Discussion – Week 9

Top of Form

Discussion: Spiritual Development

Do you identify as a spiritual or religious person? How might your spiritual identity influence your social work practice—both for those clients who have a similar worldview and those who do not?

Spirituality, which may or may not include involvement with an established religion, contributes to human diversity and influences behavior. Sensitivity to and respect for a client’s spiritual dimension reflects your appreciation of diversity and the code of ethics. As you consider the potential impact of your clients’ spirituality on their perspectives and behavior, you must also consider how your own spirituality might influence interactions with a client.

For this Discussion, you examine the potential effect of your spiritual views on social work practice and share strategies for being spiritually aware.

To Prepare:

  • Review      the Learning Resources on spiritual development.
  • Reflect      on your own spiritual or religious beliefs and how they may influence your      social work practice.

By Day 01/26/20211
 

Post a Discussion in which you explain how considerations about clients’ worldviews, including their spirituality or religious convictions (Christian), might affect your interactions with them. Provide at least two specific examples. In addition, explain one way your own spirituality or religious convictions might support your work with a client, and one barrier it might present. Finally, share one strategy for applying an awareness of spirituality to social work practice in general. Be sure to refer to the NASW Code of Ethics in your response.

Bottom of Form

Required Readings

Zastrow, C. H., Kirst-Ashman, K. K., & Hessenauer, S. L. (2019). Understanding human behavior and the social environment (11th ed.). Cengage Learning.

· Chapter 3, “Spotlight on Diversity: Relate Human Diversity to Psychological Theories” (pp. 112–114)

· Chapter 7, Sections “Review Fowler’s Theory of Faith Development,” “Critical Thinking: Evaluation of Fowler’s Theory,” and “Social Work Practice and Empowerment Through Spiritual Development” (pp. 339–342)

· Chapter 15, “Highlight 15.2: “Celebration of Life Funerals” (pp. 694–696)

Limb, G. E., Hodge, D. R., Ward, K., Ferrell, A., & Alboroto, R. (2018). Developing cultural competence with LDS clients: Utilizing spiritual genograms in social work practice. Journal of Religion and Spirituality in Social Work, 37(2), 166–181. https://doi.org/10.1080/15426432.2018.1448033

Oxhandler, H. K., Polson, E. C., & Achenbaum, W. A. (2018). The religiosity and spiritual beliefs and practices of clinical social workers: A national survey. Social Work, 63(1), 47–56. https://doi.org/10.1093/SW/SWX055

Pomeroy, E. C., Hai, A. H., & Cole, A. H., Jr. (2021). Social work practitioners’ educational needs in developing spiritual competency in end-of-life care and grief. Journal of Social Work Education, 57(2), 264–286. https://doi.org/10.1080/10437797.2019.1670306

Roh, S., Burnette, C. E., & Lee, Y.-S. (2018). Prayer and faith: Spiritual coping among American Indian women cancer survivors. Health and Social Work, 43(3), 185–192. https://doi.org/10.1093/hsw/hly015

Document: Life Span Interview (PDF)

Required Media

Walden University, LLC. (2021). Social work case studies [Interactive media]. Walden University Blackboard. https://class.waldenu.edu

· Navigate to Najeeb.

Follow Rubric

Initial Posting: Content

14.85 (49.5%) – 16.5 (55%)

Initial posting thoroughly responds to all parts of the Discussion prompt. Posting demonstrates excellent understanding of the material presented in the Learning Resources, as well as ability to apply the material. Posting demonstrates exemplary critical thinking and reflection, as well as analysis of the weekly Learning Resources. Specific and relevant examples and evidence from at least two of the Learning Resources and other scholarly sources are used to substantiate the argument or viewpoint.

Follow-Up Response Postings: Content

6.75 (22.5%) – 7.5 (25%)

Student thoroughly addresses all parts of the response prompt. Student responds to at least two colleagues in a meaningful, respectful manner that promotes further inquiry and extends the conversation. Response presents original ideas not already discussed, asks stimulating questions, and further supports with evidence from assigned readings. Post is substantive in both length (75–100 words) and depth of ideas presented.

Readability of Postings

5.4 (18%) – 6 (20%)

Initial and response posts are clear and coherent. Few if any (less than 2) writing errors are made. Student writes with exemplary grammar, sentence structure, and punctuation to convey their message.

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© 2021 Walden University, LLC.

Najeeb

Najeeb is a 72-year-old Pakistani American who immigrated to the United States 40

years ago. He has two grown daughters, Nasrin and Mira, who live in nearby

communities with their families. His wife, Maryam, passed away approximately 10 years

ago after a long illness. Najeeb and one of his daughters served as her caregivers

during that time. Najeeb currently lives alone in the house he and his wife bought, in a

predominantly Pakistani American neighborhood.

Najeeb owned and ran a popular news stand in the city until 5 years ago, at which point

he retired and sold the business. Najeeb disclosed that he enjoyed operating the news

stand because he had “a sense of purpose” and “lots of people to talk to.” Since retiring,

much of his social life has been focused on his Muslim faith and his family, with worship

at the mosque and visits with his daughters and grandchildren. His routine has also

included daily walks around the neighborhood for fresh air and communion with others.

Recently, Najeeb has begun to experience health-related concerns which have

impacted his ability to walk and socialize with peers. Najeeb disclosed that religion is a

big part of his life; however, he now has limited ability to ambulate, so he cannot engage

in daily ritual prayer in the manner he is used to. He also cannot easily get to the

mosque, as he does not own a car, cannot walk, and public transportation is difficult for

him to navigate. According to Najeeb’s daughters, these mobility concerns have had a

major impact on his psychological functioning. Nasrin and Mira have recognized a

change in their father’s demeanor, describing him as “depressed” and “hopeless.” They

encouraged Najeeb to reach out to the local agency on aging for assistance.

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© 2021 Walden University, LLC

Week 10 Life Span Interview

Below are some questions to start the conversation with your interviewee. Do not

hesitate to add more questions as needed.

You are encouraged to reach out to a senior center, adult living facility, or nursing home

to locate an interviewee, or you may use an older friend or family member. When

interviewing an individual, please consider how to show respect to an individual of this

age within their cultural values.

Demographics

How do you prefer to be addressed?

What is your age?

Where were you born and raised?

How do you identify your ethnicity?

How do you identify your gender?

Childhood and Adolescence

How many siblings do you have?

How would you describe your childhood?

Who were your friends when you were growing up? Did you maintain those

friendships throughout life? Any reason why or why not?

What was your favorite thing to do for fun (movies, beach, etc.) growing up? In

your young/middle adult years?

Where did you go to school? What was school like for you as a child? What were

your best and worst subjects?

At what age did you leave home?

Young and Middle Adulthood

Did you marry? If so, at what age? If you have children, how many?

Were you employed? If so, where?

Where did you live?

Were you involved in the military in your young or middle adulthood? If so, how

did it mold you as a person?

Later Adulthood

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© 2021 Walden University, LLC

Have you retired? If so, from where? How would you rate your retirement

experience? (Did you return to work?)

Have you experienced any financial limitations in later adulthood?

Do you have any health issues? If so, what are they? Do these health issues

place limits on your functioning?

Has religion/spirituality been a part of your life? If so, how has your religious or

spiritual development changed in later adulthood?

What has been your experience with aging (physically, psychologically, socially,

environmentally)?

Do you have any challenges accessing healthcare?

How would you describe your social life, friendships, and social activities?

How do you see yourself today? (e.g., as an elder, senior, older adult?)

Have you had any experiences with services not being available to you as an

elder/senior/older adult?

Have you experienced age-related discrimination? Other types of discrimination?

Looking Back

What has been the happiest moment of your life?

Who is the person who has influenced your life the most?

Have you lost a loved one? If so, how has that loss affected your life?

What world events have had the most impact on you?

What are some of the most important lessons you have learned over the course

of your life?

As you look back over your life, do you see any “turning points”; that is, a key

event or experience that changed the course of your life or set you on a different

track?

What are you most proud of?

How would you like to be remembered?

Prayer and Faith: Spiritual Coping among
American Indian Women Cancer Survivors

Soonhee Roh, Catherine E. Burnette, and Yeon-Shim Lee

Although cancer disparities among American Indian (AI) women are alarming, research on
spiritual coping among this population is virtually nonexistent. This is particularly problem-
atic, given the importance of medical practitioners’ discussing the topic with cancer patients,
along with the centrality of spirituality to many AI patients. The purpose of this article was
to explore AI women cancer survivors’ spiritual coping with their experiences. Using a
community-based participatory research approach, this qualitative descriptive study included
a sample of 43 AI women cancer survivors (n = 14 breast cancer, n = 14 cervical cancer,
and n = 15 colon and other types of cancer). Qualitative content analysis revealed that most
participants (76 percent, n = 32) cited prayer as an important part of their cancer recovery
and coping strategies. Many participants expressed how prayer and spirituality connected them to
family, to faith communities, and to others. In addition to prayer, over a third (36 percent, n = 15)
of participants emphasized faith as a recovery and coping strategy. Results indicate that most
women drew great comfort, strength, hope, and relief from their spiritual and faith traditions,
indicating that religious and spiritual practices may be an important protective factor against the
strain of the cancer experience.

KEY WORDS: American Indian or Native American women; cancer; qualitative studies; spiritual
and religious coping

According to the U.S. Department of theInterior, Bureau of Indian Affairs (2018),the treaty agreements between the United
States and the 573 federal sovereign tribes include
a trust responsibility to provide for the health and
well-being of American Indian and Alaska Native
(AI/AN) people (U.S. Commission on Civil Rights,
2004). Yet, AI/AN people experience prevalent
health disparities as compared with the general U.S.
population (U.S. Commission on Civil Rights,
2004). Cancer, the leading cause of death among
AI/AN women, is experienced at 1.6 times the
rate of white Americans (Espey et al., 2014).

Cancer incidence and death rates vary by tribes,
cancer types, regions, and gender (Plescia, Henley,
Pate, Underwood, & Rhodes, 2014). For example,
lung cancer rates continue to increase for AI/AN
women while decreasing for their male counterparts
(Plescia et al., 2014). Breast cancer death rates are
lower for AI/AN women than for white women,
but there is variation by age group and region.
Moreover AI/AN women did not experience a
decline in breast cancer death rates as white women
did (White, Richardson, Li, Ekwueme, & Kaur,
2014). For both kidney and colorectal cancers,

incidence rates were higher for AI/AN people; AI/
AN women, in particular, experienced higher inci-
dence and death rates than both AI/AN men and
white women (Perdue, Haverkamp, Perkins, Daley,
& Provost, 2014). Cancer rates and related factors
vary by gender, making it important to examine AI
women’s cancer experiences separately.

A literature review indicates that research on
AI/AN women cancer survivors’ spiritual coping is
virtually nonexistent, which impairs the ability of
social work practitioners to adequately understand
and incorporate information related to spiritual
coping into practice. This absence is also problem-
atic given the importance of spirituality to many
AI/AN people (Burhansstipanov & Hollow, 2001)
and because spirituality can be an important pro-
tective factor related to the quality of life among
cancer patients (Vallurupalli et al., 2012). Indeed,
spiritual coping has been found to be highly rele-
vant for cancer treatment and care (Burhansstipa-
nov & Hollow, 2001; Kalish, 2012).

SPIRITUAL COPING AMONG AI/AN PATIENTS
The context of cancer and spiritual coping among
AI/AN women is situated in a broader context of

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historical oppression (Burnette & Figley, 2017).
Historical oppression includes the chronic, impactful,
and intergenerational experiences of oppression
that AI/AN people have experienced throughout
colonization and into the present that over time
may be introduced, normalized, and internalized
into peoples’ daily lives (Burnette & Figley, 2017).
The concept is inclusive of historical trauma, which
describes the massive and chronic trauma imposed
on a group, such as land dispossession, early death,
forced removal and relocation, environmental
injustice, assimilative abusive boarding schools,
and the prohibition of AI/AN spiritual practices
(Evans-Campbell, 2008; Harper & Entrekin, 2006).
Historical oppression focuses on both historical and
contemporary forms of oppression (that is, proxi-
mal stressors), which can exacerbate and perpetuate
oppression (that is, stress, poverty, and health
disparities).

Religious and spiritual suppression have been
insidious forms of historical oppression that have
affected AI/AN people, such as the Indian Reli-
gious Crimes Code of 1883 (Irwin, 1997). This
law prohibited AI/AN ceremonial activity under
the penalty of imprisonment (for a history of AI
religious suppression and resistance, see Irwin,
1997). The multitude of legal precedents outlaw-
ing AI/AN religious and spiritual practices has
legitimized non-AI/AN spiritual traditions while
delegitimizing AI/AN spiritual traditions (Irwin,
1997). This marginalization is perpetuated in the
health care arena, where the centrality of AI/AN
spiritual practices tend to be ignored and deterred
by health care workers (Shelley et al., 2009).

Despite this suppression, spirituality and AI/AN
healing practices have been found to have profound
importance and meaning for cancer survivors (Struthers
& Eschiti, 2004). Despite heterogeneity across tribes’
spiritual practices, some important concepts that
tend to be true across tribes are holistic conceptua-
lizations of health and wellness that focus on the
balance and harmony across environmental, physi-
cal, mental, and spiritual dimensions of health (See
Portman & Garrett, 2006 for more detail on AI/
AN spiritual practices). AI traditional beliefs may
include the following beliefs: (a) one sacred power,
known as Creator or Great Spirit, among other
names, who may not necessarily be one gender
and may have spirit helpers; (b) plants, animals, and
humans are part of the spirit world that never dies,
and this spirit world exists parallel to and interacts

with the physical world; (c) mind, body, and spirit
are interconnected, both in health and in sickness;
(d) wellness is harmony across the mind, body, and
spirit, as is disharmony or “unwellness”; (e) unwell-
ness may be caused by a violation of the sacred or
natural law of creation (for example, participating in
a ceremony while under the influence of drugs or
alcohol); and (f) all are responsible for their own
wellness through attunement to others, the envi-
ronment, and the universe (Portman & Garrett,
2006).

