Spiritually Sensitive Social Work with Victims of Natural Disasters and Terrorism.

As a primary intervention, raising the topics of faith and religion with individuals traumatised by terrorism and/or natural disasters can be daunting for social workers, because victims often enter the helping relationship with feelings of helplessness, loss of personal control and of doubt about their relationships, environment, and their cultural and belief systems. Just as clients benefit from knowledge and awareness in the aftermath of a traumatic event, insights gleaned from traumatic experiences and from research can be useful for social workers grappling with the challenges associated with designing and deploying appropriate helping strategies with victims of disaster and terrorism. This article draws on extant literature and survey research, to explore how social workers might ethically assess clients' spiritual perspectives and incorporate helping activities that support clients' recovery, in the context of a spiritually sensitive helping relationship with victims of disaster and terrorism.

Introduction

Disasters and terrorist attacks have become widespread, affecting individuals and communities around the world. Such disasters as flooding, earthquake, tornado, hurricane, or terrorist attack can impact migration patterns, induce traumatic stress, and affect the mental and physical health of survivors, including vulnerable populations (Rosenfeld ). The religious and spiritual orientations of individuals and communities can support resilience or can exacerbate crisis, so they are important to take into account in social services for disaster victims. For example, religious communities might provide physical, emotional, social and philanthropic supports to victims (Koenig, 2006). But sometimes differences and conflicts regarding religious beliefs and values among survivors and between survivors and professional helpers can interfere with service delivery (Rosenfeld ).

Victims' experience of shock can generate existential challenges to their spiritual perspectives, worldviews, and their sense of identity and purpose in the world. Even without a belief in a spiritual or transcendent aspect, people may feel disillusionment and angst. Victims might find solace by strengthening their religious and spiritual commitments, or by returning to abandoned spiritual and religious values and practices. Conversely, spiritual or religious belief systems may collapse if victims' sense of security and trust is severely damaged (Coisman, 2002; Tan, 2006). Although natural disasters and terrorist attacks are inherently local and specific, the mass media play a role as well, determining which disasters receive coverage, disseminating information to the public and shaping collective emotional responses to the disaster via sensational coverage, which may contribute to distant suffering in survivors and the general public (Yell, 2012). Thus, from the perspective of care-givers, helping activities should be aligned with the immediate and long-term effects of a traumatic event, and aid in recovery by fostering resilience.

Historically, arguments for the inclusion of religion and spirituality in social work practice and education have been contested in numerous ways, including claims that educational curricula are already laden in terms of content and training protocols, and the phenomenon of religion and spirituality is incongruous with the tenets of logical empiricism (Barker and Floersch, 2010; Canda and Furman, 1999; Moss, 2005). This article follows common trends in social work and related fields to distinguish spirituality and religion as related but distinct concepts (e.g. Canda and Furman, 2010; Johnson, 2013; Koenig, 2007; Moss, 2005). Spirituality refers to religious and non-religious ways that people search for a sense of meaning, purpose, moral frameworks and connection with what they believe is most profound or sacred. Religion refers to organised spiritually oriented beliefs, rituals and practices shared by a community. In this usage, the term ‘spirituality’ includes religious and non-religious expressions. However, the terms ‘religion’ and ‘spirituality’ are sometimes used separately in order to highlight distinctions between the religious and non-religious expressions of spirituality (Canda, 1990, 1990; Canda and Furman, 1999, 2010).

Previous research has shown that the spirituality discourse in social work is often marginalised in agency and educational settings (Furness and Gilligan, 2014; Gilligan and Furness, 2006). This article develops guidelines for a spiritually sensitive way to address people's challenges related to disasters. Spiritually sensitive practice ‘seeks to nurture persons’ full potentials through relationships based on respectful, empathic, knowledgeable, and skillful regard for their spiritual perspectives, whether religious or nonreligious' (Canda, 2008, pp. x–xi). These guidelines are developed by converging insights from inter-disciplinary literature on spirituality related to disaster and trauma response, and responses of social workers to national surveys about spirituality in four countries (i.e. Norway, New Zealand (NZ), the UK and the USA). Accordingly, this article first presents the conceptual background, methodological details, sample characteristics and study limitations from the surveys, and then findings. The conclusion draws together a summary of insights for spiritually sensitive practice with people who have experienced disasters.

