Spirituality and Elders

1
Spirituality and Elders

• Emily K. Schulz, PhD, OTR/L
• OT 665

2
Todays Topic of Discussion is
SPIRITUALITY (not Religiosity)
SPIRITUALITY
RELIGIOSITY
3
Spirituality

• Why do we need to know about it for Occupational
  Therapy?

4
Literature Review

• The literature indicates that
• Spirituality is important in Health Care,
  including occupational therapy.
• Spirituality is part of an holistic approach,
  wellness, and quality of life, all issues that
  occupational therapists are concerned about.
• However - Occupational therapists are unsure how
  to address spiritual issues in practice.

5
AOTA and Spirituality

• The Representative Assembly recently adopted the
  Commission on Practice's (COP) Occupational
  Therapy Practice Framework Domain and Process.
• The Framework describes the professions domain
  of activity and explains how the process of
  occupational therapy service delivery occurs
  within that domain, using updated language and
  terminology that is more easily understood by
  external audiences. The Framework replaces the
  "Uniform Terminology for Occupational
  TherapyThird Edition (UT-III)."
• Terminology
• A motion that was submitted to the RA to add the
  words "spirit/spiritual" to the philosophical
  base was defeated as the concept is included in
  the Occupational Therapy Practice Framework
  document. (fromhttp//www.aota.org/members/area6/l
  inks/link40.asp?PLACE/members/area6/links/link40.
  asp)

6
AOTAs Commission On Practice and Spirituality

• Context a variety of interrelated conditions
  within and surrounding the client that influence
  performance (COP, 2002, p.54)
• Spiritual Context the fundamental orientation
  of a persons life that which inspires and
  motivates that individual (COP, 2002, p.42).
• Examples Essence of the person, greater or
  higher purpose, meaning, and substance (COP,
  2002, p.42).

7
Spirituality

• Experiential Learning

8
Instructions

• Working in small groups, take about 10 minutes to
  come up with a definition of spirituality.
• Write the definition down on a piece of paper.
• Choose a spokesperson to share your definition
  with the larger group.

9
Definition of Spirituality
10
Ross (1995) Description of Spirituality
Connectedness to Beliefs/Values and/or a Higher
Power
VERTICAL ELEMENT
Connectedness to Self, Others, and/or the World
HORIZONTAL ELEMENT
11
A Proposed Definition of Spirituality for
Occupational Therapy From a Literature Review

• Experiencing a meaningful connection to our
  core self, other humans, the world, and/or a
  Greater Power, as expressed through our
  reflections, narratives, and actions.

12
Research Study about Spirituality

• And individuals with disabilities

13
Research Questions

• 1. What is the meaning of spirituality in the
  lives of individuals with disability?
• 2. How has the spirituality of individuals with
  disability evolved across the life span?
• 3. How does spirituality relate to the adaptation
  process of individuals with disability?

14
Three Studies

• Study 1 Reviewing Literature (from which
  definition of spirituality was derived).
• Study 2 Interviewing Adults with Childhood
  Onset Disabilities
• Study 3 Interviewing Adults with Adult Onset
  Disabilities

15
Methodology and Data Analysis

• Study 1
• Literature review OT and Other Health
  Professions re Spirituality
• Proposed Definition of Spirituality
• Applying Themes from Definition of Spirituality
  to autobiographical, empirical and philosophical
  writings of individuals with disabilities

16
Methodology and Data Analysis

• Study 2 Study 3
• Qualitative research
• Semi-structured, face to face, audio taped
  interviews
• Verbatim transcription of interviews
• Two levels of member checking
• (1) transcriptions (2) open coding
• Three levels of Coding open, axial, selective
• axial coding Causal Conditions, Strategies,
  Context, Intervening Conditions,Consequences
• Demographic questionnaire

17
Participants

• Study 2
• Three men and three women with visibly apparent
  childhood onset disabilities.
• 5 Caucasian 1 Hispanic
• Age range 30-58
• All grew up with some form of Christianity.

• Study 3
• Three men and three women with visibly apparent
  adult onset disabilities.
• All 6 Caucasian
• Age range 40-82
• All grew up with some form of Christianity.