Sweat lodge ceremonies, spiritual healing, and
herbal remedies are some of the more commonly
reported healing practices (Marbella, Harris, Diehr,
Ignace, & Ignace, 1998). Ceremonies can serve vari-
ous functions including giving thanks, acknowledg-
ing rites of passage, and connecting communities
(Portman & Garrett, 2006). Ceremonies include the
following: (a) the sweat lodge ceremony, which is a
purification ceremony; (b) the vision quest, which is
a healing ritual requiring an individual to withdraw
from daily activities to spiritually focus and self-
reflect; (c) smudging, or burning special herbs as a
form of cleansing and purification; (d) the pipe cere-
mony, which is thought to connect the physical and
spiritual realms and turn prayers into smoke; (e) the
Sundance, which is a complex ceremony that may
involve fasting, receiving visions, and receiving treat-
ments; and (f) the Blessing Way, which may contain
songs and prayers to restore harmony to individuals,
families, clans, and communities (Portman & Garrett,
2006).

AI/AN spiritual and health practices are com-
monly used among AI/AN people, with 70 per-
cent of an urban AI/AN sample reporting that
they use such practices often (Buchwald, Beals, &
Manson, 2000). Another study reported that 38
percent of AI/AN patients used AI/AN healers,
with this rate being higher for AI/AN women and
older patients (in contrast to men or younger
patients) (Marbella et al., 1998). Even among
AI/AN participants who did not report using hea-
lers, 86 percent expressed an openness to their use in
the future (Marbella et al., 1998). Although patients
generally want health practitioners to talk about spiri-
tuality and alternative or complimentary medicine
(Best, Butow, & Olver, 2015), research with a sub-
sample of AI participants revealed barriers to such
open discussions, including the clinician’s lack of
knowledge and receptivity to initiating such con-
versations (Shelley et al., 2009).

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If spirituality is germane to AI/AN people and
social work practice and cancer care, it is important
for social work practitioners to facilitate an open dis-
cussion about the topic and gain some knowledge
about AI spiritual coping. This information is impor-
tant for cancer patients’ health care experiences.
Therefore, the purpose of this article was to explore
AI women cancer survivors’ spiritual coping with
their experiences, particularly their description of
their experiences of prayer and faith.

METHOD
Research Design
We used a community-based participatory research
approach, with a community advisory board (CAB)
made up of leaders in the AI community, along
with health care professionals working in two AI com-
munities. The responsibilities of the CAB members
were to (a) identify the community needs relevant
to cancer survivors; (b) assist with recruiting and
dissemination; and (c) enhance community and
research engagement. We used a qualitative descrip-
tive study design, a naturalistic and inductive inquiry
that provides a rich account of experiences in easily
accessible language (Sullivan-Bolyai, Bova, & Harper,
2005), to investigate AI women cancer survivors’
experiences as they related to familial social sup-
port. Our overarching research question was: “What
are AI women cancer survivors’ spiritual coping prac-
tices?” Qualitative description has been found to be
especially useful in working with populations that
tend to be marginalized to understand culturally
specific phenomena, as it prioritizes the voices of par-
ticipants themselves rather than the highly abstracted
interpretation of researchers (Sullivan-Bolyai et al.,
2005). Because highly abstracted interpretations are
not focal, the direct suggestions of participants results
in practical knowledge with broad applicability, such
as what roles family supports play in AI women’s
cancer experiences (Sullivan-Bolyai et al., 2005).

Setting and Sample
This research was conducted in collaboration with
two community hospitals in the Northern Plains
region, in the state of South Dakota: (1) the Avera
Medical Group Gynecologic Oncology in Sioux
Falls and (2) the John T. Vucurevich Cancer Care
Institute, Rapid City Regional Hospital, in Rapid
City. These sites were chosen as the primary medical
institutions serving AI women in the eastern regions
and western regions of South Dakota, respectively.

The sample was composed of 43 AI women
cancer survivors (n = 14 breast cancer, n = 14 cer-
vical cancer, and n = 15 colon and other types of
cancer). We were inclusive of cancer types to assess
the underlying spiritual coping practices that
were present across types. We used purposeful
sampling, determining who was most capable of
adequately addressing research questions (that is,
AI women cancer survivors) and when the data
reaches saturation (that is, when redundancy, or no
new information is gleaned from results) (Sandelows-
ki, 1995). Inclusion criteria for participants were (a)
having a personal history of any type of cancer in the
previous 10 years; (b) completion of cancer treatment
without signs or symptoms of recurrence; (c) being
female; (d) being 18 years or older; (e) living in South
Dakota; and (f) being AI.

Participant ages ranged from 32 to 77 years (M =
56.33, SD = 12.07). Regarding educational attain-
ment, 97.7 percent of participants held a high school
degree or GED. Regarding monthly household
income, almost half (49 percent) of participants
reported less than $1,499. Although 32.5 percent
of participants self-reported poor or fair health, 67.5
percent reported their health as good or excellent.
Participant cancer types included breast (n = 14, 32.6
percent); cervical (n = 14, 32.6 percent); colon (n = 5,
11.6 percent); lung (n = 2, 4.7 percent); non-Hodg-
kin’s lymphoma (n = 2, 4.7 percent); and others
(n = 6, 13.9 percent). Most respondents (n = 39,
90.7 percent) indicated membership to a religious
affiliation, and 93 percent had medical insurance.
The average time with cancer was approximately
two and a half years (SD = 2.19).

Data Collection
The approvals of the following institutional review
boards were secured before data collection began:
(a) University of South Dakota, (b) Avera McKen-
nan Hospital, (c) Rapid City Regional Health, and
(d) Sanford Research Center. Participants com-
pleted voluntarily signed consent prior to study
enrollment. The lead author and two extensively
trained and experienced research assistants with
backgrounds with AI populations and cancer survi-
vors conducted the interviews. Recruitment efforts
included mailing fliers to cancer survivors at the
two hospitals, posting fliers at community agencies,
newspaper and public radio announcements, and
word-of-mouth at local agencies and churches.
A total of 46 potential participants responded

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with interest, and the three respondents who had more
than 10 years of cancer history were excluded; the final
sample was 43. Data were collected where participants
preferred (for example, participants’ homes, a private
conference room at a hospital, community church, or
the lead author’s office) from June of 2014 to February
of 2015.

The semistructured qualitative interview guide
was developed in collaboration with CAB. Guides
were developed according to the research questions
and community research needs identified by CAB,
who reviewed the interview guide, paying attention
to the language used and how culturally appropriate
each question was, ensuring cultural sensitivity for
AI women cancer survivors. Examples of interview
questions included, “Do you have spirituality that
has helped you cope with your cancer? Is there any-
thing in your beliefs that helps you cope with can-
cer?” The audio-recorded interviews, transcribed
verbatim by graduate students, ranged from 30 to
120 minutes, with participants being compensated
$50 for their time, along with a gift card to cover
travel and participation expenses. Transcribed inter-
views were entered into NVivo data analysis soft-
ware (QSR International, 2015).

Data Analysis
Qualitative content analysis, which is the analysis of
choice for qualitative descriptive studies (Milne &
Oberele, 2005; Sandelowski, 2000; Sullivan-Bolyai
et al., 2005), enabled inductive themes to arise from
data directly (Milne & Oberele, 2005). Data anal-
ysis involved the following steps: (a) researchers
becoming immersed in data through listening to
audio transcriptions and reading interview transcripts
numerous times to gain a holistic understanding of
data; (b) coding each line of the data adding notes to
identify salient concepts; (c) identification of 430 pre-
liminary meaning units, or themes, that were sorted
into broader themes with respective subthemes; (d)
coauthors engaged in dialogue about themes and
subthemes, identifying whether significant distinc-
tions were present with respect to cancer types (no
distinctions were identified); (e) broad themes were
used to create meaningful clusters of themes with de-
finitions for clusters; and (f) clusters were presented
to participants with respective quotes through mem-
ber checks, identifying whether interpretations were
on-target with participants’ intentions. Authors
contacted all participants up to three times for
member checking. Over half (n = 23, 53.5 percent)

responded, with close to half (n = 21, 46.5 per-
cent) having phones that were disconnected, and
thus being unreachable. Participants requested no
changes in the data or interpretations.

Strategies for Rigor
We used Milne and Oberele’s (2005) strategies for
rigor specific to qualitative descriptive studies (Milne
& Oberele, 2005), which ensured (a) authenticity to
the purpose of the research; (b) credibility, or trust-
worthiness, of results; and (c) criticality, or intentional
decision-making processes. These strategies were
incorporated through use of a semistructured and
flexible interview guide (ensuring that participants
were free to speak), making sure participants’ voices
were heard by probing for clarity. We gained an
accurate understanding of participants’ perceptions
by conducting member checks, and maintaining
inductive analysis, so that coding emerged from the
data through conventional content analysis. We also
promoted authenticity by examining potential bias
and engaged in peer review across coauthors, ensur-
ing study integrity (Milne & Oberele, 2005). Partici-
pants were given anonymous identification numbers
for reporting purposes, demonstrating that quotes are
representative across the continuum of participants.

RESULTS
Results revealed that most participants (76 percent,
n = 32) cited prayer as an important part of their
cancer recovery and coping experiences. Prayer was
spoken about as an indispensable coping tool by the
majority of participants. Participant 3 stated, “I pray
all the time. Every morning, every night, in
between if I think about it, whenever I have a
chance.” Prayer tended to provide meaning
through the adversity of cancer experiences and
connect cancer survivors with family and com-
munity members, whereas faith tended to pro-
vide hope and strength throughout the cancer
experience.

Providing Meaning through Adversity
Participant 40 spoke about how her faith gave her
cancer journey meaning, stating,

You don’t give up just because you have it,
because, like my mother used to tell me all the
time . . . “When you get cancer or something
like that, He [God] puts these obstacles in front
of us.”

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She added, “Each time we overcome . . . we
become stronger people.” Similarly, participant 28
felt, “In the long run, you have to pull yourself
together and understand that there is . . . there is a
path for you, this is where God wants you to be.”
Participant 42 remarked,

Faith helped really a lot because I believe that
all things happen for a reason. God puts us in a
situation for reasons. We don’t know . . . and I
told my kids that, we don’t know why things
happen to us, but we just have to have faith
that it is there for a reason, and it will be
revealed to us or it may not be revealed to
us, and so this is just one of those things that
we just have to live through.

Participant 8 added, “I just have a lot of faith and I do.
It’s supportive. It gives you strength. It helps you.”

Some participants exercised spiritual coping in
faith communities, where they experienced much
support throughout their cancer experience. When
asked about her spiritual coping, Participant 30
talked about her Catholic faith community, stat-
ing, “I guess the church . . . a lot of times, uh, people,
um, find out or hear or know that you’re ill and they
pray for you, and keep you in your prayers, just like
we always do when someone’s sick.” Likewise, Par-
ticipant 32 explained,

Yes, I am a Christian, and I believe in God and I
feel like God has helped me through the breast
cancer diagnosis, the treatments. I feel like with-
out God I couldn’t have gotten through all of the
stuff that I’ve been through, and my family and I
would go to church every Wednesday and twice
on Sunday, and I think for me I was kind of taken
from our, from the Lakota culture, from the cere-
monies, and I love the smell of sage. A lot of our
people, it’s called smudging. You just get the sage
and you burn it and then you just kind of use it
for incense. I’ve done that. I’ve used that. The
cedar. We use cedar, but I just got cedar from
trees in our yard and burned some of that.

Spirituality and prayer helped many of the cancer
survivors we spoke with to confront their own
mortality. Participant 3 stated,

I didn’t want to face death and dying so I had
to do the let go and let God, you know,

spirituality-type thinking and—until I got my
positive. All I can do is one step in front of the
other, one at a time, one day at a time.

Prayer Fostering Connection to Others
Many participants expressed how prayer and spiri-
tuality connected them to family, faith communi-
ties, and others. Participant 37 talked about the
support from her family, and how much it meant
that they were doing tribal ceremonies for her:

It really helped my prayer, with the healing
ceremonies and knowing that I had that type
of support from family that were doing the cer-
emonies for me; that I knew that I had that
support and the prayers were there for me, and
that helped me get through with the diagnosis
and just getting through the whole ordeal.

Similarly, Participant 31 shared how she and her
family’s spiritual practices also made a difference in
her cancer experience:

We’re praying. . . . Having relatives, my uncle
and my grandpa, pray a lot, and they go into
sweats. I myself haven’t been to a sweat, but just
doing what I’m told, or instructed, I should say,
by my grandfather and my uncle. And just stay-
ing positive and praying, and being focused.

Participant 18 stated,

It really helped my prayer, with the healing
ceremonies and knowing that I had that type
of support from family that were doing the cer-
emonies for me—that I knew that I had that
support and the prayers were there for me and
that helped me get through with the diagnosis
and just getting through the whole ordeal.

Participant 18 also experienced benefits from main-
taining connection to her tribal faith community,
stating,

Whenever I felt like the radiation burns or the
chemo, the nausea, and all of that [were too
much], I just asked for help and strength to deal
with this—to bear it. I think that’s what I . . .
did anyway. And I followed up and I went back
when they didn’t find any more of the cancer, I
did a thank-you ceremony, and then I asked

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again to continue to be with me, and just this
past weekend, I had another ceremony. And
kept them all updated, saying that things are
working well, you know, I’ve been asking for
help. I’ve been praying. Things are going well.