The multinational surveys

Conceptual background

The multinational studies were designed to explore workers' perspectives on the inclusion and use of spirituality and religion in direct practice. Factors that served as the impetus for the studies included: (i) social work's alignment with a secular humanist orientation and a holistic view of the person-in-environment was challenged in the mid-1980s, as evidenced by a body of literature that advocated for a bio-psycho-social-spiritual view of personhood and anti-oppressive practice (Canda and Furman, 2010); (ii) emerging political theories (e.g. Huntington, 1996) indicated that religious identity would influence post-Cold War relations and geopolitical formations; (iii) given that the profession had abandoned the religious/spiritual dimensions of personhood (Canda and Furman, 2010), there was a perceived need in the late 1990s to collect empirical evidence on this subject; and (iv) the subject's controversial nature (Canda and Furman, 1999). The studies asked respondents to provide basic demographic information, educational background, religious and spiritual affiliation, and level of agreement on raising the topics of religion and spirituality with specific client issues. Additionally, respondents were presented a set of spiritually based helping activities and asked to identify those they used in practice and those they felt were appropriate for use in practice. Other questions measured respondents' agreement on potential conflicts between religion and spirituality, and social work's mission and ethics.

Methodology

Social workers from the UK (2000), NZ (2006), the USA (2008) and Norway (2011) were randomly sampled from memberships of national social work organisations in each country. Each study was submitted to country-specific Institutional Review Boards (IRBs) for approval before being administered to social workers. Respondents were informed that there are no known risks associated with this research and that participation is voluntary (for further details on methodology, reliability and validity, please see previous publications by Canda and Furman, 1999, 2010; Furman , 2004, 2007; Zahl and Furman, 2005; Stirling ; Vetvik ).

Sample characteristics and study limitations

Findings from attitudinal research reflect the personal interests and ideologies of participants, the effects of acculturation, values and group norms, the dominant theories and practice paradigms that shape researchers' construction of survey instruments, the administrative constraints imposed by institutions, the availability of economic support and technology, extant research methodologies and the contexts in which surveys are deployed (Saris and Gallhofer, 2014). Respondents may have had an interest in religion and spirituality, either for or against. Researchers also were constrained by the limited opportunities for attending to non-response given strictures on respondent confidentiality, which resulted in lower response rates. The findings, therefore, do not permit generalisations about social workers as a whole in each respective country. The surveys, furthermore, were conducted over the course of ten years and may not reflect attitudinal changes engendered by historical events, and alterations to ethical codes, policies and educational curricula.

Demographics reveal that respondents are predominantly white, female, forty to sixty years old, and practising in a Euro-American context (Canda and Furman, 2010; Furman ; Stirling ; Vetvik ). The profession in NZ has been shaped by models of welfare provision from the UK introduced via colonialism and Maori culture, wherein spirituality plays an important role (Stirling ). A majority in the UK (56 per cent), NZ (53 per cent), the USA (57 per cent) and Norway (52 per cent) self-identified as exclusively Christian. Another 20 per cent in the USA reported an affiliation with Judaism. Some respondents in the UK (16 per cent), NZ (11 per cent), the USA (14 per cent) and Norway (33 per cent) identified with a singular non-religious orientation (e.g. Agnosticism, Atheism or Secular Humanism). A small minority reported multiple affiliations (e.g. Christianity/Buddhism, Atheism/Existentialism, etc.) (Canda and Furman, 2010; Furman ; Stirling ; Vetvik ). Amongst those who responded, a majority in the USA (58 per cent) were engaged in private practice. A large majority in the UK (91 per cent), NZ (67 per cent) and Norway (85 per cent) were practising in the voluntary or public/statutory sectors.

As Table 1 shows, some items (6, 7, 12, 14, 15, 16 and 21) were excluded in Norway in order to accommodate questions that address social workers' actual experiences with the theme of religion and spirituality in practice. Concerns about questionnaire length contributed to this decision. Items 20 and 21 were added to the US survey instrument due to growing interest in multidisciplinary teams and spiritual care, and thus were absent in the UK and NZ questionnaires.

Table 1

Percentage of respondents who endorse spiritually based helping strategies by countrya

