4), 580-596.

Ai, A., Tice, T., Peterson, C., & Huang, B. (2005). Prayers, spiritual support, and positive attitudes in coping with the September 11 national crisis. Journal of Personality, 73(3), 763-791.

Canda, E., & Furman, L. (2019). Spiritual diversity in social work practice: The heart of helping. (Third edition). New York: Oxford University Press.

Callahan, A. (2019). Do atheists have end-of-life spiritual needs? Social Work Today, 19(6), 17-18.

Gall, T. L., & Cornblat, M. W. (2002). Breast cancer survivors give voice: A qualitative analysis of spiritual factors in long-term adjustment. Psycho-Oncology, 11(6), 524-535.

Hussain, F., & Cochrane, R. (2003). Living with depression: Coping strategies use by South Asian women, living in the UK, suffering from depression. Mental Health, Religion & Culture, 6(1), 21-44.

Miller, J., Fletcher, K., & Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17, 192-200.

Sheridan, M. (2010). Ethical issues in the use of prayer in social work: Implications for professional practice and education. Spirituality in Social Work, 91(2), 112-120.

Van Hook, M., & Rivera, J. (2004). Coping with difficult life transitions by older adults: The role of religion. Social Work and Christianity, 31(3), 233-253.