Some of this connection to others had to do with
helping others, taking participants out of themselves
and their own circumstances. When asked how her
spirituality and faith help her, Participant 18 replied,

Every morning I have my devotional time with
God, and then throughout the day I say prayers
and stuff, but if I’m feeling bad or something I’ll
just say a little prayer. I pray for everybody else
that I know. It makes me feel better.

Participant 19 noted,

I go ahead, and I do a lot of praying. And another
thing that I do. I go out and I help other people.
Since I’m retired, I go out and help other people.
I go and you know, like, I help other people, like
you challenge yourself to help someone that you
don’t even know to do something nice for them.

Faith and Hope Providing Relief and
Strength
In addition to prayer, over a third (36 percent, n =
15) of participants emphasized faith in their cancer
experiences. Participant 8 talked about her faith
and related hope:

Because I have strong faith. I have strong spiritual-
ity. . . . I believe in a higher power that—I pray a
lot and I just believe that I wanted to do this and I
knew it would work for me because I believe.

Many participants expressed a faith that healing
was possible through spiritual means. Participant
32 explained,

Yes, I believe that in my religion, which is Chris-
tian Pentecostal, I believe that we just need to go
to God and tell Him everything that is going on
in my life, and I believe that He is my healer.

She also stated it helped her cope with feeling ill:

A lot of times when I don’t feel good I listen to
music, and I have a lot of good Christian

music. A lot of times I’ll pray, and then I’ll lis-
ten to the music, and it helps me lift my spirits.

Faith that God answers prayers was an important
part of some survivors’ stories. Participant 8 relayed,

Yes. I feel like I can pray to God and ask Him,
you know, sometimes I get to hurting too bad,
and I ask Him to take away the pain. I believe
He does. I believe He answers my prayer,
yeah. So I believe in prayer. . . . It’s a strong, to
me it’s a strong force that really works.

Participant 16’s faith made all the difference in her
perspective on cancer, as she explained:

I just believe that when God speaks that He
means it, and I believe. I was told that every-
thing would be OK. I would go through this,
but in the end it wouldn’t be long. In other
words, OK. And that’s what I stood on.

Likewise, Participant 22 explained how prayer and
faith removed the burden of her cancer:

Whenever I pray, . . . I ask God to take it away
from me, and to help me, to guide me and give
me the direction I need in my life to cope with
it, or to cope with anything in general. And
then it’s like, you know, my stomach hurts so
bad, but you know, please take this pain away.
And then, if I really, really give it my all, then
He takes the burden away. Then I feel better.
Yeah. He takes it . . . it feels like there’s a big
old heavy weight on my shoulders, but when-
ever I meditate and give it to Him, then it’s
lifted. And then I don’t have to worry.

In a similar way, when asked how her higher
power or spirituality helped her, Participant 18
replied, “Turn everything over to Him,” which
made all the difference.

DISCUSSION
Results indicate that prayer and faith were integral
protective aspects of our respondents’ cancer experi-
ences, and women practiced both AI/AN (for
example, smudging, seeing spiritual healers) and
Judeo-Christian (for example, attending church)
spiritual traditions. Some women felt that their can-
cer experience was a challenge that promoted

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personal growth, and that there was a broader pur-
pose and meaning to the experience (that is, “all
things happen for a reason”). Although the reasons
for enduring cancer were not always clear, many
women felt assurance that it was part of their life
path. Most women were part of faith communities,
both Christian and tribal, and felt support when
members of this faith community prayed for them,
even if the women themselves did not partake in the
given activity. Indeed, prayer connected women
with others in an important way, buffering against
feelings of having to endure cancer alone.

AI women cancer survivors often felt they experi-
enced healing through spiritual practices and faith.
They believed that if they prayed, God or a higher
power would answer, providing hope and healing.
Women also focused on helping others, which tended
to broaden their perspective for the greater good and
lessen the burden of the cancer experience. Indeed,
many women talked about prayer and faith providing
relief or lifting the “heavy weight” and “taking the pain
away.” Thus, women tended to report great impor-
tance and relief from their prayer life and spiritual prac-
tices, indicating that this is a crucial component of the
cancer experience for many AI women.

Limitations
Given the dearth of research, more studies examining
spiritual coping practices among AI/AN cancer survi-
vors are needed. Results are self-report only, and this
study does not examine the efficacy of any specific
practices; conclusions on this regard are beyond the
scope of this inquiry. This qualitative study is not …

The Religiosity and Spiritual Beliefs and Practices
of Clinical Social Workers: A National Survey

Holly K. Oxhandler, Edward C. Polson, and W. Andrew Achenbaum

This article describes the religious and spiritual beliefs and practices among a national sample
of 426 licensed clinical social workers (LCSWs). Given the significant role LCSWs’ intrinsic
religiosity plays in whether or not they consider clients’ religion and spirituality (RS) as it re-
lates to practice, it is critical that the profession best understands current LCSWs’ religious
and spiritual beliefs, and in what ways these mirror or contrast those of the clients whom
they serve. Findings from this secondary analysis of a recent national survey suggest that
compared with the general U.S. population, fewer LCSWs self-identify as Protestant or
Catholic, fewer engage in frequent prayer, and fewer self-identify as religious. However,
more LCSWs engage in meditation and consider themselves to be spiritual. Although it ap-
pears that RS is an important area in both LCSWs’ and clients’ lives, the beliefs, practices,
and degree of importance with either differ. This article addresses implications for practice
and education, as identifying such differing views calls on the profession to strengthen its
training surrounding LCSWs’ self-awareness of their RS beliefs and recognizing that their
clients may not hold similar beliefs or engage in similar practices.

KEY WORDS: beliefs and practices; clinical social work; religion; spirituality; therapists

Licensed clinical social workers (LCSWs) areoften aware that one aspect of their clients’culture that occasionally emerges in treatment
is the way in which their religious or spiritual (RS) be-
liefs are interwoven into presenting clinical issues.
Not always having been trained on how to assess or
integrate clients’ beliefs, LCSWs may consider the use
of self, not to impose one’s spiritual beliefs, but to be
mindful of the role it has in their lives while honoring
its role in clients’ lives. Yet, as LCSWs inquire about
clients’ beliefs, they may realize that many are very
different from theirs or their colleagues’ RS beliefs.

Although definitions abound, religion is “a system of
beliefs and practices observed by a community, sup-
ported by rituals that acknowledge, worship, commu-
nicate with, or approach the Sacred, the Divine, God
(in Western cultures), or Ultimate Truth, Reality, or
nirvana (in Eastern cultures),” relying on teachings and
scriptures and offering a moral code of conduct
(Koenig, 2008, p. 11). As for spirituality, it may be
defined as “the personal quest for understanding an-
swers to ultimate questions about life, about meaning,
and about relationship to the sacred or transcendent,
which may (or may not) lead to or arise from the
development of religious rituals and formation of
community” (Koenig, McCullough, & Larson, 2001,
p. 18). Furthermore, Allport and Ross (1967) have

described two poles of religiosity, intrinsic and extrin-
sic, where “the extrinsically motivated person uses his
religion, whereas the intrinsically motivated lives his
religion” (p. 434). For the extrinsically religious, their
religion exists for the individual’s needs (for example,
social support, status, self-justification, or some form of
security), whereas the intrinsically religious are moti-
vated by their religion with a desire to fully internal-
ize, embrace, and live out their beliefs (Allport &
Ross, 1967).

Recently, Pew Research Center (2015) reported
that 77 percent of Americans consider religion to be
at least somewhat important in their lives, and a recent
increase in spiritual well-being. Furthermore, most
Americans consider themselves to be at least moder-
ately religious (58.3 percent) and spiritual (66.4 per-
cent), revealing an overlap between the two groups;
however, many consider themselves more spiritual
and less religious or more religious and less spiritual
(Hodge, 2015).

RS IN SOCIAL WORK
Even though RS is considered important in many
Americans’ lives (Hodge, 2015; Pew Research Cen-
ter, 2015) and may be interwoven in clinical issues
either as a source of strength or angst (Pargament,
2007), social work has not always attended to RS in

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education or practice (Canda & Furman, 2010;
Oxhandler & Pargament, 2014; Oxhandler, Parrish,
Torres, & Achenbaum, 2015; Sheridan, 2009;
Sheridan, Bullis, Adcock, Berlin, & Miller, 1992).
With a growing body of research showing that RS
integration has the potential of improving health and
mental health outcomes (Koenig, King, & Carson,
2012; Koenig et al., 2001), the evidence-based prac-
tice (EBP) process serves as one method to support the
integration of clients’ RS in treatment, if the client de-
sires (Oxhandler & Pargament, 2014). It is interesting
to note that not only are clients expressing a prefer-
ence for their RS—a client value and important aspect
within the EBP process (Sackett, Straus, Richardson,
Rosenberg, & Haynes, 2000)—to be included in
treatment (Lietz & Hodge, 2013; Stanley et al., 2011;
Tepper, Rogers, Coleman, & Maloney, 2001), but
clients also express preference regarding therapists’ RS.
Indeed, highly religious prospective clients have indi-
cated a preference to see therapists affiliated with a
major religion as compared with atheism (Gregory,
Pomerantz, Pettibone, & Segrist, 2008).

Although it is imperative for social workers to be
equipped to assess and understand the role clients’ RS
plays in health and mental health treatment, it is also
important to consider the role social workers’ RS has
in their daily life, extending into their practice. Social
workers’ RS may be intrinsically interwoven into
their work, informing their practice as their practice
informs their RS beliefs (Singletary, 2005), and in
many cases, their decision to become social workers
may have been heavily influenced by their RS beliefs
(Garland, 2016). However, social workers must cau-
tiously consider the role their RS has in practice,
ensuring that their beliefs are never imposed on a vul-
nerable client. Doing so would violate the National
Association of Social Workers’ (NASW) Code of Ethics
(2015), especially under code 1.06 as it relates to not
exploiting or taking advantage of clients to further
any RS interests. RS is also woven into our ethical
responsibilities to clients regarding cultural compe-
tency and social diversity (code 1.05), respecting col-
leagues’ diversity (code 2.01), not discriminating
(code 4.02), and the broader society regarding social
and political action (code 6.04) (NASW, 2015). Just
as social workers are trained to practice self-awareness
by exploring how their values and biases can influence
their practice, social workers’ RS beliefs can also influ-
ence their practice behaviors and views.

In fact, a social worker’s RS beliefs and practices
are predictive of whether clients’ RS is assessed and

integrated in treatment (Canda & Furman, 2010;
Kvarfordt & Sheridan, 2009; Larsen, 2011; Oxhandler
et al., 2015). Not only does intrinsic religiosity pre-
dict LCSWs’ views and behaviors toward integrat-
ing clients’ RS, but also LCSWs’ self-efficacy and
perceived feasibility (Oxhandler et al., 2015). Recently,
LCSWs’ intrinsic religiosity was identified as the top
predictor (β = .44) of their orientation toward integrat-
ing clients’ RS—including attitudes, self-efficacy, per-
ceived feasibility, and behaviors—followed by prior
training in this area (β = .32) (Oxhandler et al., 2015).
Among the same sample of LCSWs, 329 responded
to two items on what helps or prevents the assessment
and integration of clients’ RS in practice. Of the 319
who responded to what helps them integrate RS,
personal religiosity emerged as an overarching theme,
with 44 percent mentioning their RS journey, RS
belief system, RS practices, or RS curiosity (Oxhandler
& Giardina, 2017). This critical role of the practi-
tioners’ RS—primarily, their intrinsic religiosity—in
the process of considering clients’ RS is not limited to
social work, as Namaste Theory was developed based
on similar quantitative findings across helping profes-
sions (Oxhandler, 2017). Therefore, LCSWs’ RS
beliefs cannot be ignored as part of the treatment
process, particularly as they influence the consider-
ation of clients’ RS beliefs, which have the poten-
tial of affecting client outcomes.

PREVIOUS STUDIES OF SOCIAL WORKERS’ RS
BELIEFS
Given the significant role that social workers’ RS plays
in whether this area of clients’ lives is considered, cli-
ents’ expressed preferences regarding social workers’
RS and the importance of assessing for and integrating
clients’ RS in practice, it is critical for the profession to
understand current LCSWs’ RS beliefs and practices
and how they compare with those of the general U.S.
population. Previous studies have gathered minimal
information about practitioners’ RS beliefs, and few
used items from national surveys of Americans with
the intention to compare results. In an effort to paint a
broad picture of social workers’ RS, we have included
a few studies’ findings.

In 2004, Sheridan surveyed 204 LCSWs in a mid-
Atlantic state and found that a majority of respondents
were Christian (57 percent), followed by Buddhist
(18 percent), existentialist (14 percent), Jewish (12
percent), and agnostic (8 percent); 32 percent selected
multiple affiliations. Among various ideological posi-
tions, 46 percent reported a “belief in a personal God

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whose purposes ultimately will be worked out in
human history” (Sheridan, 2004, p. 12), with 29
percent reporting a “belief in a transcendent or divine
dimension found in all manifestations of nature”
(p. 12). Regarding current RS practices, LCSWs re-
ported regular service attendance (38 percent weekly,
21 percent monthly), over half reported some daily
RS practice (such as praying, reading scriptural texts,
or meditating), with an additional 28 percent using
such practices several times a week. Finally, 25 percent
reported active participation and high involvement in
an organized religious or spiritual group, and another
26 percent engaged in regular participation and some
involvement.

Much like Sheridan’s (2004) findings, a majority
of Murdock’s (2005) national sample of geronto-
logical social workers (N = 299) self-identified as
Christian (65 percent), followed by Jewish (19 per-
cent). Murdock’s (2005) questions on religiosity
were slightly different than Sheridan’s, and fewer
respondents (28 percent) reported weekly commu-
nal spiritual activity or daily private spiritual activ-
ity (39 percent). In these two studies, there is a
similarity with affiliation activity level, with 21
percent reporting high or active, and 38 percent
reporting regular or some activity.

