End of Life: Do Atheists Have End-of-Life Spiritual Needs?
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.1,2 Some patients will suffer in silence for fear of upsetting loved ones,3 while others will receive mismatched interventions that fail to support them.4 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, patients need to feel involved and in control, engage in religious/spiritual activities, finish business, maintain a positive outlook, have companionship, and experience nature.5 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 the National Association of Social Work’s 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.
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.7 The reasons why 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%).8 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.9,10
Needs That Transcend Worldview
Speed suggests that the effect of religion and/or spirituality depends on personal values; however, research by Pedersen and colleagues found that the need for a meaningful life transcends individual differences in worldview.14,15 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 and colleagues found that atheists in their study did experience religious and/or spiritual struggles.13 The authors describe three broad categories of struggles that include supernatural struggles, interpersonal struggles, and intrapersonal struggles. While struggles with supernatural beings (eg, 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 studies 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.16 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
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.17 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
Spiritually sensitive social work can be delivered through generalist, advanced generalist, and clinical interventions. A meta-analysis of psychology research by Norcross 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.19 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
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.
2. Peteet JR, Balboni MJ. Spirituality and religion in oncology. CA Cancer J Clin. 2013;63(4):280-289.
3. Yang W, Staps T, Hijmans E. Existential crisis and the awareness of dying: the role of meaning and spirituality. Omega. 2010;61(1):53-69.
4. Wang T, Molassiotis A, Chung BPM, Tan JY. Unmet care needs of advanced cancer patients and their informal caregivers: a systematic review. BMC Palliat Care. 2018;17(1):96.
5. Callahan AM. Spirituality and Hospice Social Work. New York, NY: Columbia University Press; 2017.
6. Lipka M, Gecewicz C. More Americans now say they’re spiritual but not religious. Pew Research Center website. https://www.pewresearch.org/fact-tank/2017/09/06/more-americans-now-say-theyre-spiritual-but-not-religious/. Updated September 6, 2017.
7. Fahmy D. Among religious ‘nones,’ atheists and agnostics know the most about religion. Pew Research Center website. https://www.pewresearch.org/fact-tank/2019/08/21/among-religious-nones-atheists-and-agnostics-know-the-most-about-religion/. Updated August 21, 2019.
8. Alper BA. Why America’s ‘nones’ don’t identify with a religion. Pew Research Center website. https://www.pewresearch.org/fact-tank/2018/08/08/why-americas-nones-dont-identify-with-a-religion/. Updated August 8, 2018.
9. Keller B, Bullik R, Klein C, Swanson SB. Profiling atheist world views in different cultural contexts: developmental trajectories and accounts. Psychol Relig Spiritual. 2018;10(3):229-243.
10. Villa V. Religiously unaffiliated people face harassment in a growing number of countries. Pew Research Center website. https://www.pewresearch.org/fact-tank/2019/08/12/religiously-unaffiliated-people-face-harassment-in-a-growing-number-of-countries/. Updated August 12, 2019.
11. Taves A, Asprem E, Ihm E. Psychology, meaning making, and the study of worldviews: beyond religion and non-religion. Psychol Relig Spiritual. 2018;10(3):207-217.
12. Kristeller JL, Sheets V, Johnson T, Frank B. Understanding religious and spiritual influences on adjustment to cancer: individual patterns and differences. J Behav Med. 2011;34(6):550-561.
13. Sedlar AE, Stauner N, Pargament KI, Exline JJ, Grubbs JB, Bradley DF. Spiritual struggles among atheists: links to psychological distress and well-being. Religions. 2018;9(8):242.
14. Speed D. Unbelievable?! Theistic/epistemological viewpoint affects religion-health relationship. J Relig Health. 2017;56(1):238-257.
15. Pedersen HF, Birkeland MH, Jensen JS, et al. What brings meaning to life in a highly secular society? A study on sources of meaning among Danes. Scand J Psychol. 2018;59(6):678-690.
16. Brennan M. Christopher Hitchens’ public dying: toward a secular-humanist ars moriendi? Omega. 2018;77(2):99-132.
17. Ben Natan M, Garfinkel D, Shachar I. End-of-life needs as perceived by terminally ill older adult patients, family and staff. Eur J Oncol Nurs. 2010;14(4):299-303.
19. Norcross JC, ed. Evidence-Based Therapy Relationships. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.463.7645&rep=rep1&type=pdf. Updated 2012.
20. 2017 hate crime statistics: victims. Federal Bureau of Investigation website. https://ucr.fbi.gov/hate-crime/2017/topic-pages/victims