Helping strategy	UK 2000 (N = 789)		NZ 2006 (N = 162)		USA 2008 (N = 1,804)		NOR 2011 (N = 134)
	%	N	%	N	%	N	%	N
1 Use or recommend religious or spiritual books or writings	43.3	322	62.4	93	76.5	1,308	58.1	75
2 Pray privately for a client	48.8	359	58.4	87	68.3	1,168	28.6	36
3 Pray with a client	28.4	205	59.6	87	44.8	750	21.7	28
4 Meditate privately to prepare for seeing a client	61.8	444	n/a	n/a	86.3	1,478	57.4	74
5 Meditate with a client	n/a	n/a	37.5	54	60.4	1,020	15.9	21
6 Use religious language or concepts	48.3	362	59.0	85	73.3	1,265	n/a	n/a
7 Use non-sectarian spiritual language or concepts	68.1	504	78.2	115	90.7	1,581	n/a	n/a
8 Recommend participation in a religious or spiritual support system or activity	53.2	397	72.4	110	85.3	1,485	39.4	52
9 Touch clients for ‘healing’ purposes	8.7	66	15.6	23	22.3	382	4.7	6
10 Help clients develop religious and spiritual rituals as clinical intervention	61.5	464	75.3	116	77.1	1,333	34.4	45
11 Participate in a client's religious or spiritual rituals as practice intervention	35.8	269	56.1	83	32.3	553	25.8	34
12 Encourage the client to do regular religious or spiritual self-reflective diary keeping or journal keeping	47.4	354	66.0	99	78.8	1,371	n/a	n/a
13 Discuss the role of religious or spiritual beliefs in relation to significant others	74.4	557	75.9	110	88.2	1,536	80.2	105
14 Assist clients to reflect critically on religious or spiritual beliefs or practices	57.9	435	62.2	92	73.2	1,253	n/a	n/a
15 Help clients assess the meaning of spiritual experiences that occur in dreams	26.3	197	31.3	47	67.9	1,155	n/a	n/a
16 Help clients consider the spiritual meaning and purpose of their current life situations	61.7	461	63.3	95	81.9	1,417	n/a	n/a
17 Help clients reflect on their belief about what happens after death	74.8	557	73.8	110	88.1	1,526	51.9	68
18 Help clients consider the ways their religious and spiritual support systems are helpful	86.4	654	90.0	135	96.2	1,667	80.6	104
19 Help clients consider the ways their religious and spiritual support systems are harmful	69.6	523	71.9	105	82.0	1,403	66.2	86
20 Refer clients to a clergy person, or other religious or spiritual helpers or leaders	n/a	n/a	n/a	n/a	89.5	1,551	82.4	108
21 Collaborate with a clergy person or other religious or spiritual leaders	n/a	n/a	n/a	n/a	85.9	1,473	n/a	n/a

aPercentages and frequencies are based on valid responses. The notation ‘n/a’ indicates that the helping activity was not included in the country's survey instrument.

Respondents' attitudes towards the integration of religion and spirituality in social work practice also may reflect nation-specific responses to secularisation, or the historical process in which religious authority is differentiated from governmental and public life, and an epistemology shaped by rationalism, utilitarianism and empiricism displaces religious or spiritual epistemologies as the dominant way of perceiving the world (Canda and Furman, 2010). Although a secular state, the USA continues to exhibit higher levels of religious involvement than other industrialised countries, and some social services are provided by religious organisations. References to Judeo-Christian conceptualisations of morality and God are pervasive in the country's civil religion (Canda and Furman, 2010). A large majority of US respondents do not believe that addressing religion (84 per cent) and spirituality (91 per cent) in practice violates the constitutional principle of separation of church and state. The UK and Norway both have state churches, albeit with much lower levels of participation than in the USA (Canda and Furman, 2010; Furman ; Stirling ; Vetvik ) and social work remains a highly secular profession in which matters of religion and spirituality receive little, if any, priority (Furman ; Furness and Gilligan, 2014; Gilligan and Furness, 2006; Zahl and Furman, 2005). Historically, religious interests never played a role in Norwegian social work, which was influenced by Marxist ideologies in the 1960s and 1970s (Canda and Furman, 2010; Furman ; Zahl and Furman, 2005). In NZ, social work and society in general are highly secular, although Maori spirituality and culture are recognised at the state and professional levels (Canda and Furman, 2010; Stirling ). Even though a large majority in the UK (76 per cent), NZ (86 per cent), the USA (81 per cent) and Norway (79 per cent) believe that spirituality is a fundamental aspect of being human, a higher percentage in NZ (48 per cent) believe that practice with a spiritual component has a better chance to empower clients, compared with respondents in the UK (38 per cent), the USA (45 per cent) and Norway (26 per cent).

In sum, differences in response patterns between countries may be impacted by a number of factors that influence the degree to which matters of religion, spirituality, belief and non-belief, receive professional recognition and endorsement, including agency-level policies and legislative mandates, representation in academic curricula, professional codes defining ethical conduct, acceptance amongst practitioners, and the importance afforded to matters of belief and non-belief in the larger culture (Canda and Furman, 2010; Furness and Gilligan, 2014).

Finally, the studies presented above were designed in Euro-American academic settings and administered to workers in Euro-American practice settings. The findings, therefore, should be evaluated and adapted accordingly to clients' cultural and spiritual backgrounds, strengths and presenting issues. Coates, Gray and Hetherington (2006) have observed that ‘a paradox exists as the foundational, universalising beliefs of mainstream social work have not been successful in accommodating or integrating First Nations’ or indigenous perspectives and modes of helping and healing' (p. 384). If workers adopt a receptive stance to clients' worldviews, it might in turn inform workers' efforts in designing effective helping strategies and anti-oppressive practice models.

Spiritually sensitive guidelines and activities for practice with disaster victims

The guidelines presented below focus on spiritual and other difficulties that disaster victims might bring to the post-disaster helping relationship, challenges faced by practitioners with regard to using spiritual and religious themes in practice, the characteristics of a spiritually sensitive helping relationship, spiritual assessment and specific helping activities.