18
Study 1- Childhood OnsetDemographics of
Participants

• Name Age Marital Childhood Current
  Cause of
• (gender) Status Religion
  Religion Disability
• Butterfly(f) 37 Married Methodist
  Baptist C.P.
• Lisa(f) 47 Married Catholic
  Catholic Post-Polio
• Marie(f) 35 Married Non-Den.
  Lutheran R.A.
• Mikey(m) 58 Single Methodist
  None C.P.
• Jack (m) 30 Divorced Methodist
  Exploring C.P.
• GeeTee(m) 48 Single Catholic
  Catholic C.P.

19
Study 2 - Adult OnsetDemographics of Participants

• Name Age Marital Childhood
  Current Cause of
• (gender) Status Religion
  Religion Disability
• Joy (f) 52 Married Baptist
  Non-Den. A.V.M.
• Avis (f) 82 Widowed Lutheran
  Lutheran Surgery(blind)
• DeeGee(f) 57 Widowed Baptist
  Pentecostal knee surgery
• Kermit(m) 40 Married Baptist
  None S.C.I.
• Alton (m) 66 Engaged Ch. of
  Christ Ch. of Christ Spinal tumor
• Butch (m) 46 Single Methodist
  Non-Den. Diabetes-BKA

20
Findings

• The Meaning of Spirituality

21
Findings Meaning of Spirituality Analysis
Process

• Meaning of Spirituality
• Definition of Spirituality
• Responses to Literature Review Definition of
  Spirituality.
• Number of times a dimension of spirituality was
  mentioned was tallied and organized into chart
  format.

22
Meaning of Spirituality - Childhood Onset

• Butterfly Spirituality to me means having a
  relationship with Jesus Christ and knowing Him as
  the person who came to save them from death and
  an eventuality of eternal hell.... Spirituality
  is the daily decision making.
• Lisa spirituality means belief in a Higher
  Power, something greater than you, and it also
  deals with your responsibility towards the rest
  of mankind and the world that you live in.
• Marie It is something that keeps you going when
  you are really upset and you cant do anything
  else that keeps you truly structured and reality
  based and where you need to be. it is something
  inside you that is connected to your life, to
  your world and to the world outside you.
  Timeless, ageless, it doesnt matter how old you
  are, where you are, it is something inside you
  that you can access through whatever methods are
  tangible to you.

23
Meaning of Spirituality - Childhood Onset

• Mikey Im not sure what spirituality is.
• Jack Spirituality to me means a connection with
  a higher power and its about learning lessons
  that a higher power whos higher than you is
  trying to teach you.
• GeeTee Spirituality is very important. It helps
  me look at myself and follow through with my
  life. Without spirituality I wouldnt be able to
  exist. Spirituality is a blessing and if you
  believe in it, it works. If you believe
  wholeheartedly that your spirit can be cleansed
  and in yourself and God things can come true.

24
Meaning of Spirituality - Childhood Onset

• Name self others world G.Power reflections
  narratives actions
• Butterfly x
  x x
• Lisa x x
  x x
  x
• Marie x x x
  x
  x
• Mikey
• Jack
  x x
• GeeTee x
  x x
• Totals 3 2 2 4
  5 0
  2

25
Meaning of Spirituality- Adult Onset

• Joy Its what you have in your heart, I think,
  and its not what you have in your head but what
  you have in your heart. what you want to do
  everyday Its what a person feels.
• Avis Thats your trust in the Lord and your
  faith.
• DeeGee Anyway you look at spirituality. Its a
  type of love, and love is something that you give
  whether it be a small smile, a hug, or if you
  give money to your church, your tithe,
  spirituality - it comes from nature, from Gods
  goodness and its love.

26
Meaning of Spirituality - Adult Onset

• Kermit to me, you dont have to have religion in
  order to have spirituality. Spirituality is how
  one feels within themself and to me the way they
  treat others and society and our earth.
• Alton I would define spirituality as being a
  guideline to follow and adhere to and to use to
  understand myself.
• Butch its something that comes over you a
  warm fuzzy feeling Or sometimes it just strikes
  you just like you know its there and its just
  like a bolt - ...and you know thats what it is.
  To me, thats spirituality.