Likewise, Larsen (2011) conducted a national sur-
vey of NASW members’ (N = 225) personal spiritual
beliefs, how those beliefs affect their attitudes regard-
ing RS in social work practice, and the use of RS in-
terventions in practice. Among the respondents, 58
percent were affiliated with a Christian denomination,
45 percent reported attending weekly religious ser-
vices (a higher percentage than the previous studies),
and 82 percent reported believing in God or a higher
power. Unlike previous researchers, Larsen asked
about the degree to which respondents perceived
themselves as religious or spiritual, with 59 percent
reportedly religious and 94 percent spiritual. She also
asked about their intrinsic religiosity using the Intrinsic
Spirituality Scale (Hodge, 2003) and found that her
sample had a slightly higher degree of intrinsic religi-
osity as compared with the instrument’s average score.

Finally, Canda and Furman (1999, 2010) conducted
two national surveys of NASW members’ use of spiri-
tually derived interventions and their personal RS.
The 2008 sample (N = 1,804) had 57 percent self-
identify as Christian (58 percent in 1997), 20 percent
self-identify as Jewish (6 percent in 1997), and 14 per-
cent nonreligious. Canda and Furman compared these
results with data from the Association of Religion

Data Archives that suggested 82 percent of Americans
are Christian—a large discrepancy from the social
workers. As Canda and Furman (2010) noted, many
studies echo these findings, with social work having
“fewer Christians, more Jews, more other religious,
and more nonreligious” people (p. 118) as compared
with the general population.

Although these studies help us begin to under-
stand social workers’ RS, they are limited in gener-
alizability. Furthermore, items used in these surveys
of social workers are not used in surveys of U.S.
adults, preventing the ability to make side-by-side
comparisons. Only one study to date has attempted
to compare social workers with U.S. adults using 10
items from the General Social Survey (GSS) and a
demographic item to identify whether the respon-
dent is a social worker (N = 145, of which 53 held
graduate degrees) (Hodge, 2002). Although this
study used a relatively small sample, Hodge (2002)
noted it included BSW and MSW-level practi-
tioners that closely matched NASW’s demo-
graphics. His findings indicated a large shift in social
workers’ belief system from childhood to adult-
hood, with MSW-level practitioners less likely to
believe in a life after death or that the Bible repre-
sents the actual word of God as compared with the
beliefs of U.S. adults. Social workers were more
likely to self-identify as Jewish or unaffiliated and as
being part of a more liberal denomination as com-
pared with the general U.S. adult population. It is
interesting to note that there was little difference
between social workers and U.S. adults with regard to
frequency of religious service attendance or strength
of religious affiliation. Hodge (2002) concluded that
although similarities exist between social workers and
U.S. adults regarding religious service attendance, the
two groups’ beliefs are different. He posited that this
difference might result in secular social workers not
valuing or recognizing RS strengths or struggles,
which could affect the delivery of services. However,
this study is 14 years old, had a small sample pooled
over 26 years (1972–1998), and did not explore other
facets of RS that may be important to understanding
the similarities and differences among social workers’
and clients’ RS.

CURRENT STUDY
To date, no study has simultaneously examined a
national sample of LCSWs’ intrinsic religiosity and
frequency of religious activities, extent to which
they are religious or spiritual, or their RS affiliation

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and practice behaviors and do a side-by-side compari-
son with U.S. adults. Our research questions were: (a)
What are LCSWs’ degrees of intrinsic religiosity and
frequency of religious activities? (b) How religious
and spiritual do LCSWs consider themselves, and
how does this compare with the U.S. population?
(c) What RS practices do LCSWs most frequently
engage in, and how do they compare with those of
the U.S. population? and (d) What religious affilia-
tions do LCSWs identify with, and how do their af-
filiations compare with those of the U.S. population?

METHOD
To address our questions, we analyzed data gath-
ered from a 2013 national survey of LCSWs. The
original study consisted of 984 social workers ran-
domly selected from the National Social Work
Finder on HelpPro who were contacted by e-mail
and mail to participate in an online survey; 482 (49
percent) responded (Oxhandler et al., 2015). For
this study, the analysis was restricted to the 426
LCSWs who responded to RS items.

The online survey contained the Religious/
Spiritually Integrated Practice Assessment Scale
(Oxhandler & Parrish, 2016) and a variety of demo-
graphic items. RS-specific items included one item
to assess religious preference, two from the GSS mea-
suring the extent one is religious or spiritual (Smith,
Marsden, Hout, & Kim, 2014), one item developed
for this survey assessing frequently practiced RS be-
haviors, and the Duke University Religion Index
(DUREL) (Koenig & Büssing, 2010). The DUREL
includes two items to measure religious activities
(organized and nonorganized religious activity) and
three items to measure intrinsic religiosity. The intrin-
sic religiosity subscale was based on items from Hoge’s
(1972) Intrinsic Religiosity Motivation Scale, built on
Allport and Ross’s (1967) work.

To compare LCSWs’ RS beliefs and practices with
those of the general U.S. population, we assessed
items drawn from the GSS and the Baylor Religion
Survey (BRS). The GSS is a nationally representative
survey of noninstitutionalized adults conducted every
two years by the National Opinion Research Center
(NORC) at the University of Chicago (Smith et al.,
2014). The BRS is a repeated, cross-sectional national
survey of U.S. adults conducted by researchers at
Baylor University and the Gallup Organization
(Dougherty et al., 2011). For our analyses, we used
data from the 2010 and 2014 waves of the BRS
and the 2014 wave of GSS. The GSS data were

weighted using WTSSALL, as advised by NORC
(Smith et al., 2014). SPSS 23 was used to run descrip-
tive analyses on all variables. In addition to describing
LCSWs’ religiosity and making descriptive compari-
sons with similar items in the GSS or BRS, chi-square
analyses compared the LCSWs’ and GSS participants’
categorical responses regarding the extent to which
they consider themselves religious or spiritual (Smith
et al., 2014), as well as their religious affiliations across
the United States and within each region (Northeast,
South, Midwest, and West).

RESULTS
Not surprisingly, all LCSWs reportedly hold a mas-
ter’s degree, with 9.3 percent also holding a doctoral
degree. Respondents’ average age was 56 years, and
they were mostly female (78.7 percent). A majority
identified as white or Caucasian (86.9 percent), with
fewer identifying as Hispanic or Latino (4.2 percent),
African American or black (3.8 percent), Asian or
Pacific Islander (2.0 percent), or as some other racial
or ethnic group (3.1 percent). Our sample includes
LCSWs systematically drawn from all U.S. regions,
with 39.6 percent living in the Northeast, 24.2 per-
cent in the South, 20.4 percent in the West, and 15.9
percent in the Midwest.

LCSWs’ Intrinsic Religiosity and Religious
Activities
Responses to the DUREL items are presented in
Table 1. Among the first three items, measuring intrin-
sic religiosity, over two-thirds (67.1 percent) reportedly
experience the presence of the divine in their lives, and
more than half (54 percent) indicated their religious be-
liefs lie behind their whole approach to life. Just under
half of LCSWs (48.2 percent) reportedly try to carry
religion over into all other dealings in their life.

Many LCSWs also regularly participate in religious
activities such as community and private religious activ-
ities, and at a slightly lower frequency than the general
population. Specifically, one-third of LCSWs reported
attending religious services at least a few times a month
(31.9 percent) compared with 38 percent of 2014 GSS
respondents. When asked how often they spend time
in private religious activities such as meditation or
prayer, more than half of LCSWs (57.3 percent) re-
ported engaging in such activities at least weekly.
Although other national surveys do not ask this specific
DUREL item, of 2014 GSS respondents, 74.3 percent
reported praying at least weekly (57.5 percent of which
pray daily). Although not a direct comparison, like

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religious service attendance, engagement in private reli-
gious activities occurs less frequently among LCSWs
than in the general population.

LCSWs’ Degree of Being Religious or
Spiritual
A significant majority of LCSWs (81.9 percent) re-
ported being at least moderately spiritual, whereas

only 35.1 percent are at least moderately religious,
and a pronounced contrast exists between those
who are very spiritual (44 percent) and very reli-
gious (8.8 percent). Furthermore, 38.4 percent of
LCSWs reported not being religious, versus only
6.1 percent who are not spiritual.

This pattern differs substantially from that of the
U.S. population. Drawing on both our survey and
the 2014 GSS data, Table 2 shows that U.S. adults are
more religious [χ2(3, N = 2,943) = 78.07, p < .001]
and less spiritual [χ2(3, N = 2,939) = 61.41, p < .001]
compared with LCSWs, with small effect sizes for
each. Over half of GSS respondents (54.2 percent)
consider themselves at least moderately religious (ver-
sus 35.1 percent of LCSWs), and 65.1 percent are at
least moderately spiritual (versus 81.9 percent of
LCSWs). Additional analyses reveal that the cor-
relation between measures of RS is higher for U.S.
adults in the GSS sample (0.56, p < .001) than for
LCSWs (0.33, p < .001), further suggesting that RS
may be more intertwined for the general population
than for LCSWs (see Hodge, 2015).

LCSWs’ RS Practices
LCSWs were provided a list of RS activities to select
any they practice frequently. Meditation (56.7 per-
cent), prayer (45.7 percent), and yoga or other physi-
cal practice (37.7 percent) were the most frequently
selected. Fewer reported regularly attending religious
services (31.6 percent), reading religious texts (25.1
percent), listening to RS music or radio (20.1 per-
cent), or attending small social gatherings devoted to
RS matters (19.0 percent). The least reported prac-
tices were watching RS television (8.7 percent),
worshiping outside of religious services (8.2 percent),
and other RS practices (16.4 percent).

Whereas few surveys have asked about the U.S.
population’s use of such RS activities, data from the
2014 GSS and 2010 and 2014 BRS allow limited
comparisons. In 2010, 24.8 percent of BRS respon-
dents reported meditating, which is much lower than
the rate reported by LCSWs in our survey. In 2014,
36.6 percent of BRS respondents read religious texts
at least monthly and 27.7 percent participated in reli-
gious education in the previous month. Finally, 74.3
percent of GSS respondents pray at least weekly.
These results suggest that LCSWs rely on many RS
activities less frequently than do U.S. adults, with the
exception of meditation.

Table 1: Intrinsic Religiosity and
Religious Activities among LCSWs

(DUREL Measures)

DUREL Item % n

Intrinsic religiosity
“In my life, I experience the presence of the Divine (i.e.,
God).” (n = 423)
Definitely true of me 38.3 162
Tends to be true 28.8 122
Unsure 13.0 55
Tends not to be true 8.0 34
Definitely not true for me 11.8 50

“My religious beliefs are what really lie behind my whole
approach to life.” (n = 424)
Definitely true of me 24.8 105
Tends to be true 29.2 124
Unsure 12.0 51
Tends not to be true 12.5 53
Definitely not true for me 21.5 91

“I try hard to carry my religion over into all other dealings
in life.” (n = 421)
Definitely true of me 15.9 67
Tends to be true 32.3 136
Unsure 14.0 59
Tends not to be true 12.4 52
Definitely not true for me 25.4 107

Religious activities
“How often do you attend religious services?” (n = 423)
More than once a week 3.3 14
Once a week 16.5 70
A few times a month 12.1 51
A few times a year 29.1 123
Once a year or less 17.3 73
Never 21.7 92

“How often do you spend time in private religious activities,
such as prayer, meditation, or Bible Study (or other
religious text)?” (n = 426)
More than once a day 8.9 38
Daily 26.1 111
Two or more times a week 17.8 76
Once a week 4.5 19
A few times a month 15.7 67
Rarely or never 27.0 115

Notes: LCSW = licensed clinical social worker; DUREL = Duke University Religion Index;
data from 426 LCSWs who responded to RS items in Oxhandler et al. (2015).

51Oxhandler, Polson, and Achenbaum / The Religiosity and Spiritual Beliefs and Practices of Clinical Social WorkersDownloaded from https://academic.oup.com/sw/article-abstract/63/1/47/4607904
by Adam Ellsworth, Adam Ellsworth
on 30 December 2017

LCSWs’ RS Affiliations
Table 3 reveals that LCSWs’ religious affiliation dif-
fers from that of the general population [χ2(4, N =
2,393) = 593.41, p < .001] in two important ways
and reports large effect sizes across regions. First,
LCSWs are about half as likely as GSS respondents to
identify with either of the two largest religious tradi-
tions in the United States—Protestantism and Cathol-
icism. Second, affiliation with non-Christian groups
is much higher for LCSWs (42.9 percent) than for
GSS respondents (5.5 percent), with 21.6 percent of
LCSWs self-identifying as Jewish. It is interesting to
note that the percentage of LCSWs indicating no reli-
gious preference (20 percent) corresponds well with
GSS respondents (20.7 percent).

Because patterns of RS affiliation vary across the
United States (Grammich et al., 2012), we examined
affiliation patterns across U.S. Census divisions. Table 3
indicates that regional patterns generally reflect the
national pattern, with LCSWs’ affiliations significantly
different from those of the U.S. population in each of
the regions: Northeast [χ2(4, N = 571) = 118.07, p <
.001], South [χ2(4, N = 1,014) = 192.3, p < .001],
Midwest [χ2(4, N = 628) = 85.4, p < .001], and West
[χ2(4, N = 719) = 155.61, p < .001]. In the Northeast
and West, Catholics seem to be particularly underrep-
resented among LCSWs, whereas in the South Protes-
tants are less represented. Alternatively, there are more
LCSWs who self-identify as Jewish, Buddhist, or other
across all four regions and the nation overall.