Client-based spiritual challenges in disaster situations

In the aftermath of catastrophes, early intervention is critical in ameliorating harmful physical, psychological and emotional effects, including vulnerability to Post Traumatic Stress Disorder (PTSD) (Rosenfeld ). Trauma, generally defined, includes intense feelings of fear and helplessness in response to overwhelming circumstances. Furthermore, individual coping skills and once reliable communal and family support systems may fail. Traumatic wounding may also impinge upon an individual's internal meaning system and sense of identity (Farley, 2007). An individual's response may be influenced by proximity to the event. Victims may experience the event directly, or vicariously, for example, when friends and family members are involved, or through service delivery in post-disaster relief efforts (Smith). The degree of disruption, the meaning assigned to the event, the presence of familial and social support, and stage in life (e.g. elderly) can impact whether an event is perceived as traumatic (Miller and Heldring, 2004). Adverse effects may manifest in an individual's inability to cope and maintain relationships, neurobiological harm, shortened attention span, and negative cognitions, memories and emotions (e.g. dissociation, numbing) and loss of beliefs (Perez ).

Survivors may be preoccupied by concerns related to basic survival and safety of self and others, finances, health, relocation, isolation and loss of loved ones, pets and possessions. Thus, social workers may be called upon to assess the client's safety and well-being, the impacts of the event upon a client, and the client's cognitive abilities and the conditions of the post-event environment. Optimally, the social worker will have the opportunity to build rapport with the client, secure the client's safety and well-being, help the client process the catastrophe and the client's subsequent emotional and behavioural responses in the aftermath, discuss and prepare the client for the future, and facilitate referrals should they be needed. Even when basic needs and concrete services are the focus of concern, the helping process itself can be enhanced through a spiritually sensitive relationship with clients, characterised by qualities of empathy, respect, trust, unconditional positive regard and openness to the client's culture, worldview and existential questions, even if explicitly religious or spiritual matters are not of interest or relevance to the client (Canda and Furman, 2010; Cooper, 2004).

In addition, as discussed above, workers may encounter clients for whom a catastrophic event is contributing to a newly discovered spiritual awareness; clients who turn to their religious and spiritual beliefs and support systems as sources of strength and resilience; and clients who are reflecting upon a catastrophic event in terms of their personal histories and altered circumstances (Vis and Boynton, 2008). Therefore, it can be important to assess whether religion and spirituality are relevant and significant to the clients in these situations. For these reasons, it is useful to consider the comfort level of social workers for exploring and engaging spirituality and religion.

Social worker-based spiritual challenges in disaster situations

Workers may be reticent to incorporate spiritual care due to the possibility of proselytising, or of tensions stemming from differences between workers' and clients' spiritual beliefs and values. Workers, furthermore, may lack agency support, training and familiarity with spiritually based helping activities (Canda and Furman, 2010; Furman ; Furness and Gilligan, 2014; Gilligan and Furness, 2006).

In response to these concerns, social workers have several avenues to develop competence in spiritual care. Furness and Gilligan (2014), for example, encourage workers to explore various religious and spiritual beliefs, practices and traditions. A programme of study might include an examination of transpersonal behaviour theories (e.g. Fowler, 1981), culturally competent practice with clients from various faith-based traditions (e.g. Hodge, 2005) and ethical frameworks for practice that take into account worker preparedness, informed consent, client self-determination and the presence of a spiritually sensitive helping relationship (Canda and Furman, 2010; Hodge, 2011). Second, as part of establishing cultural competence and developing a spiritually sensitive practice, workers should engage in ongoing self-reflection regarding their personal spiritual values, beliefs and assumptions (Barker and Floersch, 2010; Canda and Furman, 2010; Furness and Gilligan, 2014).

Establishing a spiritually sensitive helping relationship

Workers should take care to ensure confidentiality and safety in consideration of survivors' vulnerability and suffering (Rosenfeld ). As mentioned above, workers should refrain from any form of proselytising in the post-disaster spiritually sensitive helping relationship. General qualities, such as respect for diverse cultural and spiritual backgrounds, empathy, openness to clients' religious and spiritual strengths and resources, positive regard, active listening and creative engagement with clients' worldview and existential questions, can enhance the helping relationship and encourage spiritual growth and transformation (Canda and Furman, 2010; Furness and Gilligan, 2014).

