A review of the literature to-date (2022) on occupational therapy and spirituality.

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Literature Review: Spirituality and Occupational Therapy
“If occupational therapy is to be complete and genuine in its consideration of humans as occupational
beings, it must acknowledge spirituality as an important dimension.” (Christiansen, 1997, p. 169)
~~
The following paper is a review of the current literature on the topic of spirituality and occupational
therapy (OT). Specifically, the role of spirituality within OT practice: how it is understood, how it is—
or is not—being addressed in practice, and opportunities for the future. A total of 42 publications were
reviewed consisting of peer-reviewed papers, reports, and textbooks. Four key themes were identified
amongst the literature. First, that spirituality is seen as a core aspect of holistic, client-centered OT
practice and is an integral component of patient recovery. Second, that despite this, many OTs do not
feel confident to address spirituality in practice. Third, there is a lack of formal assessments which can
be utilised by OTs in their various practice contexts to evaluate a patient’s spirituality (including the
patients’ spiritual history). And finally, that practical information, training, education, and critical self-
reflection are essential in overcoming this ‘gap’ between theory and practice.
In its beginnings, OT was firmly rooted within religious movements and continues to be
associated with the spiritual dimension of healthcare (Jones et al., 2016). Today, spirituality is widely
acknowledged as a key part of OT practice amongst therapists (Belcham, 2004; Collins, 2016; Egan &
Swedersky, 2003; Hemphill, 2020; Jones et al., 2016; Milliken, 2020; Misiorek & Janus, 2019; Morris
et al., 2014). According to the Royal College of Occupational Therapists (RCOT):
Spirituality can be defined as the search for meaning and purpose in life, which may or may not
relate to a belief in God or some form of higher power. For those with no conception of
supernatural belief, spirituality may relate to the notion of a motivating force, which involves
an integration of the dimensions of mind, body and spirit. This personal belief or faith also
shapes an individual’s perspective on the world and is expressed in the way that he or she lives
life. Therefore spirituality is expressed through connectedness to God, a higher being; and/or
by one’s relationship with self, others or nature. (Johnston & Mayers, 2005, p. 386).
In a similar vein, Belcham (2004) notes that it is the underlying philosophical concept of holism in OT
which—in theory—prioritises not just the treatment of body and mind, but spirit also. This centrality
of spirituality is underscored in a number of OT models including the Canadian Model of Occupational
Performance and Engagement (CMOPE) which identifies spirituality as a fundamental component of
human function. Likewise, the Canadian Association of Occupational Therapists (CAOT) acknowledge
the centrality of spirituality and the way in which it is “shaped and expressed through occupations”
(Polatajko et al., 2007, p24). Collins (2016) notes that, alongside bio-psycho-social considerations, OT

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considers spirituality as an equally important component of a patient’s well-being and quality-of-life.
This includes experiences of transcendence which may form a crucial part of a patient’s rehabilitation
(recovery) journey, leading to an increased sense of meaningful participation in one’s occupations.
Alongside the interpersonal and intrapersonal, these experiences can be categorised as being
transpersonal in nature: that is, transformational experiences of interconnectedness and
interdependence which go beyond one’s existing ego/identity boundaries, leading to a change in how
people consciously experience everyday life and their occupational identity (do Rozario, 1997). Indeed,
during major life events, transitions, and illness, patients from a variety of contexts report maintaining
or a deepening of their spiritual beliefs (Milliken, 2020). Spirituality can become a life-sustaining
phenomenon which assists individuals to cope with the challenges bought on by illness and disruptive
life changes (Wilding, 2007; Wilding et al., 2005). Moreover, it is often during a health crisis or at the
end-of-life that one’s spiritual needs more strongly emerge. This is seen most evidently in palliative
care settings where spirituality—often in the form of religious ritual-based practices—become a vital
source of sustenance and meaning-making for patients journeying through the end-of-life process
(Weegan et al., 2019). Whilst the exact nature of the relationship is unclear from the research thus far,
it is clear that a strong sense of spirituality is associated with embracing acceptance and coping with
suffering, fear, and guilt, as well as growth, finding hope, and the will to fight (Maley et al., 2016).
Collins (2007) suggests that this association is due to a change in the patients’ occupational identity:
that is, spiritual practices and experiences can lead to transformations in consciousness whereby an
individuals’ self-awareness and occupational identity expand. This, in turn, counteracts the occupational
deprivation and de-adaptation that is initially experienced by patient’s when encountering a major
illness or health-related life transition. Thus, an expanded occupational identity—connected to one’s
being—can become the primary source of a process of self-renewal, enabling a person to engage in
occupations—their doing—in new ways as well as envisioning a new future (i.e. their sense of
becoming). This process is described by transpersonal therapists as a ‘spiritual emergency’ and is
inextricably linked with one’s occupational identity. A crucial role of the therapist, then, is to provide
a safe and supportive relational environment in which this process can take place. In prescribing
occupational engagement during this time, the therapist must be sensitive to the balance of ‘inner’ and
‘outer’ adaptations that can enable the patient to engage in creative forms of self-expression which
support self-renewal. Here, Wilcock’s (2015) Occupational Perspective of Health (OPH) becomes a
helpful lens, highlighting the interconnected role of spirituality and occupations—including
occupational identity—in human health and well-being.
Nevertheless, whilst the role of spirituality is clearly acknowledged in dominant OT models as
well as the research literature to-date, there remains a significant gap between theory and practice. Put
simply, challenges are faced by many therapists when seeking to operationalise spiritually competent
care in everyday occupational therapy practice. Such challenges stem from difficulties in defining