DISCUSSION
Many noteworthy findings emerged from this
study. First, although LCSWs’ RS differs from that
of the general population in several ways, our

findings reveal that many LCSWs are far from sec-
ular, view RS as important in their lives, experi-
ence the transcendent or the divine, and view RS
as intertwined with other areas of their lives, ex-
tending into their social work practice. In addition
to these intrinsic expressions of RS, many LCSWs
engage in RS activities, such as attending religious
services and prayer.

However, our findings indicate ways in which
LCSWs’ RS differs from that of the U.S. population.
First, LCSWs appear to distinguish between the two
aspects of RS more clearly than do U.S. adults, with
more LCSWs at least moderately spiritual (82 percent
versus 54 percent of Americans) and fewer religious
(35 percent versus 65 percent of Americans), whereas
many U.S. adults are both spiritual and religious or
view RS as intertwined. Although LCSWs report par-
ticipating in RS activities, they engage in more private
or individual religious activities (for example, medita-
tion, prayer, yoga), and fewer participate in activities
such as worship outside of a religious service, attending
small social gatherings on an RS matter (for example,
Bible studies), or reading religious texts. This finding
is not surprising, given the large presence of non-
Christian LCSWs in our sample; however, it suggests
that LCSWs should be aware of and seek training on
clients’ RS practices that differ from their own.
Finally, we found that LCSWs’ RS affiliation in the
United States, and across U.S. regions, differs from
that of the U.S. population, with LCSWs more likely
to identify with non-Christian traditions. The per-
centage of LCSWs who identify as Jewish is notewor-
thy and consistent with previous studies (Canda &
Furman, 2010; Hodge, 2002; Murdock, 2005). While
we recognize that some LCSWs may identify as

Table 2: Level of Spirituality and Religiosity among LCSWs and the General Population

Item

LCSW Survey GSS

χ2 p% n % n
“To what extent do you consider yourself a religious person?”
Very religious 8.8 37 16.8 423 78.07a <.001
Moderately religious 26.3 111 37.4 942
Slightly religious 26.5 112 25.4 641
Not religious 38.4 162 20.4 515

“To what extent do you consider yourself a spiritual person?”
Very spiritual 44.0 187 28.2 709 61.41a <.001
Moderately spiritual 37.9 161 36.9 928
Slightly spiritual 12 51 23.7 597
Not spiritual 6.1 26 11.1 280

Notes: LCSW = licensed clinical social worker; GSS = General Social Survey. Data from 2013 LCSW survey and 2014 GSS.
aThe effect sizes for both chi-square analyses were calculated using Cramér’s V and were considered small (extent religious, V = .16; …

Discussion – Week 9

Top of Form

Discussion: Spiritual Development

Do you identify as a spiritual or religious person? How might your spiritual identity influence your social work practice—both for those clients who have a similar worldview and those who do not?

Spirituality, which may or may not include involvement with an established religion, contributes to human diversity and influences behavior. Sensitivity to and respect for a client’s spiritual dimension reflects your appreciation of diversity and the code of ethics. As you consider the potential impact of your clients’ spirituality on their perspectives and behavior, you must also consider how your own spirituality might influence interactions with a client.

For this Discussion, you examine the potential effect of your spiritual views on social work practice and share strategies for being spiritually aware.

To Prepare:

· Review the Learning Resources on spiritual development.

· Reflect on your own spiritual or religious beliefs and how they may influence your social work practice.

By Day 01/26/20211
Post a Discussion in which you explain how considerations about clients’ worldviews, including their spirituality or religious convictions (Christian), might affect your interactions with them. Provide at least two specific examples. In addition, explain one way your own spirituality or religious convictions might support your work with a client, and one barrier it might present. Finally, share one strategy for applying an awareness of spirituality to social work practice in general. Be sure to refer to the NASW Code of Ethics in your response.

Bottom of Form

Required Readings

Zastrow, C. H., Kirst-Ashman, K. K., & Hessenauer, S. L. (2019). Understanding human behavior and the social environment (11th ed.). Cengage Learning.

· Chapter 3, “Spotlight on Diversity: Relate Human Diversity to Psychological Theories” (pp. 112–114)

· Chapter 7, Sections “Review Fowler’s Theory of Faith Development,” “Critical Thinking: Evaluation of Fowler’s Theory,” and “Social Work Practice and Empowerment Through Spiritual Development” (pp. 339–342)

· Chapter 15, “Highlight 15.2: “Celebration of Life Funerals” (pp. 694–696)

Limb, G. E., Hodge, D. R., Ward, K., Ferrell, A., & Alboroto, R. (2018). Developing cultural competence with LDS clients: Utilizing spiritual genograms in social work practice. Journal of Religion and Spirituality in Social Work, 37(2), 166–181. https://doi.org/10.1080/15426432.2018.1448033

Oxhandler, H. K., Polson, E. C., & Achenbaum, W. A. (2018). The religiosity and spiritual beliefs and practices of clinical social workers: A national survey. Social Work, 63(1), 47–56. https://doi.org/10.1093/SW/SWX055

Pomeroy, E. C., Hai, A. H., & Cole, A. H., Jr. (2021). Social work practitioners’ educational needs in developing spiritual competency in end-of-life care and grief. Journal of Social Work Education, 57(2), 264–286. https://doi.org/10.1080/10437797.2019.1670306

Roh, S., Burnette, C. E., & Lee, Y.-S. (2018). Prayer and faith: Spiritual coping among American Indian women cancer survivors. Health and Social Work, 43(3), 185–192. https://doi.org/10.1093/hsw/hly015

Document: Life Span Interview (PDF)

Required Media

Walden University, LLC. (2021). Social work case studies [Interactive media]. Walden University Blackboard. https://class.waldenu.edu

· Navigate to Najeeb.

Follow Rubric

Initial Posting: Content

14.85 (49.5%) – 16.5 (55%)

Initial posting thoroughly responds to all parts of the Discussion prompt. Posting demonstrates excellent understanding of the material presented in the Learning Resources, as well as ability to apply the material. Posting demonstrates exemplary critical thinking and reflection, as well as analysis of the weekly Learning Resources. Specific and relevant examples and evidence from at least two of the Learning Resources and other scholarly sources are used to substantiate the argument or viewpoint.

Follow-Up Response Postings: Content

6.75 (22.5%) – 7.5 (25%)

Student thoroughly addresses all parts of the response prompt. Student responds to at least two colleagues in a meaningful, respectful manner that promotes further inquiry and extends the conversation. Response presents original ideas not already discussed, asks stimulating questions, and further supports with evidence from assigned readings. Post is substantive in both length (75–100 words) and depth of ideas presented.

Readability of Postings

5.4 (18%) – 6 (20%)

Initial and response posts are clear and coherent. Few if any (less than 2) writing errors are made. Student writes with exemplary grammar, sentence structure, and punctuation to convey their message.

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Developing cultural competence with LDS clients:
Utilizing spiritual genograms in social work
practice

Gordon E. Limb, David R. Hodge, Kaitlin Ward, Alissa Ferrell & Richard
Alboroto

To cite this article: Gordon E. Limb, David R. Hodge, Kaitlin Ward, Alissa Ferrell & Richard
Alboroto (2018) Developing cultural competence with LDS clients: Utilizing spiritual genograms
in social work practice, Journal of Religion & Spirituality in Social Work: Social Thought, 37:2,
166-181, DOI: 10.1080/15426432.2018.1448033

To link to this article: https://doi.org/10.1080/15426432.2018.1448033

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Developing cultural competence with LDS clients: Utilizing
spiritual genograms in social work practice
Gordon E. Limb a, David R. Hodgeb, Kaitlin Ward a, Alissa Ferrella,
and Richard Alborotoc

aSchool of Social Work, Brigham Young University, Provo, Utah, USA; bArizona State University,
Phoenix, Arizona, USA; cUniversity of Hawaii at Manoa, Honolulu, HI, USA

ABSTRACT
In recent years, social work has increasingly focused on spiri-
tuality and religion as key elements of cultural competence.
Consequently, specific strategies have been developed to pro-
vide the most appropriate interventions for religious clients.
The Church of Jesus Christ of Latter-day Saints (LDS) is the
fourth largest and the fastest growing church in the United
States and is one of the fastest growing churches worldwide. In
an effort to facilitate cultural competence with LDS clients, a
spiritual assessment tool was developed based upon the gen-
ogram. Evaluation of this tool was facilitated through a survey
of 100 practitioners. Participants liked the idea of using a
spiritual genogram and felt it would be a useful tool in therapy.
In general, they thought the questions associated with the
spiritual genogram were appropriate and consistent with LDS
culture, although numerous suggestions for improvement
were offered.

ARTICLE HISTORY
Received 18 September 2017
Accepted 28 February 2018

KEYWORDS
spirituality; religion; clinical;
mental health/health

Cultural competence is highly emphasized in both the National Association
of Social Workers (NASW) Code of Ethics (2008) and the Council on Social
Work Education’s (CSWE) Educational Policy and Accreditation Standards
(2015). Moreover, spirituality and religion are increasingly addressed in the
literature as important components of cultural competence (e.g., Canda &
Furman, 2010; Harris, Ellor, & Yancey, 2017; Hodge, 2015a; Whitley, 2012).
The Church of Jesus Christ of Latter-day Saints, commonly known as the
Mormon Church (“the LDS Church”), now represents the fourth largest
church in the United States, with a worldwide membership of over 15 million
The Church of Jesus Christ of Latter-day Saints, 2017a; (Lindner, 2012).

Additionally, it is estimated that over half of the LDS Church’s member-
ship live outside of the United States, increasing the likelihood that LDS
members could be found among social work clientele worldwide (Petersen,
2013). Despite the hundreds of thousands of individuals joining the LDS
Church each year (The Church of Jesus Christ of Latter-day Saints, 2017a),

CONTACT Gordon E. Limb [email protected] BYU School of Social Work, 2190A JFSB, Provo, UT
84602

JOURNAL OF RELIGION & SPIRITUALITY IN SOCIAL WORK: SOCIAL THOUGHT
2018, VOL. 37, NO. 2, 166–181
https://doi.org/10.1080/15426432.2018.1448033

© 2018 Taylor & Francis

very little published material is available to aid social workers as they seek to
provide culturally competent services to LDS clients. Therefore, the purpose
of this study was to examine a spiritual assessment tool as it has been
modified for use with LDS clients.

Spirituality and religion

As social workers attend to a variety of issues presented by clients, conduct-
ing comprehensive bio-psycho-social-spiritual assessments is a critical part of
their ability to adequately administer mental health treatment (Hodge,
2015a). Indeed, attending to clients’ religion and spirituality (RS) can posi-
tively affect mental health outcomes, such as the ability to cope with stress,
increase positive emotions, and increase well-being and quality of life
(Koenig, King, & Carlson, 2012; Prieto Peres, Kamei, Tobo, & Lucchetti,
2017). Additionally, implications for health and well-being can arise if RS is a
source of distress or internal conflict (Park et al., 2017).

Spirituality can be defined as a personal entity, construct, or a relationship
with the sacred (Boyatzis, 2005). Religion, on the other hand, is often defined
in the literature as personal beliefs as well as communally affirmed beliefs
and practices (Hodge, 2015b). For many, RS can be a cultural worldview
through which reality is experienced, similar to that of race or ethnicity
(Madsen, 2016). Additionally, RS can be a fundamental component of clients’
identities (Hodge, 2015a). Therefore, it is critical that practitioners work to
expand their cultural competency and understand clients’ unique experiences
with RS.

In fact, the CSWE’s Educational Policy and Accreditation Standards
(2015) require that social work students in accredited programs understand
how varying dimensions of diversity, including RS, affect human experience
and identity formation. Furthermore, the NASW Standards for Cultural
Competence in Social Work Practice (NASW, 2015) emphasize the ethical
responsibility of social workers to engage in culturally competent practice
and interventions that address the importance of RS in clients’ lives. Given
these obligations, it is apparent that RS is an important aspect of many
clients’ lives that should be assessed and possibly incorporated in treatment
interventions.

The focus on cultural competence and the recognition of RS as key factors
in cultural understanding has led to an increased interest in using spiritual
assessments to identify clients’ strengths and address treatment/intervention
strategies (Canda & Furman, 2010; Hodge, 2015a; Tracey, 2017). Moreover,
spiritual assessments have become mandated in many settings across the
United States. The Joint Commission, the largest health care-accrediting
organization in the United States, requires the administration of spiritual
assessments in many settings frequented by religious clients, including

JOURNAL OF RELIGION & SPIRITUALITY IN SOCIAL WORK: SOCIAL THOUGHT 167

hospitals, agencies providing addiction treatment, and other settings where
mental health services are available (Hodge, 2015a). The current study
examined a distinct cultural group of religious clients—those who belong
to the LDS Church. Following a brief introduction to LDS beliefs and culture,
the next section examines a spiritual assessment tool that may be particularly
useful with this commonly overlooked population—spiritual genograms.

LDS beliefs and culture

Building on a strength-based approach for those working with this popula-
tion, knowledge of basic LDS beliefs and cultural values are essential for
conducting an appropriate therapeutic assessment and selecting the best
intervention approach. Established in 1830, the LDS Church combines
Judeo–Christian traditions with modern prophetic leadership. Members of
the LDS Church believe the founder and first modern-day prophet to be
Joseph Smith, a man members believe was visited by God the Father and the
resurrected Lord, Jesus Christ. Joseph Smith is believed to have “restored”
Jesus Christ’s original church that was lost from the Earth after Christ’s
resurrection and ascension to heaven and the death of the apostles (The
Church of Jesus Christ of Latter-day Saints, 2012). This claim, like many
others, sets the LDS Church apart from other Christian denominations.