Spiritual assessment

After a disaster, administering complex spiritual assessments may not be feasible. Figures 1 and 2 show workers' endorsement of raising the topics of religion and spirituality with clients experiencing the effects of natural disaster. A higher percentage in each country supported raising the topic of non-sectarian spirituality compared to religion by a margin of about 11 to 21 percentage points. For all countries combined, 48.5 per cent supported raising the topic of religion, whereas 65.1 per cent supported raising the topic of non-sectarian spirituality. Norwegian respondents were the most reluctant to raise either topic. Religion and spirituality, as noted earlier, have not played significant roles in Norwegian social work (Zahl and Furman, 2005). The government, however, mandates that workers attend to the spiritual dimensions of their clients (Rammeplan, 2005).

Figure 1

Respondents' endorsement of raising the topic of religion with clients experiencing the effects of natural disaster by country.

Figure 2

Respondents' endorsement of raising the topic of spirituality with clients experiencing the effects of natural disaster by country.

This difference between comfort levels of raising the topics of spirituality and religion may reflect either social workers aversion to the subject, or a wise caution to avoid inappropriate proselytising and imposition of beliefs. Further, people recovering from trauma are especially vulnerable to re-traumatisation and distress that might be induced by inappropriate impositions of spiritual beliefs and practices favoured by social workers or service organisations that do not match clients' own preferences. Certain cultures or communities may have conventions in place that discourage the discussion of personal beliefs and practices. Workers should consider the forms of religious and spiritual expression in a community in their initial assessments. This caution may be more pronounced in more secular countries, as indicated by the highest levels of support among American respondents and the lowest among Norwegian. Yet, given the spiritual and religious issues that can be triggered by catastrophic events, it seems prudent for social workers to become more comfortable and skilled in spiritual assessment. Practitioners may want to limit their initial assessment efforts to include basic questions related to religious or spiritual affiliation and group membership if the situation warrants it. A victim's openness, or lack thereof, to such questions may cue the social worker as to the importance of religious and spiritual matters.

Given due caution about inappropriate introduction of the topics of spirituality and religion, as well as recognition of their potential importance, workers might want to start with implicit assessment questions to determine relevance to clients. These address issues of meaning, purpose, hope, moral codes, significant support systems and significant life priorities, without using such terms as ‘religion, spirituality, or faith’ (Canda and Furman, 2010), such as ‘What gives you a sense of hope in the midst of this crisis?’ Or ‘How are you trying to make sense of this situation?’ or ‘What are your most important support systems in the community?’.

Then the worker can follow the client's cues to determine whether explicit exploration of religion or spirituality is relevant. Cultural or religious references embedded in the client's responses can also cue the worker about what terminology, beliefs and support systems would be appropriate to engage. For example, Starnino, Gomi and Canda (2012) present a set of guidelines for spiritual strengths assessment in mental health work.

Given clients' responses to implicit exploration, as part of the post-disaster assessment process, workers might pose questions to determine whether spirituality is important to the client, such as (i) Are spirituality, faith, or religion important to you in dealing with this crisis? (ii) Earlier, you mentioned a religious (or spiritual) group that is supportive and meaningful you. Could you explain how it might be helpful in this situation? (iii) Do you have any beliefs, religious or spiritual practices such as prayer, meditation or rituals which are especially meaningful to you at this time? (iv) Are there any clergy or spiritual advisers whom you would like me to contact? (v) Is there anything related to your spiritual or religious life that might be relevant to our work together? (adapted from Canda and Furman, 2010; Moss, 2005).

The responses to these assessment approaches can open up possibilities for any of the spiritually oriented helping activities discussed below that are an appropriate fit for the client and situation.

Helping strategies

Workers engaged in disaster relief may work with economically and socially disenfranchised victims, indigenous peoples, as well as those from more privileged backgrounds. Coates , however, have criticised social work's problematic relation with the values of inclusivity and cultural diversity, and the limitations of its practice models in meeting these ideals. The following helping strategies are offered with the intent that they may inform workers' efforts in developing strategies and practice models that include the spiritual care of victims experiencing the effects of disasters and terrorism. Table 1 shows social workers' endorsement of twenty-one helping activities for potential use with clients who express an interest in religion and/or spirituality. These data, furthermore, should be evaluated with the study limitations in mind.

Worker preparation for practice

Workers may want to employ practices such as prayer or meditation that will prepare them to be mindful and fully present to clients in the practice setting. A majority in NZ and the US surveys indicated that praying privately for a client is appropriate (item 2). Another majority in the UK, USA and Norway endorsed private meditation in preparation for seeing a client (item 4; note, not surveyed in NZ). Some believe that prayer can contribute to clients' resilience and positive health outcomes (Koenig, 2007). If prayer is integrated into preparation for practice, workers should obtain clients' consent.

In disaster settings, the danger of vicarious trauma is heightened for relief workers. Dombo and Gray (2013) stress the importance of rest-taking, attendance at religious spiritual services, involvement in professional spiritual support groups, spiritual cleansing, private spiritual practices and meditation to offset vicarious trauma and fatigue.