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exactly what spirituality is: what is considered spiritual by one patient may significantly differ from
another (Jones et al., 2016). In addition to this, organised religion and spirituality are closely connected
however not completely analogous: many people are increasingly identifying today as ‘spiritual but not
religious’. In a survey of 97 OTs, Morris et al. (2014) found that therapists acknowledged the
importance of spirituality as a part of holistic, client-centered practice however many felt discomfort in
addressing it in their everyday practice. Four key reasons were identified as to why this gap exists: a
lack of formal OT curricula on spirituality, a lack of assessment instruments, lack of clarity around OT
scope-of-practice (or ‘role ambiguity’), and challenges in understanding spirituality as a concept. It is
for these reasons that therapists from a diversity of practice contexts have acknowledged spirituality as
a ‘neglected core’ in occupational therapy practice (Belcham, 2004; Babaei et al., 2021; Misiorek &
Janus, 2018; Pham et al., 2022). Rather than attempting to define spirituality, Jones et al. (2016) sought
to describe the key aspects of spirituality. Seven concepts were identified via a concept analysis of eight
studies: addressing suffering, meaning, connectedness, transcendence, becoming, being, and
centeredness. In a survey of occupational therapists, Egan and Swedersky (2003) likewise identified
four key themes amongst those addressing spirituality in practice: addressing religious concerns,
addressing suffering, encouraging the self, and growing as a person. Thus, any OT practice framework
relating to spirituality must be flexible enough to encompass all these key dimensions whilst
acknowledging that they are expressed—or not expressed—in unique and diverse ways amongst
patients. Understanding what spirituality encompasses rather than trying to neatly define and quantify
it—a reductionistic approach which potentially misunderstands the very nature of spirituality (Wilson,
2010)—is necessary in order to address the subsequent role ambiguity which many therapists encounter.
The provision of practical, context-appropriate training and information by appropriately qualified and
experienced therapists has been identified as one important means of remedying this (Belcham, 2004).
Another identified challenge is the lack of formal OT assessments which evaluate a person’s
spirituality and spiritual history (Belcham, 2004; Johnston & Mayers, 2005). In a survey of 310
occupational therapists, over 80% of participants did not feel that valid assessments of spirituality or
spiritual need were available to them (Morris, 2013). Without such assessments, therapists do not feel
equipped to make clinical judgements of when and how to conduct interventions or measure outcomes
related to spirituality. As a consequence, it is only in very specific practice contexts that spirituality will
be addressed by individual therapists who feel comfortable approaching the topic. Despite the lack of
OT-specific assessments of spirituality, a number of other assessments utilised in various healthcare
contexts have been suggested by Hemphill (2020) as appropriate for OT practice. These include
Puchalski’s (2005) FICA spiritual assessment, Maugans’ (1997) spiritual history assessment, the
Religious Society of Friends’ (2005) spiritual assessment, Engelside’s Skilled Nursing and
Rehabilitation Center Assessment Tool, the HOPE assessment (Anandarajah & Hight, 2001), and the
Brief Multidimensional Measure of Religiousness/Spirituality (Fetzer Institute & National Institute on

