Diagnosis in clinical pastoral counselling: the sanctuary model as theological anthropological framework for spiritual assessment and treatment

Sonya Hunt

Stellenbosch University, South Africa

sonyafrancishunt@gmail.com

Daniël Louw

Stellenbosch University, South Africa

djl@sun.ac.za

Abstract

The article investigates the feasibility of the sanctuary model as a possible theological anthropological framework for diagnostic and treatment purposes in clinical pastoral practice. It is argued that the wilderness tabernacle matched the criteria for qualifying as a prototype sanctuary. The building-sanctuary is viewed as a metaphorical “body” for God’s being present in, and daily engagement with, human beings throughout all life trajectories and painful events. The notion of a spirituality of sanctuary is analogously linked with similar concepts in the human body-sanctuary (soulful embodiment) in accordance with Paul’s sanctuary-related anthropological terminology. Within the framework of sanctuary thinking and the founding of a theological anthropology, indicators for the assessment of a Christian spiritual praxis in clinical environments have been derived, suitable for diagnostic assessments and treatment. It is argued that the identification of possible directives for making a spiritual assessment of a person’s state of well-being (wholeness), could provide a broader platform from which patients can describe and interpret their responses to God within the therapeutic process of pastoral caregiving. In this regard, the praxis of a clinical approach is in fact a prolongation of wisdom counselling within the parameters of the discipline of cura animarum.

Keywords

theological anthropology; spiritual assessments; pastoral therapy; sanctuary model; clinical practice; diagnostic indicators; spectrum of lived experiences

Background

The professionalization of pastoral care has been hotly debated over the past few decades. The process and impact of professionalizing pastoral care was carefully examined and succinctly presented in a recent thesis by G.A Dames (2018), entitled The professionalisation of pastoral caregiving: A critical assessment of pastoral identity within the helping professions. Dames argues that the notion of Christian pastoral caregiving, working from the base of psychologically developed conceptual frameworks, is insufficient within the paradigmatic framework of pastoral caregiving as it does not take cognisance of the impact of salvation and biblical thinking on theory formation and the praxis of ministerial engagements (Dames 2018:70–72). Objections to the professionalization of pastoral care is strongly embedded in the argument that pastoral care in a very secular environment is running the danger of becoming so psychologized (Sullivan 2014:54) that it could become uprooted from its theological and spiritual roots.

The ability to make accurate diagnoses and offer appropriate treatment (cf. Ganzevoort et al 2013) forms the basis of any clinical profession (Sullivan 2014:54; Miller-McLemore 2000:273). Despite determined efforts made in this regard by professionals in various clinical fields, there is a limited and very scarce pool of critical reflection around clinical care and appropriate diagnostic criteria to facilitate the assessment of specifically Christian spirituality. In this regard, Louw (2015:213) highlighted the need for a diagram with diagnostic criteria that depicts an integrative approach to a pastoral anthropology. He suggests that such a depiction would assist the pastoral caregiver in understanding the unique character of caregiving and the identity of the caregiver in a team approach to helping and healing.

Furthermore, the argument will be, that soulful embodiment (see Louw 2015:213) in a Christian approach to caregiving, should become aligned with the pneumatological focus of Pauline anthropology. This pneumatological focus should be linked to the sanctuary metaphor stemming from the Exodus tradition and the depiction of the tabernacling presence of God with his people in their journey through the desert. The metaphor could also serve as an analogous description of what a spiritual embodiment entails when caregivers function as spiritual guides for people struggling to cope with the demands of life. Therefore, an adequate diagnosis of brokenness (Fretheim 2010:283–285) in clinical practice is undisputedly reliant on the understanding of spiritual wholeness by which effective planning of therapeutic intervention is guided.

The intention to investigate the sanctuary-metaphor towards finding a suitable theological framework for diagnosis1 in clinical practice, was based on the analogous association between the designs of bodies and buildings. Aimed at giving more concrete substance to the sanctuary metaphor, the research linked its reflection to a hermeneutical and literature study2 of the tabernacle as a prototype sanctuary. The wilderness tabernacle, as a microcosmic sanctuary representing the final cosmic temple, presented an organized model from which to launch the critical and hermeneutical reflection.