Activities that support clients' self-expression and self-reflection

Expressive therapies such as art, music and bibliotherapy can be used as alternative modes of communication, spiritual exploration, assessment and intervention in the practice setting (Malchiodi, 2005). A majority of respondents in NZ, the USA and Norway indicated that it is appropriate to use or recommend religious or spiritual media (item 1). Furthermore, encouraging clients to do regular religious or spiritual self-reflective journal keeping can be meaningful, not only in discerning the effects of a traumatic event, but also as an instrument for constructing a life narrative, or a spiritual autobiography. A majority in the USA and NZ felt this is appropriate (item 12; note, not surveyed in Norway). Should the client share this narrative with family and community, it can promote a shared sense of understanding and serve as an articulation of trauma and grief that others may not be able to voice.

Prayer and meditation with clients

Some victims might wish to utilise spiritually based activities that relieve stress, help them to feel centred, work through shock, reflect on existential questions or connect with a sacred source of support. These commonly include prayer, meditation and ritual. A majority in NZ indicated that praying with a client is appropriate (item 3), which may reflect the support for Maori spirituality in the social services. A majority in the USA endorsed meditation as an appropriate activity (item 5). This response may reflect the latitude that US social workers have in their private practices. If a spiritually sensitive helping relationship is in place, prayer and meditation with clients may be appropriate if the worker and client have complementary belief systems and informed consent has been established. If this is not the case, a worker can demonstrate respect for the client by maintaining a period of silence, for example, when the client prays (Canda and Furman, 2010).

Non-sectarian spiritual and religious language and concepts

If a client frames the catastrophic experience in religious or spiritual terms, it may be appropriate to use religious or non-sectarian spiritual language and concepts within the context of the helping relationship (items 6 and 7). A majority in NZ and the USA approved of using religious language and concepts. A large majority in three of the four studies approved of using non-sectarian spiritual language and concepts (not surveyed in Norway). Clients may find meaningful parallels to their experiences, insights and inspiration, and models for recovery in the metaphors and stories found within their religious and spiritual traditions.

Touch therapies

A small minority in each country approved of body therapies (e.g. touching clients for healing purposes, body work, massage therapy, etc.) (item 9). The risks for misuse by workers or clients' misinterpretation of workers' gestures are high given that disaster victims may be at the height of vulnerability. Workers should ensure that best practices for informed consent and training are in place (Canda and Furman, 2010; Whiteside and Butcher, 2015). Therapeutic forms of touch, however, have been shown to affect the release of neurochemicals in the brain that impact pain response and the ability to bond with others, and to decrease negative symptoms related to cancer, insomnia, PTSD and mental health disorders (McKinney and Kempson, 2012; Weze ). Touch in practice, furthermore, may reinforce efforts to establish empathy in the helping relationship, provide reassurance, support or ‘symbolic mothering’ if a client regresses to a pre-verbal stage, and help clients navigate other difficult emotional states such as anxiety (Lynch and Garrett, 2010; McKinney and Kempson, 2012; Strozier ).

Rituals and ceremonies

Rituals and commemorative events can be an important way to structure the experiences of loss and grief in the aftermath of a disaster. Rituals and ceremonies can give meaning to a traumatic event and help clients cope with their grief and suffering. Public rituals, such as religious services, can offset clients' isolation and restore a sense of belonging in a community (Thompson, 2008). Consistently with this, a majority in the UK, NZ and US surveys endorsed helping clients develop religious and spiritual rituals as a clinical intervention (item 10). Norwegian social workers, however, did not endorse this activity to the same degree as the other countries. This may be due to lack of training and agency support, and cultural conventions concerning the private nature of belief (Zahl and Furman, 2005; Furman ). A minority in each country, however, endorsed social worker participation in clients' rituals (item 11). There may be times, however, when collective grief may warrant participation by the worker, especially in the case of public events of commemoration after a catastrophic event. Canda and Furman (2010) offer guidelines for designing rituals and ceremonies in the helping relationship (pp. 346–9).

Reflective activities

At times, a traumatic event may produce uncanny moments where clients may ask ‘what if’ questions: What if I had arrived 5 minutes earlier? Why was I spared, but not my neighbour? Underlying such questions, of course, is an unspoken question: what if I had died?

Apropos to these questions, a majority in each country endorsed helping clients reflect on their belief about what happens after death (item 17). Existential and spiritual questions related to mortality also may be linked to other transformations in clients' recovery. A change in a clients' worldview may impact relations with family members, friends and co-workers. At times, such changes can result in estrangement from others (i.e. I no longer feel that I know my loved one). A majority in each country endorsed discussing the role of religious or spiritual beliefs in relation to significant others (item 13). Clients may not be aware of the impact that their personal transformations may be having on those around them, and workers can play an important role in shaping the client's awareness.

