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Do Atheists Have End-of-Life Spiritual Needs?
By Ann M. Callahan, PhD, LCSW
Social Work Today
Vol. 19 No. 6 P. 16

Individuals with unorthodox or no spiritual beliefs can face additional complexity at the end of life. Spirituality can be defined in various ways and the experience of relationships that enhance life’s meaning is a spiritual need.

The purpose of hospice care is to promote quality of life by addressing a patient’s biopsychosocial and spiritual needs until the end of life, but as many as 80% to 90% of patients have spiritual needs that risk going unmet (Gijsberts et al., 2011; Peteet & Balboni, 2013). Some patients will suffer in silence for fear of upsetting loved ones (Yang, Staps, & Hijmans, 2010), while others will receive mismatched interventions that fail to support them (Wang, Molassiotis, Chung, & Tan, 2018). Hospice social workers may not be able to prevent spiritual suffering, but they can ensure that patients have the support to meet their spiritual needs.

As described in the author’s book Spirituality and Hospice Social Work (2017), patients need to feel involved and in control, engage in religious/spiritual activities, finish business, maintain a positive outlook, have companionship, and experience nature. Although these needs have been described as “spiritual needs,” patients need not identify as spiritual or religious to experience them. Depending on how spirituality is defined, the experience of relationships that enhance life meaning can be a spiritual need. It is this experience of enhanced life meaning through relationships that defines relational spirituality. Therefore, in applying the concept of relational spirituality, meaningful relationships reflect spiritual needs and can be a source of spiritual support.

Social workers who are sensitive to relationships clients find meaningful can help them identify and cultivate relationships that are spiritually supportive. Multidisciplinary research, social work theory, and traditional practice approaches can help social workers facilitate this process. With an increasingly diverse society, it is important for social workers to protect, support, and respect the rights of all clients (see NASW Standards for Cultural Competence and Code of Ethics). This requires the capacity to be responsive to the unique worldview of all clients and how those clients define their own “spiritual” needs.

Changing Demographics
The Pew Research Center found that between 2012 and 2017, the number of people who identify as “spiritual but not religious” has rapidly increased to about one-fourth of all Americans (27%) (Lipka & Gecewicz, 2017). In addition, 22% of all Americans identify as being “religiously unaffiliated.” People who identify as “religiously unaffiliated” are a heterogeneous group. This includes people who identify their religion as “nothing in particular” (15.8%), agnostics (4%), and atheists (3.1%). More men (62%) than women (38%) identify as being “neither religious nor spiritual.” People who are “neither religious nor spiritual” are also more likely to be white (65%), younger (56%), and have at least some college education (59%). (Learn more at www.pewforum.org/religious-landscape-study.)

For some people who identify as religiously unaffiliated, being so has required a concerted effort. A survey testing religious knowledge by the Pew Research Center found that atheists and agnostics know the most about religion compared with others who are religiously unaffiliated and compared with people in most other religious groups (Fahmy, 2019). The reasons why (Alper, 2018) people do not choose to be affiliated with a religious group is because they do not believe in any kind of god (89%), question many religious teachings (77%), believe religion is irrelevant (63%), and dislike positions taken by churches (54%). They have had to develop their own worldview with limited social support since the majority of Americans identify as Christian (70.6%).

It is possible that some people have maintained religious beliefs without clear awareness. One in 10 Americans say they do not believe in a higher power or spiritual force, but three-quarters (72%) of people who are “religiously unaffiliated” say that they do. Sixty percent of people who identify as being “spiritual but not religious” and 44% of people who are “neither religious nor spiritual” also identify with a religious group. (Learn more at www.pewforum.org/religious-landscape-study/religious-tradition/unaffiliated-religious-nones.) Conflict over religious and/or spiritual questions can be stressful and linger unresolved. A minority identity can also leave one at risk for internalized stigma, discrimination, and social harassment (Keller, Bullik, Klein, & Swanson, 2018; Villa, 2019).

Needs That Transcend Worldview
When confronted by a life-limiting illness, every person needs support to find strength, hope, meaning, comfort, and healing. As such, social workers need the capacity to engage in skilled assessment and intervention that are congruent with the worldview of every client/patient (Taves, Asprem, & Ihm, 2018; Kristeller, Sheets, Johnson, & Frank, 2011). Although research supports the salutary effects of spirituality and religion (S/R) on health, this research has not focused on the experiences of people who are neither religious nor spiritual (Kristeller et al., 2011; Sedlar et al., 2018; Speed, 2017). This limits what is known about the spiritual needs and appropriate resources for atheists.

Speed (2017) suggests that the effect of religion and/or spirituality depends on personal values; however, research by Pederson et al. (2018) found that the need for a meaningful life transcends individual differences in worldview. If a person does not value S/R, then it may suggest that person would not have S/R needs. This may not be true for every person. The needs for life meaning and purpose may be considered spiritual needs based on a person’s unique worldview and how they define spiritual needs. People with implicit religious beliefs or those who continue to question their beliefs may have S/R needs that evoke spiritual suffering if they remain unmet.