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Ageing Working Group, 1999). Hemphill (2015) further suggests that any spiritual assessment used in
OT practice should be context-specific and that the therapist administering must be able to distinguish
between religion and spirituality as well as have a sound awareness of their own spirituality. It is
important, then, that any therapist addressing spirituality in their OT practice has been given the
opportunity to undergo their own spiritual history assessment and self-critically reflect on how their
own spirituality—or lack thereof—influences their clinical practice.
In a systematic review of the psychometric properties of various spiritual well-being scales, Pellengahr
(2018) identified the Spiritual Well-Being Scale (SWBS) and the Functional Assessment of Chronic
Illness Therapy – Spiritual Well-Being Scale (FACIT-Sp) as amongst the most utilised spiritual
assessments across a variety of healthcare settings. In a comparison of both assessments, the FACIT-
Sp was found to be a more suitable measure due to its content and quality. The FACIT-Sp-12 is a 12-
item questionnaire aimed at measuring the spiritual well-being of people with cancer or other chronic
illnesses. Having been developed with input from cancer patients, psychotherapists, and
religious/spiritual experts, the FACIT-Sp-12 was validated by a large ethnically diverse sample and has
been used as a successful assessment of spirituality of people from across a diverse range of religious
traditions as well as those who self-identify as ‘spiritual but not religious’ (Bredle et al., 2011). It has
been linguistically validated in 15 languages and has been used across a variety of practice contexts
including in psychiatric (Lucchetti et al., 2015; Sankhe et al., 2017), geriatric (Agli et al., 2017),
oncological (Hasewaga et al., 2017; Korup et al., 2020; Peterman, 2002), paediatric (Alvarenga et al.,
2022), neurological (Wilson et al., 2017), and palliative care settings (O’Callaghan et al., 2020). The
FACIT-Sp-12 consists of three sub-domains that constitute spiritual well-being: peace, meaning, and
faith (Bredle et al., 2011). These sub-domains were shown to be an important determinant of overall
health-related quality of life (HRQOL). Moreover, spiritual well-being was shown to be linked with
psychosocial adaptation. Thus, despite not being OT-specific, the FACIT-Sp-12 is a suitable spiritual
assessment to be used by OTs given its validity and use across a variety of practice contexts.
Importantly, the FACIT-Sp-12 can be used as a springboard for further exploration of spiritual
interventions which may enhance a patient’s HRQOL, psychosocial, and occupational adaptation.
In a study by Misiorek and Janus (2019), graduate OTs acknowledged the importance of
spirituality in their own lives, in their clients’ lives, and its positive influence on the quality of their
therapeutic relationships. Despite similar findings amongst the relevant literature, there continues to
remain a significant gap between OT theory and practice. Indeed, OT cannot claim to be truly holistic
and client-centered if spirituality continues to be neglected in practice (Morris et al., 2014). In reviewing
the relevant literature to-date, a number of recommendations will be suggested here to address this gap
in the acute-care context of Royal North Shore Hospital (RNSH). However, these recommendations
may also be applied to other relevant OT practice settings. Firstly, the importance of spirituality must
be underscored in OT frameworks and/or models which are being utilised in practice. One such model

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is the Pan Occupational Paradigm (POP) which incorporates key concepts from Wilcock’s (2015) POH.
Specifically, the concepts of doing, being, belonging, and becoming as dimensions of occupation (see
Appendix 1). Within this framework, spirituality is seen as being both distinctly aligned with being and
something which is expressed in the integrated interactions between all dimensions of occupation (Hitch
& Pepin, 2020). Thus—to use an example—if a patient identifies as Roman Catholic, this religious
tradition will be core to their being: how they understand their identity and sense-of-self (including their
occupational identity). This identity is in dynamic relationship with this patient’s everyday occupations
(doing), their sense of connectedness to others and/or to something larger than themselves (belonging),
and their sense of life direction and goal-setting (becoming). Disruptions within-and-between these
dimensions of occupation lead to greater ill-being, illness, and deprivation. Hence, whilst spirituality is
‘grounded’ within the being aspect of a person, it is also something which is expressed in, reinforced,
and shaped by a person’s doing, belonging, and becoming. It is something which, whilst only implicit
in some OT models, is vital to all dimensions of human occupation: not as another aspect in isolation
from all others but rather as that which permeates and holds together the whole (Bremault-Phillips,
2018; Wilson, 2010). Here, Iwama et al.’s (2011) Kawa River Model can serve as a useful tool in
identifying the barriers to the expression of these aspects of occupation in a patient’s life including any
disruptions—or ‘misalignment’— between them. To return to our example, the Roman Catholic patient
may be experiencing an increased sense of meaninglessness and disconnectedness due to the impact of
a chronic illness. Upon further investigation by an OT, it may be found that there are barriers preventing
this patient from expressing and engaging with their spiritual identity: being unable to participate in the
ritual practice of the Eucharist (doing) which, conversely, impacts their sense of connection to a parish
community and to God (belonging) as well as to a greater life direction or purpose (becoming). This, in
turn, significantly impacts the patient’s sense of wellbeing. The treating OT, then, will seek to address
the identified barriers and disruptions in order to allow the ‘river’ to flow freely once again between the
patient’s doing, being, belonging, and becoming. Importantly, both the POP and Kawa River Model are
flexible enough to be used with patients from a diversity of religious and spiritual backgrounds.
Secondly, an appropriate assessment of spirituality and spiritual history must be made available and
utilised consistently in-practice. On top of the reasons identified earlier in this review, the FACIT-Sp-
12 (see Appendix 2) may serve as an appropriate measure in the acute-care environment given its
validation and use across a variety of clinical settings. Where appropriate, the longer FACIT-Sp-Ex (see
Appendix 3) can also be administered to gain further insight into a patient’s spirituality. Given the lack
of longer-term data available on spiritual assessments in OT practice, utilising the FACIT-Sp-12 for an
extended period of time will provide an opportunity to gather such data and contribute to the overall
improvement of OT services delivered. Alongside this, training should be provided on the correct
administration of the FACIT-Sp-12 as well as giving therapists the opportunity to take their own
spiritual history and undertake critical self-reflection on how this may influence their own OT practice.