A catastrophic event can undermine the personal and collective identities of survivors. Belief systems that shape how a nation or community perceives itself, and feelings related to security and safety, can be decimated by a single event, prompting existential and spiritual crises. As clients move beyond the direct effects of a catastrophe, belief systems and identities may be called into question, underlining the importance of a worker's role as a guide when clients confront these difficult crises.

Many social workers felt that exploring the quality of clients' involvement with religious or spiritual beliefs and groups is appropriate. This included assisting clients to reflect critically on religious or spiritual beliefs or practices (item 14; not surveyed in Norway) and considering whether religious and spiritual support systems are helpful (item 18) or harmful (item 19). Although many social workers may be more comfortable with clients' involvement in spiritual groups structured by egalitarian principles and passive recruitment efforts, some clients may prefer groups characterised by an authoritarian leadership style, and clearly defined doctrinal teachings and moral parameters. If a client questions the beliefs and practices of, or chooses to separate from, an authoritarian group, however, the worker should be prepared to help the client ameliorate the potential effects of ostracism, including fear, shame and guilt (Canda and Furman, 1999) and the impact it may have on trauma-related stress in the aftermath of a catastrophe.

Natural disasters may result in loss of life, loss of personal possessions and memorabilia, and displacement. The world, once seemingly safe and predictable, is now hostile and frightening. A majority in each country (note, not surveyed in Norway) endorsed helping clients to consider the spiritual meaning and purpose of their current life situations (item 16). As previously discussed, this may be critical in working with disaster victims as existential and spiritual crises emerge in the aftermath of the event.

One aspect of traumatic stress can be sleep disturbance and disturbing dreamscapes (Rosenfeld ). Helping clients assess the meaning of religious or spiritual images that occur in dreams may also be useful should clients ask for assistance. Jungian concepts such as active imagination and symbol amplification could be used to help clients interpret their dreams (Hall and Nordby, 1973). This was not recognised, however, by many survey respondents (item 15; note, not surveyed in Norway).

Religious and spiritual support systems

Despite the caution expressed about raising the topics of spirituality and religion, many workers recognise the importance of engaging with spiritual support systems. A large majority in the USA and Norway indicated that referral to clergy is appropriate (item 20). Nearly 86 per cent (item 21) of US social workers also believed that collaboration with clergy or other religious or spiritual leaders is appropriate. Furthermore, a majority in the UK, NZ and USA endorsed recommending participation in a religious or spiritual support system or activity (item 8). Involvement in a religious or spiritual support system, if available, could help to offset some of the challenges related to isolation and/or distressed familial and communal support systems throughout the recovery process. Such involvement could be very helpful in later stages of recovery as clients gain some distance from the catastrophic event and seek to become more community-oriented (Rosenfeld ).

Conclusion

It is clear from the multinational surveys that many workers in these countries recognise the importance of religion and spirituality for practice, including in the event of disasters. A large majority in each country believe that spirituality is a fundamental aspect of being human, yet there is a wide range of opinion about the appropriateness of various spiritually oriented helping activities and resources. In addition, most social workers in all countries have reported that they did not receive formal educational preparation for addressing spirituality. In order to help social workers become better prepared for spiritually sensitive practice with survivors of disasters, this article has offered recommendations and suggestions for assessment and helping activities.

Previous research (Canda and Furman, 2010; Furness and Gilligan, 2014; Gilligan and Furness, 2006; Gray, 2008; Holloway, 2007; Moss, 2005) has identified a number of factors that may contribute to professional opposition and ambivalence regarding the integration of religious and spiritual concerns in education and practice. These opposing factors and views include, but are not limited to, the predominance of secular societies and epistemologies (Gray, 2008; Moss, 2005), proselytising (Canda and Furman, 2010; Moss, 2005), incidents of abuse and the potential endangerment of vulnerable service users (Furness and Gilligan, 2014; Moss, 2005), the subordinate status of women and children, and partiality towards heteronormativity in world religions (Canda and Furman, 2010; Furness and Gilligan, 2014; Moss, 2005), incompatibility between religious and spiritual values and modern consumerism and market-driven economies (Holloway, 2007; Moss, 2005), sectarian violence and terrorism (Furness and Gilligan, 2014; Moss, 2005), religion as a manifestation of psychopathology (Canda and Furman, 2010; Moss, 2005), the privileging of spiritual solipsism at the expense of material and communal concerns, and social justice (Canda and Furman, 2010; Gray, 2008), legislative and policy concerns (Furness and Gilligan, 2014), social workers' lack of education and training (Canda and Furman, 2010; Gilligan and Furness, 2006; Furness and Gilligan, 2014) and social workers' irreligion (Canda and Furman, 2010; Furness and Gilligan, 2014). Although close analysis of this array of opposing perspectives is beyond the scope of one article, it reveals the broad range of attitudes and beliefs that social workers may hold in relation to the inclusion of religious and spiritual concerns in social work practice, which in turn may influence how social workers demonstrate in practice, country-specific professional and international ethical mandates, cultural competence, respect for human diversity, and respectful and effective service delivery. If a majority of social workers truly believe that spirituality is a fundamental aspect of being human, seemingly it would be imperative that clients' spiritual and religious worldviews inform the helping relationship if they are relevant to particular clients' circumstances. Thus, spiritually ‘competent service’ should not be ‘largely a matter of chance’, but stem from a ‘shared professional view of best practice’ (Gilligan and Furness, 2006).