27
Meaning of Spirituality - Adult Onset

• Name self others world G.Power reflections
  narratives actions
• Joy x
  
  x
• Avis
  x x
• DeeGee x x
  x
  x
• Kermit x x x
  
  x
• Alton x
  x
  x
• Butch x
  x
• Totals 4 2 2
  3 2 0
  4

28
Meaning of Spirituality

• Group self others world G.Power
  reflections narratives actions
• Child
• Onset 3 2 2 4
  5 0
  2
• Adult
• Onset 4 2 2 3
  2 0
  4
• Totals 7 4 4 7
  7 0
  6

29
Findings - Meaning of Spirituality Combination
of Responses to all 3 questions

• Group self others world G.Power
  reflections narratives actions agree
• Child
• Onset 12 8 8 16
  15 6 11 4/6
• Adult
• Onset 18 10 9 11
  9 5 10 4/6
• Totals 30 18 17 27
  24 11 21 8/12

30
The Meaning of Spirituality Model - Childhood
Onset
Others
Connecting to Others through kindness, helping,
hugs, smiling, email, support groups
Higher Power
Meaning and Purpose in Life
Self
Connecting to Self and Gaining Meaning and
Purpose in Life
Connecting to a Higher Power through outward
expression (anger, gratitude, asking for help,
faith) and inward receiving (learning and
understanding)
The World
Connecting to the World through social activism,
travel and the Internet
31
The Meaning of Spirituality Model Adult Onset
Connecting to a Higher Power through Faith, Hope,
and Beliefs
Higher Power
Connecting to Others through Trust, Kindness,
Listening, Helping, Hugs, Smiling, Love
Self and Feelings
Others
Connecting to Self through Feelings From That
Connection Expressing Spirituality Through
Actions.
Connecting to the World through taking care of
Nature, Enjoying Nature, Participating in Sports,
Treating Society well.
The World
32
Spirituality

• Experiential Learning

33
Instructions

• Analyze your definition of spirituality using the
  categories of self, others, the world, greater
  power, reflections, narratives, and actions.
• Write your responses down on a piece of paper.
• Choose a spokesperson to share your results with
  the larger group.

34
Analysis of Definitions Of Spirituality From
Experiential Learning

• self others world G.Power
  reflections narratives actions

35
Analysis of Definitions Of Spirituality From
Experiential Learning

• self others world G.Power
  reflections narratives actions

36
Spirituality and Occupational Therapy Theory

• Occupational Adaptation

37
Occupational Adaptation Schematic
OCCUPATIONAL ENVIRONMENT Element
PERSON Element
INTERACTION Element
Demand for Mastery
Desire for Mastery
Press for Mastery
Occupational Challenge
Occupational Environment
Person
Occupational Role Expectations
Adaptive Response Generation Subprocess
Incorporation into Occupational Environment
Occupational Response
Adaptive Response Integration Subprocess
Adaptive Response Evaluation Subprocess
Assessment of Response Outcome
38
The Person System and the Adaptive Response
Generation Subprocess
Person
Adaptive Response Generation Subprocess
Adaptive Response Mechanism
Adaptation Gestalt
39
The Person
Adaptive Response Generation Subprocess
Adaptive Response Mechanism
Adaptation Gestalt
Adaptive Response Modes
Adaptive Response behaviors
Adaptation Energy Primary Energy Secondary Energy
Cognitive
Psychosocial
Hyperstable Hypermobile Blended
Existing Modified New
Sensorimotor
40
The Adaptation Gestalt
Psychosocial
Cognitive
Sensorimotor
41
Adaptation According to Occupational
Adaptation Frame of Reference (Schkade Schultz,
Schultz Schkade, 1992)

• Adaptation is
• A Constant
• A Life long normative process
• Involves the whole person
• Cognitive
• Psychosocial
• Sensorimotor

Adaptation Gestalt
Cognitive
Psychosocial
Sensorimotor
42
The Adaptation Gestalt and Spirituality
Connecting to self, others the world and/or a
greater power Expressing through reflections
narratives, and actions
Expressing through reflections and narratives
Psychosocial
Cognitive
Sensorimotor
Expressing through narratives and actions
43
Spirit as Integrator of the Adaptation Gestalt
Spirit
Psychosocial
Cognitive
Sensorimotor
Spirit
44
A Third Dimension of Spirituality

• Time

45
A Quote From Adolf Meyer (1922/1977)

• the culminating feature of evolution is mans
  capacity of imagination and the use of time with
  foresight based upon a corresponding appreciation
  of the past and of the present proper use, and
  a religious conscience, of time with its
  successive opportunities(p.640 642).

