Spirituality: The Forgotten Link in Occupational Therapy Practice

Clinician holding hands with patient and closing eyes, praying

“We are not human beings having a spiritual experience. We are spiritual beings having a human experience.” – Pierre Teilhard de Chardin

If spirituality is integral to the body-mind-spirit connection and client-centered care, why is this topic often neglected among occupational therapists? As several studies demonstrate, spirituality and religion (S/R) play a significant role in individuals’ understanding of their suffering, adapting, and interpreting their illness and disability through a spiritual perspective. Finding hope, peace, comfort, resilience, support, acceptance, and connection alleviates suffering.1-2 Additionally, S/R can promote healthy lifestyle choices, coping strategies, enhanced quality of life, and well-being.3-4

Spirituality, expressed through meaningful occupations, inherently falls within the domain of all occupational therapy practice. The American Occupational Therapy Association (AOTA) considers spirituality a significant client factor, and the Canadian Model of Occupational Performance and Engagement (CMOP-E) views spirituality as the core motivational force within a client.5-6

What Is Spirituality?

The AOTA defines spirituality as a “deep experience of meaning brought about by engaging in occupations that involve the enacting of personal values and beliefs, reflection, and intention; within a supportive contextual environment.”5

Many people find spirituality through religion or a personal relationship with the divine. Others may find it connected to nature, music, the arts, meditation, yoga, chanting, social action, and volunteering.

Are Religion and Spirituality the Same?

While religion and spirituality are often used interchangeably, they are not synonymous. Spirituality is broader, encompassing the search for meaning, purpose, and connection. In contrast, religion is a specific set of organized beliefs, symbols, rituals, and practices, usually shared by a community or group.

People may identify as a combination of religious and spiritual, but being religious does not automatically make one spiritual or vice versa. Other individuals do not identify as either religious or spiritual. However, Thompson and colleagues stress, “when religious observance is not given equal consideration like any other facet of the client, the overall scope of therapy may be limited from its holistic potential. Even when clients do not specifically mention religious observance as a priority, it does not negate the need to raise questions about the importance this topic may have for individuals.”7

Discomfort, Lack of Preparedness, and Fear Impede Implementation in OT Practice

The topic of spirituality is often uncomfortable for some occupational therapists and provokes a sense of vulnerability in their clients and themselves.8 This discomfort contributes to the reluctance of occupational therapists to engage their clients on this topic. Occupational therapists also report fear of offending their clients, projecting their own beliefs, lack of time, and uncertainty about reimbursement.9 As a result, occupational therapists usually wait until clients initiate discussions surrounding their spiritual needs. Moreover, academic programs that do not address the importance of spirituality leave practitioners ill prepared.10

Spiritual History Assessments

Before initiating a spiritual assessment, Anandarajah & Hight state that practitioners “need to understand their own spiritual beliefs, values, and biases to remain patient-centered and non-judgmental when addressing the spiritual concerns of patients,” primarily when the beliefs differ.11 However, when practitioners have firmly held values, they risk imposing their views; therefore, it might be necessary to refrain from conducting an assessment. Obtaining consent is essential before initiating a spiritual assessment.

The FICA assessment involves questions about clients’ faith, the importance of their beliefs, membership in a spiritual community, and if there are spiritual practices they wish to develop.12 The FICA examines four concepts:

  • F: Faith, Belief, Meaning
  • I: Importance and Influence
  • C: Community
  • A: Address/Action in Care

The HOPE assessment involves five questions addressing core aspects of spirituality. This assessment can facilitate a meaningful discussion with diverse populations whose spirituality does not affect traditional religious practice. It also allows those for whom religion, God, or prayer are significant to volunteer this information. The five questions include:

  • H: Sources of hope, meaning, comfort, strength, peace, love, and connection
  • O: Organized religion’s importance in the client’s life
  • P: Personal spirituality and practices that are helpful
  • E: Effect of medical care and end-of-life issues—This question involves possible conflicts about S/R beliefs and medical care/decisions, the impact of illness on spiritual participation, and access to S/R resources (chaplain or community spiritual leader).