LDS Church members consider many of their beliefs, attitudes, and beha-
viors similar to those of other Christian faiths (Ulrich, Richards, Hansen, &
Bergin, 2014). However, LDS Church members differ in some important
ways. LDS Church doctrine posits that God the Father, Jesus Christ, and the
Holy Spirit are three separate and distinct personages. Although LDS doc-
trine teaches that Jesus Christ is Savior and Redeemer, many denominations
hesitate to recognize Latter-Day Saints as Christians because of this belief in
three distinct members of the Godhead (Davis, 2006). Another difference
between the LDS Church and other Christian religions is the belief that the
LDS Church is led by a living prophet who receives revelations directly from
God and Jesus Christ (Mason, 2015). In terms of attitudes and behaviors,
LDS Church members tend to have higher-than-average levels of education
but, unlike other religions, higher education tends to be correlated with
increased religiosity (Pew Forum, 2012).

Marriage and family life are central to LDS beliefs and culture. Religious
teachings and LDS Church programs frequently focus on ways to strengthen
the family (Ulrich et al., 2014). Temple worship, which is separate from
Sunday worship services, are holy places of worship where individuals
make sacred covenants with God (The Church of Jesus Christ of Latter-day
Saints, 2017b). Temples have an important family component where LDS
Church members believe that, through promises made in the temple, a
husband and wife can be together and with their children—even after

168 G. E. LIMB ET AL.

death. Temples are also places where faithful LDS members perform proxy
saving practices (like baptisms) for deceased ancestors (The Church of Jesus
Christ of Latter-day Saints, 2017c). Consequently, LDS Church members are
expected to engage in temple worship and genealogical research, as well as
other family-centered activities (Walton, Limb, & Hodge, 2011).

The families of practicing LDS Church members often include extensive
kinship networks, and these members are likely to be quite familiar with
their ancestral heritage (Walton et al., 2011). Likewise, the most frequently
mentioned reason for local LDS Church leaders to refer members to
mental health providers is marriage and family problems (Barlow &
Bergin, 1998). Because of the focus on ancestors and extended kinship
networks, the genogram can be an effective tool to leverage an existing
resource for assessment and intervention. Further, social work is about
offering people options and alternatives and the spiritual genogram is an
assessment tool that may help generate options and alternatives for those
social work serves.

Spiritual genograms

Genograms are consistent with the person-in-environment perspective
and help both practitioners and clients understand the flow of histori-
cally-rooted patterns through time (Hodge, 2001). Genograms can serve
as a tracking mechanism for defining the intergenerational family struc-
ture and outline relationships, roles, resources, and strengths
(McGoldrick, Gerson, & Petry, 2008). Here, genograms are tools for
assessment as well as intervention. Creating a genogram as part of the
therapeutic process is a meaningful way of engaging clients and initiat-
ing therapeutic interventions.

The most important elements of a client’s culture are those that are
uniquely passed down through the generational transmission of family
values, traditions, and practices (Sutton, 2000). Considering this importance,
genograms have been used for the past three decades to help social workers
become more culturally competent (Hardy & Laszloffy, 1995; Limb & Hodge,
2010). Traditionally, however, social workers have not been encouraged to
delve into RS, which represent important aspects of culture for many clients
(Beyers, 2017; Dunn & Dawes, 1999; Hodge & Limb, 2014). Indeed, even
within the same denomination, clients can express their RS in very different
manners. Nevertheless, in most cases, families are successful in passing on
their values and beliefs to succeeding generations (Hodge, 2001). Religious
and spiritual values, as transmitted through the family, are the ones that are
likely to be most relevant to the client—regardless of whether it is the
perpetuation of values or intergenerational conflict resulting from those
values.

JOURNAL OF RELIGION & SPIRITUALITY IN SOCIAL WORK: SOCIAL THOUGHT 169

Spiritual genograms provide social workers with a graphic representation
of complex illustrations of spirituality and religiosity over at least three
generations. When initiating a spiritual genogram assessment, the basic
family system is demarcated in keeping with standard genogram conventions
(Frame, 2000). Color coding can be used to provide a “color snapshot” of the
overall spiritual composition of the family system. In addition, symbols
drawn from the client’s perspective can be used to describe spiritually mean-
ingful events or relationships. These symbols and short summary statements
can also be used to denote significant events, personal strengths, and other
important information. This approach allows for both the stability and
fluidity of the client’s beliefs over time. Figure 1 gives an example of what
a spiritual genogram might look like for an LDS couple within the confines of
a noncolor medium.

In addition to drawing the spiritual genogram, the assessment tool
includes a question-set broken up into two sections: historical components
and present spiritual functioning. These two sections are designed to help
social workers facilitate the construction of spiritual genograms with LDS
clients. Therefore, the purpose of this study was to examine a spiritual
assessment tool as it has been modified for use with LDS clients by examin-
ing two questions. First, how congruent are spiritual genograms with LDS
culture and what are its strengths and weaknesses? Second, how consistent
are the historical and present spiritual functioning sample questions with
LDS clients, and how might they be improved or changed to be more valid,
relevant, and consistent with LDS culture?

Nominal Inactive 18-25yrs
attender Active 25yrs–

Fred Sarah David Stacy Reggie Carol Jane

[17]

82

Karen

Strict! [21]

married in their early 30s

Kevin Rachel Frank Hannah Sue Bea

Mark Alice Beth

Married five years—frequent marital conflict

Beth hospitalized for anxiety

1st

19

28
mission

Strengths
Prayer
Scripture Study
Church and Temple Attendance
Home and Visiting Teaching

Figure 1. Spiritual genogram.

170 G. E. LIMB ET AL.

Method

Participants

Participants for this mixed method online study included social workers with
extensive practice knowledge of and experience with LDS culture. A hybrid
purposive/snowball sampling method was used to recruit participants. One of
the authors, being LDS and professionally associating with a number of potential
experts in LDS culture, contacted practitioners via e-mail, including a family
service organization composed of therapists dedicated to serving LDS clients.
After the purpose of the study was explained, contacted professionals were
asked to identify other professionals or practitioners with extensive knowledge
of LDS culture.

Practitioners with more than 5 years practice experience with LDS clientele and
who had a social work degree were asked to participate in the study. This group
included 125 professionals, of which 100 (80% response rate) completed the online
survey instrument. As part of the selection process, the percentage of social
workers and practitioners included from a given area was proportional to the
national LDS population percentage residing within the same area. One exception
was made in the southwest region, however, due to a shortage of responding
participants (i.e., one additional expert was included from the Northwest and
Midwest regions). Population percentages were obtained from the LDS Church’s
Almanac (Deseret News, 2007). Table 1 gives a brief demographic background of
the participating experts.

Table 1. Characteristics of LDS participants and perceptions of consistency
with LDS culture.

% N M SD

Gender
Male 55 55
Female 45 45

Race
White 89 89
Other 11 11

Religion
LDS 98 98
Other 2 2

Region
West 59 59
Southwest 10 10
Northwest 8 8
Midwest 9 9
East 14 14

Age 43.76 9.92
Years in Profession
Conceptual Overview

13.27 7.69

Spiritual genograms in general 8.28 1.89
Constructing Spiritual Genograms
Historical Components 8.74 1.52
Present Spiritual Functioning 8.93 1.26

Note. LDS = The Church of Jesus Christ of Latter-day Saints.

JOURNAL OF RELIGION & SPIRITUALITY IN SOCIAL WORK: SOCIAL THOUGHT 171

As can be seen in Table 1, the experts vary in age, experience, gender, and
geographic location. Participants consisted of 55% male and 45% female
practitioners, almost all were LDS members. More than half of the sample
resided in the Western United States.

Instrument development

The assessment tool was modified by the authors to remove obvious incon-
sistencies with LDS culture. The mixed-method survey instrument consisted
of four sections. The first section included a brief general conceptual over-
view of spiritual genograms. Participants were shown an illustrative example
of one individual’s spiritual genogram (see Figure 1) and asked to assess the
consistency of the spiritual genogram assessment tool with LDS beliefs,
lifestyle, and culture. The second and third sections, designed to operationa-
lize the drawing of the spiritual genogram, outlined a number of sample
questions to help practitioners facilitate the construction of a spiritual geno-
gram with LDS clients in the historical component and present spiritual
functioning areas. The final section solicited demographic information.

Within each sample question-set, a quantitative question was posited to
solicit participants’ evaluation of the consistency of the sample questions
regarding LDS beliefs, lifestyle, and culture. The quantitative question used a
0 to 10 response rating, with 0 corresponding to a complete absence of
consistency with LDS beliefs, lifestyle, and culture, and 10 equating to
complete consistency with LDS beliefs, lifestyle, and culture. Two open-
ended questions followed each question-set. The first dealt with the strengths
and limitations of spiritual genograms with LDS clients, and the second
inquired how the questions could be improved to be more valid, relevant,
and consistent with LDS clients.

After institutional review board approval was received, the survey instru-
ment was placed online and the URL link was e-mailed to participants.
Research suggests that response rates for paper- and web-based surveys are
comparable, and the data produced are generally similar in content
(Kaplowitz, Hadlock, & Levine, 2004). Participants were given a modest
remuneration upon completion of the survey instrument as compensation
for the length of time taken to complete the survey instrument.

Data analysis

All data analyses were calculated in SPSS version 23. Means, standard devia-
tions, ranges, and modes are reported. Tests of associations were conducted
between the dependent variables and the demographic variables reported in
Table 1. A constant comparative method and expert validity analysis were
used to examine similarities and common themes for qualitative data

172 G. E. LIMB ET AL.

(Glasser & Strauss, 1967). Common themes for each question-set were
continually compared to similar phenomena across the survey instrument
in a recursive process. Representative quotes were used to illustrate these
themes from the participants. The results of the data analysis are presented in
the following two sections.

Results

General conceptual overview

In response to questions regarding the conceptual overview of the spiritual
genogram, the participants generally thought the survey items were consis-
tent with LDS beliefs, lifestyle, and culture (M = 8.28, SD = 1.89, see Table 1).
Tests of association suggested that perceptions were stable across demo-
graphic variables. Here, gender, geographic region, age, and years in profes-
sion were all unrelated to perceptions of cultural consistency. Analyses of the
qualitative items help shed light on the relatively high cultural consistency
score.

A few specific themes emerged as overall strengths. These included visual
clarity of the nature, relationship, and history of the family’s spirituality and
important information on how religion impacts or influences several genera-
tions. One participant thought the spiritual genogram “gives a pictorial view
of the family system, which is quite enlightening.” Another typical response
was “The spiritual genogram would be a great tool for understanding pat-
terns and familial trends.” Also, an advantage of using the spiritual genogram
is that “you get double information (all the traditional information and how
spiritual life plays out in the system).” It was also noted that the spiritual
genogram “provides insight into a client’s spiritual background, as influenced
by immediate and extended family.”

When asked about the weaknesses or limitations of the assessment tool,
participants were mainly concerned with clients’ ability to recall information
from past generations. Some noted that spiritual genograms might be con-
fusing when clients come from a large family, where detailed information
might be overwhelming. A few participants also suggested that figures and
symbols were difficult to interpret. One commented, “Sometimes if family
information is perceived as negative, it can be overwhelming to the client.
For an LDS client, that can bring on feelings of guilt, shame, and in a
spiritual measurement it can mean the perception of unworthiness.”
Another expert noted, “Some people may procrastinate because they don’t
want to uncover painful memories. However, I think this may be less painful
for most because it’s more factual.” Finally, another expert mentioned that:

LDS families tend to have a lot of kids. This is an assignment that may require
significant time and energy that they may not have. It may also produce some guilt

JOURNAL OF RELIGION & SPIRITUALITY IN SOCIAL WORK: SOCIAL THOUGHT 173

for not knowing much about one’s ancestry since knowing is a significant concept
in the LDS church.

A respondent was especially sensitive to clients who have special needs:
“Those who are vision impaired will have difficulty using this tool.” This
participant went on to suggest that in order for the clients to understand
what the symbols are, the worker needs to be clear as he/she explains the
assessment tool. Another participant feared that some practitioners may
incorrectly interpret the significance of the assessment and intervention
method and suggested that adequate training is needed prior to using the
assessment tool. Another expert mentioned that, “it should be incorporated
into other intervention techniques [as well].”

Operationalizing the spiritual genogram

Historical components
The first set of questions in the instrument focused on religious history. They
were designed to facilitate the client’s personal disclosure. The participants
were directed to rank each question’s consistency with the LDS culture on a
scale ranging from 0 (completely absent of consistency with LDS culture) to 10
(completely consistent with LDS culture).

Among the 100 participants, the range was from 3 to 10 (M = 8.74,
SD = 1.52, see Table 1). Participants were then asked to provide feedback
on how best to improve the relevance, validity, and consistency of the sample
questions. The most common responses were affirmations that the questions
were consistent, relevant, and comprehensive (the mode was 10). However,
some practitioners expressed concerns about the wording of some of the
questions. For example, one noted the “vagueness” of the words “spiritual
walk.” One participant commented, “I think the term ‘spiritual or religious
walk’ might be confusing to an LDS individual.” Some suggested that “spiri-
tual walk” be replaced with “spiritual development” or “spiritual path.”
Another mentioned that the “clinician would need to explain congruent.”
Finally, a participant commented, “I think [if] these instruments are geared
for the LDS client, you can be straightforward in asking about religious
practices by name: temple attendance, church meeting attendance, priest-
hood blessings, sacrament, teaching, etc.”

Present spiritual functioning
The second set of questions dealt with the present spiritual functioning of the
client. In this stage of the assessment, practitioners help clients explore how
past history has shaped their present spiritual functioning. Participants gen-
erally thought these questions were consistent with LDS culture (M = 8.93,
SD = 1.26, see Table 1).