46
Ross (1995) Description of Spirituality
Connectedness to Beliefs/Values and/or a Higher
Power
VERTICAL ELEMENT
Connectedness to Self, Others, and/or the World
HORIZONTAL ELEMENT
47
Temporal Aspects of Spirituality

• The past holds a rich reservoir of spiritual
  resources for healing and recovery.
• The present offers a potent opportunity to
  connect to ones spirituality for
  self-transformation.
• The future is a beacon of hope and possibility
  for healing and recovery.

48
Three Dimensions of Reality (Smith, 1976,p.24).
49
A Revised Proposed Definition of Spirituality for
Occupational Therapy

• Experiencing a meaningful connection to our
  core self, other humans, the world, and/or a
  Greater Power, as expressed through our
  reflections, narratives, and actions within the
  context of space and time.

50
SPACE
Spirit
Cognitive
Psychosocial
Time
Time
Sensorimotor
Spirit
SPACE
51
Three Dimensional Spirituality Model
The Mystery that is Spirituality
Experiencing a meaningful Connection to a Higher
Power, Values and/or Beliefs as Expressed
through our reflections, narratives and actions.
The Past
The Adaptation Gestalt
Experiencing a disconnection from the Core self,
Others and/ or the World as Expressed through our
reflections, narratives and actions.
Experiencing a meaningful connection to the Core
Self, Others and/or the World as Expressed
through our reflections, narratives and actions.
The
Person
The Future
The Present
Experiencing a Disconnection from a Higher Power,
Values, and/or Beliefs as Expressed through our
reflections, narratives and actions.
52
Why is Spirituality

• Important to address with Elders?

53
Developmental Life Task - Integrity versus Despair

• Some elders develop a sense of pride and
  contentment with both the past and present with a
  stronger sense of community.
• Others experience despair Too many mistakes
  were made and theres no time to fix it now.
• Death as a feared end, or as a part of the cycle
  with a new view of survival the afterlife
  i.e. meeting my maker going to Heaven etc

54
Community and Connectedness

• Elders value a sense of community
• Many elders may experience isolation and
  loneliness especially the old-old
• Addressing spirituality may lead to ways to
  minimize the isolation and loneliness that elders
  experience through discovering new ways to
  facilitate connectedness.

55
Elders and End of Life

• Developmentally, elders are addressing the life
  task of Integrity versus Despair
• Life review may be painful for them.
• Helping them to find positive and healing ways to
  connect to the past and themselves (the core
  self) may be useful.
• Finding ways to help them resolve old hurts and
  reconnect with loved ones in positive ways
  through meaningful occupation may also be
  appropriate.

56
Religion and Spirituality

• Many elders equate their spirituality with their
  religious practices and beliefs.
• Finding ways to facilitate their participation in
  those practices in spite of sensory and mobility
  losses will be extremely meaningful to them.

57
Spirituality and Occupational Therapy

• Case Studies

58
Case Study

• An Elderly woman.
• A resident of a nursing home.
• Fell and fractured her right hip.
• Underwent ORIF to her right hip.
• Prior to her fall, was alert and lucid.
• Upon return to the Nursing Home after surgery,
  demonstrated increased confusion.
• Difficult to engage her in occupational therapy.

59
Case Study (continued)

• As a visiting therapist, I was asked to treat
  her.
• When I entered her room she was sitting in a
  wheelchair with her eyes closed.
• When she saw me asked me to please pray for her.
• I asked her to say the prayer instead, which she
  did.

60
Case Study (continued)

• Following her prayer, she engaged in therapy
  (grooming activities at the sink) and stayed
  focused on the task.
• She also engaged in conversation with her new
  roommate.
• They discovered they had something in common that
  they both enjoyed doing in the past (picking
  cotton as a child).