Although spirituality and religion are often ambiguous and create discomfort in occupational therapy practice, they play a vital role in health promotion, prevention, recovery, and adaptation to illness and disability. Spirituality and religion provide resources for coping, finding meaning and purpose in suffering, quality of life, and well-being. As the occupational therapy profession embraces holistic and client-centered care, implementing S/R is essential in improving our clients’ lives and demonstrating our distinct value.

  1. Büssing, A. & Koenig, H.G. (2010). Spiritual Needs of Patients with Chronic Illnesses. Religions, 1(1), 18-27. https://doi:10.3390/rel1010018
  2. Puchalski, C.M. (2001). The Role of Spirituality in Health Care. Baylor University Medical Center Proceedings, 14(4), 352-7. Retrieved from https://doi.org/10.1080/08998280.2001.11927788
  3. Cook, C.H. & White, N. H. (2018). Resilience and the role of spirituality. In Oxford Textbook of Public
  4. Johnson, S., Alonso, B., Faulkner, K., Roberts, H., Monroe, B., Lehman, L., & Kearney, P. (2017). Quality of life perspectives of people with amyotrophic lateral sclerosis and their caregivers. American Journal of Occupational Therapy, 71, 7103190010. http://dx.doi.org/10.5014/ajot.2017.024828
  5. American Association of Occupational Therapy (2020). Occupational Therapy Practice Framework: Domain & Process (4th ed.) American Journal of Occupational Therapy, 74(2). Retrieved from https://doi.org/10.5014/ajot.2020.74S2001
  6. Polatajko, H.J., Townsend E.A. & Craik, J. (2007). Canadian model of occupational performance and engagement (CMOP-E). In E. Townsend. & H. Polatajk (Eds.) Enabling Occupation 11: Advancing an occupational therapy vision of health and well-being and justice through occupation. Ottawa, ON: CAOT Publications. 
  7. Thompson, K., Gee, B. M., & Hartje, S. (2018). Use of Religious Observance as a Meaningful Occupation in Occupational Therapy. The Open Journal of Occupational Therapy, 6(1). Retrieved from https://doi.org/10.15453/2168-6408.1296
  8. Milliken, B. (2020). Clients’ Perspectives of Spirituality in Occupational Therapy: A Retrospective Study. The Open Journal of Occupational Therapy, 8(4), 1-19. Retrieved from https://doi.org/10.15453/2168-6408.1666
  9. Egan, M., & Swedersky, J. (2003). Spirituality as experienced by occupational therapists in practice. American Journal of occupational therapy, 57(5), 525-533. Retrieved from https://doi.org/10.5014/ajot.57.5.525
  10. Morris, D., Stecher, J., Briggs-Peppler, K., Chittenden, C., Rubira, J., & Wismer, L. (2014). Spirituality in Occupational Therapy: Do We Practice What We Teach? Journal of Religion & Health, 53(1), 27–36. Retrieved from https://doi.org/10.1007/s10943-012-9584-y
  11. Anandarajah, G. & Hight, E. (2001). Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment. American Family Practice, 63(1), 81-88. Retrieved from https://www.aafp.org/afp/2001/0101/afp20010101p81.pdf
  12. Puchalski, C. M. & Romer, A. (2000). Taking a Spiritual History Allows Clinicians to Understand Patients More Fully. Journal of Palliative Medicine, 3(1), 129-137. Retrieved from http://www.med.uottawa.ca/courses/totalpain/pdf/doc-32.pdf
  13. Mental Health. Bhugra, D, Bhui, K, Yeung, S, Wong, S Gilman, SE Oxford: Oxford University Press. 513-520. Retrieved from https://global.oup.com/academic/product/oxford-textbook-of-public-mental-health-9780198792994
  14. Hemphill, B. (2020). Spiritual Assessments in Occupational Therapy. The Open Journal of Occupational Therapy, 3(3). Retrieved from  https://doi.org/10.15453/2168-6408.1159
  15. Puchalski, C.M. (2001). The Role of Spirituality in Health Care. Baylor University Medical Center Proceedings, 14(4), 352-7. Retrieved from https://doi.org/10.1080/08998280.2001.11927788