174 G. E. LIMB ET AL.

The most common responses were “questions were very good,” “excel-
lent,” “no changes necessary,” “no further suggestions,” and “no concerns.”
However, a few expressed some concerns that the questions were “repeti-
tive,” “redundant,” or “too many.” One suggested, “I think there is a bit of
overkill in these questions, too complex.” Other words appeared proble-
matic for the experts. One expert mentioned using the word “motivated”
or “what led you to make” instead “prompted.” Finally, one expert noted
that “How does your present spirituality intersect . . .?” could be replaced
with “How have past religious patterns in your family shaped your current
practice of religion?”; “How does your religion or spirituality. . .” could be
worded “How do your religious beliefs assist you in dealing with difficul-
ties?”; and the second-to-last question could begin with “Are there meth-
ods . . .” Other respondents suggested using “connect or inspire you”
instead of “touch you” and using “align or fit in with” instead of “inter-
sect.” Finally, one participant noted “good questions, but too many
questions.”

Discussion

The purpose of this study was to examine a spiritual assessment tool that was
modified for use with LDS clients. Specifically, we wanted to know how
congruent a spiritual genogram was with LDS culture, and what its strengths
and weaknesses were. We also wanted to determine how consistent the
historical and present spiritual functioning sample questions with LDS clients
were, and how might they be improved or changed to be more valid,
relevant, and consistent with LDS culture.

This study responds to the lack of research on culturally validated assess-
ment tools for work with LDS clients by providing an initial evaluation of the
spiritual genogram. Two prominent themes emerged from the study’s results.
First was the consistency of the spiritual genogram assessment tool with LDS
clientele. Second was the wording given in the sample questions used for
operationalizing spiritual genograms?

Regarding the consistency aspect, while prior research (Frame, 2000)
worried about the client’s ability to recall information from past generations,
participants generally liked the idea of using a spiritual genogram and
sustained its usefulness as an assessment tool in therapy. Results suggest
that participants approved of the inclusion of both historical and present
functioning elements. Participants voiced that spiritual genograms would
help the client and practitioner better understand patterns and familial
trends. In general, participants thought the sample questions associated
with the spiritual genogram were appropriate and consistent with LDS
culture as evidenced by the high mean scores and the overall mode of 10
(complete consistency).

JOURNAL OF RELIGION & SPIRITUALITY IN SOCIAL WORK: SOCIAL THOUGHT 175

Regarding the wording given in the sample questions, most comments
were positive. There were, however, a number of suggestions for improving
the assessment tool. Some comments reflected a discomfort from a few
participants with using genograms in therapy. Counselors saw the process
as “overkill” or thought it would be overwhelming to clients. The suggestions
for improvement primarily involved changes in the wording so as to be more
consistent with common word usage among LDS clients (Walton et al.,
2011).

Finally, a few participants noted that the sample questions used in both the
historical and present spiritual functioning were too cumbersome. There
were 24 sample questions given in the historical section, while 18 questions
were listed in the present spiritual functioning section. In these two sections,
participants suggested that there should be fewer sample questions and those
included should be simpler, shorter, and be …

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Journal of Social Work Education

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Social Work Practitioners’ Educational Needs in
Developing Spiritual Competency in End-of-Life
Care and Grief

Elizabeth C. Pomeroy, Audrey Hang Hai & Allan Hugh Cole Jr.

To cite this article: Elizabeth C. Pomeroy, Audrey Hang Hai & Allan Hugh Cole Jr. (2021) Social
Work Practitioners’ Educational Needs in Developing Spiritual Competency in End-of-Life Care and
Grief, Journal of Social Work Education, 57:2, 264-286, DOI: 10.1080/10437797.2019.1670306

To link to this article: https://doi.org/10.1080/10437797.2019.1670306

Published online: 04 Dec 2019.

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Social Work Practitioners’ Educational Needs in Developing
Spiritual Competency in End-of-Life Care and Grief
Elizabeth C. Pomeroy, Audrey Hang Hai , and Allan Hugh Cole Jr.

ABSTRACT
This study’s purpose was to assess social work practitioners’ educational
needs for developing spiritual/religious competencies with end-of-life care
and grief. Competency levels and factors associated with educational
courses and content on developing spiritual/religious competencies were
identified. Data were collected in 2017 through an online Qualtrics Survey
Tool at a large public university in the Southwest. An online survey was sent
to 3,845 social work practitioners via email and 437 practitioners who met
eligibility criteria participated in the survey. Results suggest that social work
education and trainings would benefit from better integration of spiritual-
ity/religion competencies, both in general and specifically in the area of
end-of-life care and grief. Implications for social work education improve-
ment are provided.

ARTICLE HISTORY
Accepted: March 2019

Death and grief are an inevitable part of human life, and they often present challenges to people’s physical,
mental, and emotional well-being. The National Association of Social Workers (NASW, 2004) reminds social
workers that regardless of their field of practice, they will inevitably be confronted with managing grief
because of illness, dying, death, and decision making related to the relief of suffering in their work with clients.
By 2030, all baby boomers in the United States (those born between 1946 and 1965) will be age 65 years and
older and for the first time outnumber children (U.S. Census Bureau, 2018). The increasingly older
U.S. population will have wide-ranging implications for the country as well as social workers. As this trend
in aging and longer life expectancies continues, the need for end-of-life (EOL) care, grief management, and
palliative care curricula, training, and guidelines in schools of social work, nursing, and medicine will increase
(Boschert, 2013; Morrison & Meier, 2015; Richardson, 2014; Wang, Chen & Chow, 2018). Anticipating this
need, the field of social work has called for ethical standards and professional guidelines that address EOL,
hospice, and palliative care (NASW, 2004, 2009). The Institute of Medicine (IOM, 2015) identified the need
to expand and improve the quality of EOL care and knowledge among clinicians across educational
institutions and the health care delivery system. Current practices call for the establishment of career
incentives and training for social workers to build capacity in the field of palliative care and to support
educators who can integrate palliative care into postgraduate training curricula (Institute of Medicine (IOM),
2015; Morrison & Meier, 2015). Furthermore, courses in EOL care have applications beyond traditional
palliative care practice in other practice settings (Supiano, 2013).

However, tensions exist in the preparation of graduate students who will work with issues of grief and
loss in health care settings on what the workforce needs, what is pedagogically required, and what students
want to learn (Breen, Fernandez, O’Connor, & Pember, 2012). Greater experience and training integrating
spirituality and religion (SR) into EOL care has been seen as an important factor to support patients dealing
with EOL issues (Balboni et al., 2013; Richardson, 2014). Lack of EOL and grief competencies related to SR
and the need to better prepare social work students has been seen as a barrier for social work practice with
EOL care and grief (Kramer, 2013; Zollfrank et al., 2015). Those in the social work profession recommend
a holistic approach to social work practice, including spiritual health and the biopsychosocial-spiritual

CONTACT Elizabeth C. Pomeroy [email protected] Steve Hicks School of Social Work, The University of Texas at
Austin, 1925 San Jacinto Blvd., 3.106B, Austin, TX 78712.
© 2019 Council on Social Work Education

JOURNAL OF SOCIAL WORK EDUCATION
2021, VOL. 57, NO. 2, 264–286
https://doi.org/10.1080/10437797.2019.1670306

issues that affect well-being (NASW, 2016; Richardson, 2014). The National Consensus Project for Quality
Palliative Care, an evolving consortium of numerous organizations in palliative care (including the
NASW), has created clinical practice guidelines that contain the SR aspects of care (Ferrell, Twaddle,
Melnick, & Meier, 2018; National Consensus Project for Quality Palliative Care, 2013). This study aims to
fill a gap in the literature by examining the educational needs of social work practitioners in multiple
practice settings for developing SR competency with EOL and grief. The following literature review
provides an overview of contributions as well as gaps in knowledge and points to subjects for future
research.

Literature review

Social workers practice in a variety of health care, hospice, palliative, and integrated care settings and play an
important role in helping individuals and families with EOL and grief issues (Bailey, 2012; Cacciatore, Thieleman,
Killian, & Tavasolli, 2015; Fraher, Richman, de Saxe Zerden, & Lombardi, 2018). Social work pedagogy focuses on
building EOL and grief competencies that reinforce the comprehensive philosophy of palliative care (Bosma et al.,
2010). Palliative care is understood as a holistic approach to providing care to individuals and their families affected
by life-threatening illnesses, with a focus on symptom relief and improving the quality of life. It encompasses EOL
care but is more expansive (National Academies of Sciences, Engineering, and Medicine, 2016). Moreover, social
workers in other non-health-care settings are also likely to encounter individuals who are dealing with EOL issues,
illness, dying, death, and grief experiences (Bosma et al., 2010). The promotion of a client’s right to self-
determination as informed by professional standards requires continued education in EOL issues (e.g., advanced
directives), not only for direct practice but also to support policy work (Galambos, Starr, Rantz, & Petroski, 2016;
Lupu, Deneszczuk, Leystra, McKinnon, & Seng, 2013). The literature shows a critical need for social workers with
specific knowledge and competencies who can help individuals and families cope with bereavement, grief, and EOL
decisionsaswellastheculturalandSRaspectsofEOLandpalliativecare(Adshead&Dechamps,2016;Bosmaetal.,
2010; Forrest & Derrick, 2010; Morrissey, 2005; Morrissey, Herr, & Levine, 2015; Wang, Chan, & Chow, 2018).

The literature consistently shows a shortage of social workers prepared to provide quality palliative and EOL care
(Gardner, Gerbino, Walls, Chachkes, & Doherty, 2015; Gwyther et al., 2005). One large study (n=641) of social
workers who practice in hospice palliative care settings in the United States reported a lack of clarity in roles and
responsibilitiesfor socialworkersinthispracticesettingandtheneedforCenterforMedicareandMedicaidServices
reimbursementpoliciesthatacknowledgesocialworkcontributionsinadvancecareplanning(Stein,Cagle,&Christ,
2017). Another study (n=102) of students at a school of social work in the southeastern United States showed that
experiential EOL-specific education and training, field and service learning are effective ways to increase the level of
comfort with EOL issues. Making EOL and grief courses compulsory across disciplines and connecting with
experienced practitioners could also reduce the gap in practice knowledge (Kwon, Kolomer, & Alper, 2014). The
literature also lacks significant articles on the evolving field of EOL care in addition to a gap in and a call for social
workers to take on empirical research to better represent their important contribution in EOL care (Henry et al.,
2015; National Academies of Sciences, 2016).

The growth of EOL care and palliative services in the United States and globally is well supported
(Dumanovsky et al., 2016; Hughes & Smith, 2014), which has expanded the need for relevant
knowledge and skills training on the cultural and SR issues related to grief and loss and EOL and
palliative care (Etkind et al., 2017; Hauser, Preodor, Roman, Jarvis, & Emanuel, 2015; Murty,
Sanders, & Stensland, 2015).

There is a shortage of practitioners who have palliative care expertise and recognized knowledge
in the skills that are culturally and spiritually appropriate (Berkman & Stein, 2018; Kramer, 2013).
This supported earlier research by Bosma et al. (2010) that identified the need for further profes-
sional development and educational curricula related to SR (of self, team, and others). Additionally,
there appears to be a gap between students’ academic learning of SR and their practice skills related
to grief and EOL care (Dickinson, 2013, 2017; Duncan-Daston, Foster, & Bowden, 2016; Harris,
Yancey, Myers, Deimler, & Walden, 2017; Kwon et al., 2014; Richardson, 2014; Rothman, 2009;
Turner, Kuyini, Agustine, & Hunter, 2015). Even among advanced social work practitioners, the

JOURNAL OF SOCIAL WORK EDUCATION 265

need for training in the integration of clients’ SR practices and the evaluation of such practices had
been demonstrated (Oxhandler & Ellor, 2017). Fang, Sixsmith, Sinclair, and Horst (2016) showed
that spiritually and culturally relevant practice knowledge related to EOL care was limited, especially
with underserved minority populations. In addition, research revealed the need for continuing
education on EOL and grief issues and training on compassion fatigue and secondary trauma
(Chan & Tin, 2012; Quinn-Lee, Olson-McBride, & Unterberger, 2014; Sansó et al., 2015).

Those in all levels of social work education, including the bachelor’s level, master’s level, and continuing
education, could benefit from training and knowledge about how to assist grieving or dying clients (Bosma
et al., 2010). Middleton, Schapmire, and Head (2018) conducted a qualitative content analysis of a reflective
writing assignment from 27 master’s level social work students enrolled in a palliative care clinical setting.
Findings indicated experiential interdisciplinary learning, shadowing experienced social workers, and train-
ing helped to better prepare social work students for future in practice. Murty et al. (2015) studied the
integration of EOL field of practice in the social work curriculum at a school in the United States. Findings
demonstrated that specific education on EOL care helped build foundational competencies among social
work learners as well as a cross-pollination of knowledge on EOL care. A comprehensive review of the 50
most cited papers in social work in EOL care, showed a scarcity of relevant literature and a field needing
further research (Henry et al., 2015). Other studies point out the lack of content on EOL practice and grief in
social work textbooks and the need of faculty with specialized training in EOL care (Murty et al., 2015; Wang,
Chan, & Chow, 2018). Wang et al. (2018) reported that textbook curricula focused generally on death and
dying, with limited clinical supervision in EOL care and advance care planning (ACP) practices. Simons and
Park-Lee (2009) surveyed 272 social work students (mostly MSWs) in the United States and Canada and
found that positive attitudes toward EOL planning were associated with higher levels of comfort when
discussing death and with more experiences working with clients in EOL situations. These results were
reinforced in a later study by Kwon et al. (2014), which showed the need for hands-on-experience related to
EOL care issues and suggested that academic education may improve students’ competence and comfort in
EOL decision making.