61
Case Study (continued)

• I reported to the in-house therapist the apparent
  importance of prayer to her.
• I also suggested that he set up an activity that
  simulated picking cotton for a future treatment
  session as that task might be something she would
  find engaging.

62
Another Case Study -An Elder and Spirituality

• Example A woman who was a resident in a NH who
  had organic brain disease.
• We will call her Gladys.
• The only time Gladys would not constantly call
  out was when we were discussing her baptism
  and/or reading the Bible.
• That was the last remaining aspect of her life
  that was meaningful enough to her to maintain her
  focus and attention.

63
Incorporating Spirituality into Practice

• Brainstorming

64
Instructions

• Working in small groups, take about 10 minutes to
  come up with suggestions on how to incorporate
  spirituality into practice.
• Write the groups ideas down on the paper
  provided.
• Choose a spokesperson to share the ideas with the
  larger group.

65
Spirituality Assessment Treatment Planning Grid
Connectedness Past Present Future
Why ? How ? Goals To Self High
3 3
3 Medium 2 2 2 Low
1 1
1 None 0
0 0 To Others High
3 3
3 Medium 2 2 2 Low
1 1
1 None 0
0 0 To the World High
3 3
3 Medium 2 2 2 Low
1 1
1 None 0
0 0 To a Greater Power High
3 3
3 Medium 2 2 2 Low
1 1
1 None 0
0 0
66
Questions and Answers

• ?

67

• References
• American Occupational Therapy Association (1979).
  The philosophical base of occupational therapy.
  American Journal of Occupational Therapy, 33,
  785.
• Batterham, R.W., Dunt, D.R. Disler, P.B.
  (1996). Can we achieve accountability for
  long-term outcomes? Archives of Physical Medicine
  and Rehabilitation, 77, 1219-1225.
• Bufford, R., Paloutzian, R., Ellison, C.
  (1991). Norms for the Spiritual Well-Being Scale.
  Journal of Psychology and Theology, 19, 56-70.
• Collins, M. (1998). Occupational therapy and
  spirituality Reflecting on quality of experience
  in therapeutic interventions. The British Journal
  of Occupational Therapy 61(6), 280-284 .
• Csikszentmihalyi, M. (1998). The flow experience
  and human psychology. In M. Csikszentmihalyi,
  I.S. Csikszentmihalyi, I. S. (Eds.) Optimal
  Experience Psychological Studies of Flow in
  Consciousness. Cambridge University Press
  Cambridge, England.
• Csikszentmihalyi, M. Csikszentmihalyi, I. S.
  (Eds) (1998). Optimal experience Psychological
  studies of flow in consciousness. Cambridge
  University Press Cambridge, England.
• Do Rozario, L. (1994). Ritual, meaning and
  transcendence The role of occupation in modern
  life. Journal of Occupational Science, 1(3),
  46-53.

68

• References (Continued)
• Dunn, W., Foto, M., Hinojosa, J., Schell, B.,
  Thomson, L.K., Hertfelder, S.D. (1994).
  Uniform terminology for occupational therapy -
  Third edition. The American Journal of
  Occupational Therapy 48(11), 1047-1054.
• Egan, M. DeLaat, M.D. (1997). The implicit
  spirituality of occupational therapy practice.
  Canadian Journal of Occupational Therapy, 64(1),
  115-121.
• Engquist, D.E., Short-DeGraff, M., Gliner, J.
  Oltenbruns, K. (1997). Occupational therapists
  beliefs and practices with regard to spirituality
  and therapy. The American Journal of Occupational
  Therapy, 51(3), 173-180.
• Frank, G., Bernardo, C.S., Tropper, S., Noguchi,
  F., Lipman, C., Maulhardt, B. Weitze, L.
  (1997). Jewish spirituality through actions in
  time Daily occupations of young orthodox Jewish
  couples in Los Angeles. The American Journal of
  Occupational Therapy, 51(3),199-206.
• Hamilton, D.M. Jackson, M.H. (1998). Spiritual
  development Paths and processes. Journal of
  Instructional Psychology, 25(4), 262-270.
• Hatch, R.L., Burg, M.A., Naberhaus, D.S.,
  Hellmich, L.K. (1998). The Spiritual Involvement
  and Beliefs Scale. Development and testing of a
  new instrument. Journal of Family Practice,
  46(6), 476-486.