There are several practical suggestions that workers can consider when evaluating interventions and preparing practice models that include a spiritual component for a post-disaster environment: These guidelines, although presented sequentially, should be viewed as a process in which workers' self-reflections, ongoing research and evaluations of the effectiveness of various helping activities in practice inform the unfolding of workers' practice models and enrich their expertise. The guidelines also incorporate the concept of evidence-based practice, which may be important for workers in agency and academic settings who might need to demonstrate various helping activities' effectiveness in producing positive client outcomes. Reflections upon the scholarly literature on disaster and trauma recovery, and the views of social workers on spirituality in several countries take us into the complex, challenging, yet significant territory of spiritually sensitive social work practice. When social workers are both empathetic and professionally engaged, we can share the pain as fellow humans, and accompany others helpfully on their journeys of distress and recovery.

Study the impact of disasters on humans and the environment. As part of an evidence-based spiritual practice, Hodge (2011 suggests that practitioners consult empirical research on spiritual interventions and mental health outcomes in peer-reviewed literature and books. Rosenfeld , for example, offer a comprehensive examination of the nature of disasters and their effects on humans and the environment. As part of this process, social workers can compile a catalogue of potential symptoms that clients might experience due to acute stress and spiritual concerns that may surface in a post-disaster environment. This catalogue, in turn, can be used by social workers in later efforts to research and design effective helping strategies.

Conduct a spiritual self-assessment. Moss (2005), Canda and Furman (2010) and Furness and Gilligan (2010) stress that social workers should articulate their personal values and spiritual orientation (or lack of one) before engaging in spiritually sensitive practice with clients. Workers also may want to develop a self-care plan to help sustain them in post-disaster relief efforts.

Identify the characteristics of a spiritually sensitive helping relationship. A spiritually sensitive helping relationship includes rapport and trust, empathic listening, respect for and openness to the spiritual dimensions of clients' lives, and the strengths and needs that stem from clients' spiritual perspectives (Canda and Furman, 2010; Furness and Gilligan, 2010). Workers may want to personally define what a spiritually sensitive helping relationship means to them as part of the process of preparing a practice model for both the short- and long-term post-disaster environment.

Develop spiritually sensitive assessment strategies. Although religion and spirituality are important, they may or may not be relevant to a client, and thus assessment practices must be adapted to the person. The need for and types of spiritual assessment and intervention strategies should flow from clients' needs (Hodge, 2005, 2013) and personal accounts of the disaster's impact.

Pursue training on spiritual diversity and spiritually based helping strategies. Training is essential to ensure that professional and ethical standards are not compromised and to reduce the risk for harm. Workers also may need to consult other professionals for supervision, or discuss interventions with clergy (Hodge, 2011, 2011), regarding the efficacy of assessment and intervention strategies in a disaster setting. In some countries, opportunities for training may limited (Furness and Gilligan, 2014). Given technological advances, social workers facing these conditions may find opportunities for training in the form of online academic courses on spirituality and social work, such as webinars and podcasts.

Research and evaluate spiritually based helping strategies. Workers may be able to find meta-analyses and cross-sectional studies that measure workers' use of spiritually based helping activities and attitudes regarding the appropriateness of such activities in a variety of academic and practice settings (Koenig, 2011). Workers might want to develop an assessment rubric that includes (i) a description of the intervention, (ii) any reports on validity and reliability, (iii) the actual use and effectiveness of the helping activity in terms of presenting issues related to religion and spirituality, including its appropriateness in terms of clients' (a) stage of life, (b) gender, (c) race, (d) cognitive and physical abilities, (e) cultural background, (f) religious or spiritual orientation(s), (g) literacy and (h) access to materials or media (e.g. books, films, technology, art supplies, etc.). Workers also might want to consider the activity's appropriateness in terms of practice setting (i.e. agency, private practice) and the stage of post-disaster recovery.

Design and use spiritually based helping strategies. The design and use of helping activities should be informed by the results from the discovery process (i.e. research, evaluation), social workers training and expertise, the client's presenting issue and informed consent (Aten ; Hodge, 2011, 2011). The nature and purpose of the helping activity should be explained to the client before using it in the helping relationship (Hodge, 2011).