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Finally, increased training and education is essential in overcoming this gap between OT theory and
practice. More broadly, this means incorporating spiritual assessment and intervention in OT university
training programs. Today, OT programs teach units focussed solely on psychosocial assessment and
intervention. However, the spiritual dimension of the bio-psycho-social-spiritual framework (Collins,
2016) continues to remain largely neglected. Beginning to incorporate spirituality within psychosocial-
focussed teaching units is one suggested path forward given the close link between spirituality and the
psychosocial. More specifically to the RNSH acute-care context, practical in-service training and
information can be provided: on the concept of spirituality, it’s connection to OT/OT models and health,
its various expressions in patients’ lives (including the difference between religion and spirituality),
how to administer the FACIT-Sp-12, and spiritual interventions which can be utilised. As a part of this,
an interdisciplinary approach is vital as OTs may need further input from religious and spiritual care
professionals—such as licensed chaplains and pastoral carers—on specific spiritual interventions
relevant to the patient’s unique spiritual history (Maley et al., 2016). As has already been mentioned,
therapists being trained in administering spiritual assessments should be given the opportunity to
undertake their own spiritual history and critically reflect on their findings under the supervision of an
appropriately trained therapist. Additionally, students-on-placement may be encouraged to do the same
as a part of developing greater therapist self-awareness and understanding of the holistic nature of OT.
Such training may encourage therapists to understand the role of spirituality in OT through four key
themes: meaning, connection, compassion, and transcendence. That is, OT which is spiritually-
competent will endeavour to address and/or increase a patient’s sense of meaning, connectedness,
compassion, and experiences of transcendence. By nature, OTs understand the centrality of meaning: it
is found and expressed through one’s occupational identity, roles, and everyday activities.
Connectedness encompasses a variety of relations that we each participate—or don’t participate—in as
human beings: one’s relationship to self, others, nature, and/or the transcendent. Closely related to this
is the notion of compassion: for self, others, and other living beings. Whilst compassion has been central
to various religious and spiritual traditions for millennia, its effective use in clinical contexts has only
recently been recognised through therapeutic interventions such as Compassion Focussed Therapy
(CFT) (Craig et al., 2020; Gilbert, 2020), Acceptance and Commitment Therapy (ACT) (Dindo et al.,
2017; Hayes, 2019), and self-compassion training (Neff & Germer, 2017). The development of
compassion within-and-between both patient and therapist can be a powerful catalyst for behavioural
change. Likewise, one’s spiritual/religious beliefs, practices, and experiences can be a source of
compassion amidst challenging health-related life circumstances. And importantly, spiritually-
competent OT will address patients’ religious and/or mystical experiences of self-transcendence—
otherwise known as transpersonal experiences—which can be powerful catalysts for positive changes
in their health and well-being. Using these four descriptive themes to understand and operationalise
spirituality may allow the necessary flexibility which a rigid definition would hinder (Smith, 2008). As
Hayward and Taylor (2011) identify, current OT practice risks becoming overly-medicalised and,

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consequently, focussed solely on the doing component of occupation. In re-integrating spirituality back
into OT practice, OTs can ensure that they are genuinely holistic and client-centered, addressing all
aspects of the occupational person—doing, being, belonging, and becoming—and thereby giving those
we work alongside the best possible chance of truly flourishing.

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Appendices
Appendix 1
Hitch & Pepin (2020)

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Appendix 2
Accessed at https://www.facit.org/measures/FACIT-Sp-12

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Appendix 3
Accessed at https://www.facit.org/measures/FACIT-Sp-Ex