69

• References (Continued)
• Kirsh, B. (1996). A narrative approach to
  addressing spirituality Exploring personal
  meaning and purpose. Canadian Journal of
  Occupational Therapy, 63(1), 55-61.
• Loukas, K. M. Steib, P.A. (1999). Results from
  the 1999 meeting of the RA. OT Week, 13(17), 8-9.
• Johnson, R. A. (1993). The fisher king and the
  handless maiden Understanding the wounded
  feeling function in masculine and feminine
  psychology. Harper San Francisco.
• Kyllo, D. O.(1996). Spiritual topics in stroke
  rehabilitation. Topics in Stroke Rehabilitation,
  2(4), 38-43
• Mathew, R.J., Mathew, V.G., Wilson, W.H.,
  Georgi, J.M. (1995). Measurement of materialism
  and spiritualism in substance abuse research.
  Journal of the Study of Alcoholism, 56(4),
  470-475.
• McLoughlin, K., Williams, S., Schiefelbein, J,
  McGuire, C. (1999). Resolution I Position paper
  on spirituality in occupational therapy. OT Week,
  13(5), RA8-RA9.
• Meraviglia, M.G. (1999). Critical analysis of
  spirituality and its empirical indicators.
  Journal of Holistic Nursing, 17(1), 18-33.

70

• References (Continued)
• Meyer, A. (1922). The philosophy of occupational
  therapy. Archives of Occupational Therapy, 1(1),
  1-10. Nelson, D.L. (1988). Occupation Form and
  performance. The American Journal of Occupational
  Therapy, 42(10), 633-641.
• Pulchalski, C.M. (1998). Spirituality and
  medicine. World I, 13(6), 180-185.
• Roberts, G. W. (1999). Values in the spiritual
  context of occupational therapy. The British
  Journal of Occupational Therapy, 62(2), 51.
• Robnett, R.H. Gliner, J.A. (1995). Qual-OT A
  quality of life assessment tool. The Occupational
  Therapy Journal of Research, 15(3), 198-214.
• Ross, L. (1995). The spiritual dimension Its
  importance to patients health, well-being and
  quality of life and its implications for nursing
  practice. International Journal of Nursing
  Studies, 32(5), 457-468.
• Sands, I. F. (1928). When is occupation curative?
  Occupational Therapy and Rehabilitation, 7(2),
  115-122.
• Schkade, J.K. Schultz, S. (1992). Occupational
  adaptation Toward a holistic approach for
  contemporary practice. Part 1. American Journal
  of Occupational Therapy, 46, 829-838.
• Schultz, S. Schkade, J. K.(1992). Occupational
  adaptation Toward a holistic approach for
  contemporary practice. Part 2. American Journal
  of Occupational Therapy, 46, 917-926.

71

• References (Continued)
• Schulz, E.K. (1998, September 28). Interview with
  a chaplain. Unpublished raw data.
• Schulz, E. K. (1988). Therapist qualities and
  behaviors valued by occupational therapists and
  persons with acquired brain injury. Unpublished
  Masters Thesis. Medford, MA Tufts University.
• Schulz, E. K. (1999a). Spirituality and
  disability A literature review. Unpublished
  Manuscript.
• Schulz, E.K. (1999b). The OT-Quest A
  spirituality and quality of experience assessment
  tool. Unpublished Manuscript.
• Smith, H. (1992). Forgotten truth The common
  vision of the worlds religions. Harper San
  Francisco, CA.
• Unruh, A.M. (1997). Spirituality and occupation
  Garden musings and the Himalayan blue poppy.
  Canadian Journal of Occupational Therapy,
  64(1),156-159.
• Ziegler, J. (1998). Spirituality returns to the
  fold in medical practice. Journal of the National
  Cancer Institute, 90(17),1255-1257.
• Zinnbauer, B.J., Pargament, K. I, Cole, B., Rye,
  M.S., Butter, E.M., Belavich, T.G., Hipp, K.M.,
  Scott, A.B., Kadar, J.L. (1997). Religion and
  spirituality Unfuzzying the fuzzy. Journal for
  the Scientific Study of Religion, 36(4), 549-564.