Many variables contribute to students’ level of comfort working with EOL care, including self-
awareness and experiential training in academic settings (Kwon et al., 2014; Wang et al. 2018).
Research shows the need for the social work profession to develop and integrate evidence-based
interventions for EOL-related issues (Murty et al., 2015). A study by Dickinson (2013) reported the
results of a 2012 survey that investigated 88 U.S. graduate social work programs’ curricular offerings in
EOL and palliative care and compared the results with those of a similar survey in 1990. There has been
some progress, yet the preparation at the master’s level for EOL care is far from adequate. Major progress
was found in separate death and dying course offerings, which increased from 40% to 64%. Although
schools were offering more curricula and course work, only 42% of master’s level students actually
completed these courses. Ninety-four percent (94%) of programs offer at least one lecture on death and
dying, but the number of teaching hours averaged only seven (Dickinson, 2013). In addition, inter-
disciplinary education on EOL care was found to be limited. Seventy-six percent (76%) percent of
programs offered at least a lecture or two on palliative care, with the average number of hours being
almost three times that of death and dying offerings; yet only 30% of students were exposed to palliative
care courses (Dickinson, 2013). Ruth et al. (2017) reviewed 4,831 courses across four domains (BSW,
MSW, DSW, PhD, and continuing education) and recommended the need for a clearer framework for
“health social work,” (p. S267) and for expanding its health content to better prepare graduates for
integrated practice. A core curriculum for all MSW students was agreed on, as well as curriculum
development on palliative care knowledge and skills for nonspecialty scopes of practice across settings to
prepare more MSWs. Findings also called for curriculum development on hospice and palliative care at
the graduate level for specialty and nonspecialty practices (Ruth et al., 2017). Dickinson (2017) showed
that efforts to enhance training in EOL topics and issues and greater experiential exposure for medical
students were seen to enhance their EOL skills. Specifically, helping students face their own anxiety over
death and dying was seen as a win-win for students and their patients. It does not seem like much of
a jump to conclude that the same would apply to social work students. The educational needs of students

266 E. C. POMEROY ET AL.

who are learning SR aspects of EOL care (e.g., advance directives) benefit from real-life situations with
repeated exposure in clinical placements and when supported by role modeling and mentorship
(Baldacchino, 2015).

SR competency and EOL care

Evolving research on the integration of SR into social work practice shows that it has the potential to improve
mental and physical health outcomes (Koenig et al., 2012; Oxhandler & Ellor, 2017; Oxhandler & Pargament,
2014). Spirituality and religion is an area of diversity requiring cultural competence for social work practice as
directed in the NASW (2017) Code of Ethics. The Council on Social Work Education (2015) recommends
diversity standards and guidelines for developing SR as a core competency. Trends in research continue to
support the need to develop SR competencies and place them on the same footing as cultural competence
(Canda & Furman, 2009; Darrell & Rich, 2017; Hodge, 2015; Husain & Sherr, 2015; Kvarfordt & Herba, 2018;
Oxhandler, Parrish, Torres, & Achenbaum, 2015).

Social work and SR have had a long but intermittent history in the United States. The profession’s
origin was deeply influenced by SR practices, and its relationship with SR continues to ebb and
resurge (Canda & Furman, 2009; Crowder, 2013; Sheridan, 2015). Therefore, social workers in every
field of practice may benefit from training and content on SR (Husain & Sherr, 2015), whether to
assist with EOL care or to inform appropriate public policy. By integrating knowledge on the general
public’s SR views, social workers are better able to provide ethical and professional services that
respect the SR beliefs and values of the individuals they serve (Hodge, 2015; Sheridan, 2015).

The lack of education on religious beliefs and spiritual issues among health care providers is a significant
barrier to the integration of SR care into health care services (Richardson, 2014; Zollfrank et al., 2015). The
need to improve education about EOL and palliative care, including SR perspectives on death and dying, is
greatly needed (Roze des Ordons et al., 2016). In terms of social work education on EOL care and grief,
education on the SR aspect is especially lacking. Knowledge of SR factors that influence advance care
planning may help providers address racial disparities in advance care planning for the growing population
of minority older adults (Huang, Neuhaus, & Chiong, 2016). To ensure effectiveness in practice and a well-
qualified workforce, social workers are called to use practice-based research and other continuous methods of
knowledge as foundations for practice (Pockett, Dzidowska, & Hobbs, 2015).

Most research on social workers’ educational needs in the SR aspect of EOL care mainly focused on the
hospice setting. Little attention has been paid to a generalist social work education. This study attempts to
answer the following research questions: Do social work practitioners feel competent in the area of SR in EOL
and grief? Do social work practitioners feel comfortable in the area of SR in EOL and grief? What are their
educational needs in the interface between SR and EOL and grief? What forms of education would be most
beneficial? The findings of this study can inform social work curricula and education policies with the goal of
improving social work education to better equip social work practitioners with competencies and skills in
serving clients with EOL care and grief issues.

Methods

Instrument

This study was approved by the institutional review board of a large public university in the Southwest.
We developed an online survey using Qualtrics survey software to assess social work practitioners’
educational needs in SR competencies in the area of EOL care and grief. The survey inquired about social
work courses, specific content and forms of education in regard to developing SR competencies in EOL
care and grief that practitioners have or have not received and consider necessary, and identifies
practitioners’ current confidence and competence levels in this area. We invited an expert panel of
hospice social workers, who deal with EOL care and grief on daily basis, to review the preliminary survey

JOURNAL OF SOCIAL WORK EDUCATION 267

for content validity, and we revised the survey according to their feedbacks. The survey contained 45
items and took about 15 minutes to complete (see Appendix for the complete survey).

Recruitment

Staff in the Office of Professional Development of a large southwestern university’s social work department
sent an e-mail with the link to the survey to 3,845 social work practitioners on its electronic mailing list
inviting them to participate in the study. The first invitation was sent in August 2017, and three follow-up
reminder e-mails were sent 7, 14, and 21 days after the initial invitation. The eligibility criteria to participate
in this study were that participants (a) must be social work practitioners, (b) have a degree in social work,
and (c) have a minimum of 6 months of practice experience in the field of social work. The opportunity to
enter a drawing to win a $100 Amazon gift card or a continuing education course was provided as an
incentive to participate in this survey. Data collection lasted from August to October 2017. Data analysis
included descriptive statistics to examine sample characteristics and participants’ responses to the survey.

Results

Participants

A total of 465 social work practitioners participated in the survey, 437 (11.4%) of whom met our eligibility
criteria and were included in the analysis. Twenty-eight participants were excluded because they were not
practicing as a social worker at the time of the survey and thus did not meet our eligibility criteria. Table 1
presents the background information of the study participants. The participants were social work practi-
tioners from diverse backgrounds. On average, they were 44 years old (ranging in age from 22 to 76).
A majority were female (89.05%), although some were male (9.95%), transgender (0.25%), or other gender
(0.75%). About 65% of participants were White (65.62%). The second largest racial group was Hispanic
(19.78%), followed by Black and African American (7.42%), Asian (2.92%), and American Indian or Alaska
Native (1.57%). About 45% of the participants reported being Christian (45.74%), about 20% were spiritual
but not religious, and about 10% reported being agnostic. A majority of participants had a master’s degree in
social work (92.64%). About a third of the participants obtained their highest social work degrees between
2010 and 2017 (36.27%), and a third obtained their highest social work degrees between 2000 and 2009
(36.13%). Participants’ practice experience ranged from 1 to 47 years (mean=14 years). In addition,
participants came from a variety of practice settings, including school, mental health center, hospital, child
welfare, hospice, skilled nursing, private practice, nonprofit, and religious congregations.

Competency in EOL, grief, and related educational needs

A majority of participants reported that they encounter EOL and grief issues in their practice (often or very
often, 39.63%; sometimes, 42.86%). However, almost 40% considered themselves not prepared at all to
address these issues when they began practicing social work (Table 2). We asked participants who reported
not feeling prepared (n=166) what would have helped them. Among the forms of social work education we
suggested (i.e., bachelor’s level course, master’s level course, continuing education courses, discussion in
supervision meetings, resources in the community, extracurricular readings, lectures, job training, and
other), the most endorsed ones were courses on EOL and grief at the master’s level, continuing education
courses on EOL and grief, and discussion about EOL and grief in supervision meetings. We also asked
participants who reported feeling prepared (n=35) or somewhat prepared (n=232) what had prepared
them. The forms of social work education that were endorsed by most participants included courses on
EOL and grief at the master’s level, discussion about EOL and grief in supervision meetings, and
extracurricular readings on EOL and grief (Table 3).

268 E. C. POMEROY ET AL.

Continuing education on EOL and grief
About half the participants (53.86%, n=230) have taken a continuing education course on EOL and
grief; and among these practitioners, more than 80% think the course increased their competency in
addressing their clients’ EOL and grief needs (82.02%). About 70% of all participants reported a need
for more continuing education course on EOL and grief (70.40%). A majority of participants
(96.68%) reported that interventions for EOL and grief would be one of the most helpful topics
for a continuing education course, about 60% considered case studies on EOL and grief (61.46%),
and about 45% considered theories on EOL and grief (44.19%) as among the most helpful topics for
continuing education.

Table 1. Background information of participants (N=437).

Frequency (%) Frequency (%)

Gender Race or Ethnicity
Female 89.05 White 65.62
Male 9.95 Hispanic 19.78
Transgender 0.25 Black or African American 7.42
Other 0.75 Asian 2.92

American Indian or Alaska Native 1.57
Religious Affiliation Native Hawaiian or Pacific Islander 0.45
Christian 45.74 Other 2.25
Spiritual but not religious 20.79
Agnostic 9.98 Social Work Degree
Nothing in particular 6.24 MSW 92.64
Jewish 4.57 BSW 15.40
Atheist 3.74 PhD 3.22
Buddhist 3.12 DSW 0.46
Muslim 0.42
Hindu 0.42 Highest Social Work
Don’t know 0.42 Degree Obtained
Other 4.57 2010s 36.27

2000s 36.13
Practice Setting 1990s 16.48
Schools 21.52 1980s 9.48
Mental health centers 21.21 Pre-1980s 4.21
Hospital 13.78
Child welfare 9.75 Practice Area
Hospice 5.73 Urban 56.72
Skilled nursing facilities 2.79 Suburban 24.63
Grief centers 1.55 Rural 17.72
Oncology and dialysis clinics 1.39 Other 0.93
Other 22.29

Note. Mean age=44; age range=22–76; mean practice experience (years)=14, practice experience range (years)=1-47. Percentages
may not sum to 100% because of rounding.

Table 2. End-of-life and grief issues in social work practice and education (N=437).

Questions About Competency Respondents’ Answers Frequency (%)

Frequency of end-of-life and grief issues in social work practice Never 2.30
Rarely 15.21
Sometimes 42.86
Often 26.96
Very Often 12.67

How prepared to address end-of-life and grief issues when first started practicing Not prepared at all 38.34
Somewhat prepared 53.58
Prepared 8.08

How prepared to address spirituality and religion issues when first started practicing Not prepared at all 47.53
Somewhat prepared 47.53
Prepared 4.94

JOURNAL OF SOCIAL WORK EDUCATION 269

The interface between SR and EOL: Educational needs

Table 4 presents the frequency of SR issues in social work practice and practitioners’ competency in
addressing these issues. A majority of participants reported that they encounter SR matters in their work
(often or very often, 37.06%; sometimes 49.42%), and nearly half the participants (49.18%) encounter these
matters often or very often when working with clients with EOL and grief issues. More than a third of
participants (35.28%) reported that their grieving or dying clients initiate discussions about SR often or very
often, whereas less than 25% of participants themselves (23.82%) initiate SR discussions with their grieving
or dying clients, and about a third of participants (33.73%) never or rarely initiate these discussions. In
addition, the majority of participants agreed with the statement that “SR is an important part of clients’ grief
and EOL care issues” (52.49% totally agree, 39.90% agree, 7.60% neutral, 0.00% disagree or totally disagree).
A majority of participants agreed with the statement that “social work should incorporate clients’ spirituality
in our biopsychosocial framework” (57.21% totally agree, 33.17% agree, 8.17% neutral, 1.44% disagree or
totally disagree), and a majority agreed that “social work should incorporate clients’ religiosity in our
biopsychosocial framework” (42.93% totally agree, 35.49% agree, 17.03% neutral, 4.56% disagree or totally
disagree). However, more than a third (36%) of participants do not feel their last social work education
program provided an environment in which they could feel free to discuss SR as these issues related to
practice.

SR competency

When asked about how competent they feel to address the spiritual issues of their grieving and dying clients
(spirituality was defined as a human quality to search for meanings, well-being, and profundity through
connections with ourselves, others, and the universe), more than 20% of participants considered themselves
incompetent (17.26% somewhat incompetent, 6.15% very incompetent). When asked about how compe-
tent they feel to address the religious issues of their grieving and dying clients (religion was defined as an
institutionalized system of beliefs, values, and practices that are oriented toward spiritual concerns and
transmitted over time by a community), more than 30% of participants considered themselves incompetent
(23.70% somewhat incompetent; 8.53% very incompetent). Additionally, more than a third of participants
reported that their personal SR poses a challenge when working with clients who have a different SR from
theirs (34.07% sometimes, 2.70% often). Table 5 shows practitioners’ self-reported comfort levels and
competencies when working with clients from various religious backgrounds. Comfortable was defined as
not experiencing uneasiness caused by personal opinions, beliefs, or values, and competent was defined as
having adequate skills and tools to address the issue. Results show that many social work practitioners
reported feeling uncomfortable or incompetent to address the SR issues of clients from various religious
background.

Table 3. Helpful forms of social work education on end-of-life and grief (N=437).

Forms of Social Work Education
Not Prepared at All (%)

(n=166)
Somewhat Prepared (%) (n=232)

and Prepared (%) (n=35)a

Courses on grief and loss at bachelor’s level 35.15 19.77
Courses on grief and loss at master’s level 75.76 …