Sedlar et al. (2018) found that atheists in their study did experience religious and/or spiritual struggles. The authors describe three broad categories of struggles that include supernatural struggles, interpersonal struggles, and intrapersonal struggles. While struggles with supernatural beings (e.g., being “tempted by evil”) may not be relevant, interpersonal struggles with others with a different worldview can evoke negative thoughts, feelings, and behaviors. Intrapersonal struggles also apply as they relate to conflicts within oneself over meeting personal moral standards and consequent guilt over infraction. This includes doubts about one’s beliefs and loss of life meaning and purpose.

For example, Brennan (2018) analyzes television interviews with Christopher Hitchens, a prolific writer who was an ardent atheist, to analyze how Hitchens approaches the dying process after being diagnosed with cancer. Hitchens seemed to marvel at how much his work had impacted others. He poignantly described his fear of losing his capacity to write, which he considered an essential part of himself and the ultimate end of his existence. Nevertheless, Hitchens remained stoic and committed to his beliefs as he courageously shared his experience. These interviews allowed Hitchens a public forum where he could share his journey, acknowledge his regrets, and gain closure in a world that had been openly hostile to his beliefs.

Spiritually Sensitive Social Work
Spiritually sensitive social work entails drawing from the healing power of meaningful relationships. Social workers can help patients experience meaningful relationships within oneself, with others, and as part of the environment, including with a higher power or spiritual being. (Learn more at www.socialworktoday.com/archive/exc_0217.shtml.) This assumes that all patients have a spiritual need for meaningful relationships and/or spiritual needs that can be met through meaningful relationships. Therefore, spiritually sensitive social work necessitates an awareness of what relationships a patient finds meaningful and the capacity to help patients cultivate relationships that spiritually support them.

Although a focus on meaningful relationships provides social workers one way to spiritually support all patients at the end of life, self-awareness and supervision are essential to determine how personal concerns, values, or beliefs may influence this process. Social workers who identify as S/R may assume that all patients have S/R needs when in fact they do not or do not interpret their needs as such (Ben Natan, Garfinkel, & Shachar, 2010). Conversely, social workers who identify as religiously unaffiliated may fail to recognize when a patient does in fact have S/R needs and miss the opportunity to comfort patients by providing spiritually sensitive social work.

Suggestions for Intervention
Social workers should employ assessment at critical times, such as at the time of diagnosis or when symptoms of illness increase, to ensure spiritual needs are met. When patients clearly identify as being S/R, Spirituality in Patient Care (Koenig, 2013) suggests that assessment may be as simple as asking, “Do you have any spiritual needs or concerns related to your health?” Other times, patients may present with questions that suggest potential for spiritual suffering, such as, “Why is this happening?”; “What purpose did my life serve?”; or “What will happen after I am gone?” Spiritually sensitive social work will focus on helping patients connect with relationships that are valued and experienced as meaningful. This may involve the creation of new relationships.

Spiritually sensitive social work can be delivered through generalist, advanced generalist, and clinical interventions. A meta-analysis of psychology research by Norcross (2012) found that person- and relationship-centered qualities such as collaboration, cohesion, empathy, goal consensus, positive regard, affirmation, congruence, and genuineness significantly influenced treatment outcomes regardless of clinical approach. Generalist social work relies heavily on these qualities to cultivate a spiritually sensitive relationship that has the potential to be therapeutic in and of itself. Depending on the social worker’s expertise and spiritual needs of the patient, advanced generalist and clinical interventions provide additional means of intervention.

Facilitating clients’ spiritual expression, enabling spiritual self-care, and encouraging life review are examples of spiritually sensitive interventions congruent with advanced generalist practice. Clinical social workers may also employ therapeutic interventions informed by, for example, humanism, dignity therapy, and cognitive behavioral therapy to address S/R concerns. A referral to a spiritual care provider is needed for patient assistance with interpreting religious scripture or processing theological issues. Therefore, care referral, coordination, and conjoint visits are important components in the delivery of spiritually sensitive social work.

Opportunity for Advocacy
According to the Pew Research Center, the United States is one of nine countries where nonreligious people have experienced increased social harassment since 2012 (Villa, 2019). Some of this harassment has resulted in hate crimes documented by the FBI (2017). Although the number of atheists is still relatively small, the overall number of people who are religiously unaffiliated is growing. Spiritually sensitive social work is one way to accommodate human diversity in a manner that is congruent with professional ethics. It can also help offset the experience of internalized stigma, discrimination, and social harassment both past and present.

Social workers who are spiritually sensitive recognize the significance of meaningful relationships. This need for meaningful relationships remains even when S/R beliefs do not. Spiritually sensitive social work at the end of life is not intended to provide answers to unanswerable questions, but to open a dialogue about how patients can engage in meaningful relationships that support life quality. Therefore, spiritually sensitive social work provides one way to recognize how relationships make life more meaningful and facilitate interventions that help patients do the same. It is this cultivation of meaningful relationships that helps ensure all patients can meet their universal need for compassionate care.

Ann M. Callahan, PhD, LCSW, (www.dranncallahan.info) is an associate professor in the social work program at Eastern Kentucky University.


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