The exegetical work done by Dunn (2006) on the apostle Paul’s theological anthropology was found to be an appropriate “other” system with analogical or metaphorical similarities to the sanctuary model. With the interpretive tasks done by Dunn, it left the researcher free to integrate these findings into the sanctuary model through careful analogous reasoning.

We now turn to an outline and explanation of “sanctuary” as a metaphorical entry point into a biblical and pneumatological approach to a spiritual understanding of wholeness in pastoral therapy, healing, helping and clinical engagements with patients.

The sanctuary model as theological anthropological framework

The lengthy and intensely detailed descriptions of the Wilderness Sanctuary construct fascinated George (2009), who was interested in the way the Wilderness Sanctuary design facilitated divine-human encounters. The organization of the tabernacle space had an inherent social sense by which the Israelites understood the logistics of their relationship with God and their community (George 2009:8). The configuration and arrangement of the tabernacle areas provided a space for specific activities and functions that facilitated divine-human interaction (George 2009:56)

Historically, the design of sanctuaries in the Ancient Near East supported the facilitation of the divine-human relationship. In near eastern minds, sanctuaries represented an archetypal cosmic temple which existed as microcosmic models in themselves (Walton 2013:123). The design of the biblical sanctuaries reflected the same cosmic perspective. Biblical sanctuaries had an outer court which represented the corporeal world inhabited by humanity. The antechamber to the inner chamber represented the visible heavens with its visible light sources and an inner chamber represented the invisible heavens where the presence of Yahweh dwelled (Beale & Kim 2014:52). The physical space created by the structure of the tabernacle was purposed for encounter with Yahweh (Ex 25:8). The tabernacle space found its symbolic meaning only when this purpose was fulfilled by means of the physical presence of Yahweh in the form of a visible cloud and his glory. The cloud and the glory meant that Yahweh was present and marked the sanctuary as a sacred and holy space (George 2009:3). In essence, it was the presence and occupation of Yahweh which brought theological and symbolic meaning to the tabernacle space (George 2009:3).

In the New Testament, the sanctuary veil that obstructed and limited entry to the most holy place was torn physically to signify a cosmic event by which access to Yahweh’s heavenly throne-room was opened. This cosmic event was accompanied by darkness across the land and a mighty earthquake that opened graves and brought people back to life (Mt 27:45–52; Mk 15:33–41; Lk 23:44–49; Jn 19:28–37). The tearing of the veil signified a shift that shook the cosmos and changed access to God.

Re-opened access to God’s presence had been secured through the tearing of Jesus’ flesh (Schreiner 2015:316). The author of Hebrews signified an anthropological link between the tearing of the veil and the flesh of Jesus (Heb 10:20).3

The painting by D. J. Louw is a depiction of “tearing of the veil and the flesh of Jesus” (Hebrews 10:20) It indicates that, according to Paul in Ephesians 2: 14: “For He Himself is our peace, who has made both one, and has broken down the middle wall of separation.” (King James translation).

The cosmic impact of the tearing of Christ’s flesh indicated anthropological and ontological influences on humanity. The change in the spatial structure of the sanctuary through the tearing of the veil at the death of Jesus was a significant cosmic event that still yields powerful influence over the daily lives of those who have access to God through the removal of the veil from their hearts. Paul clarified the concept of the removal of the veil for believers and the resultant impact of becoming Spirit filled. Only through believing in Christ could the veil be lifted from hearts to open minds for understanding (2 Cor 3:12–16; 2 Cor 4:2–4), and for God to take up residence by God’s Spirit. The veiled understanding and knowledge of God under the Old Covenant had given way to a transformed perspective and new awareness of God under the New Covenant (Dunn 2006:318–319).

In order to reflect on the meaning of sanctuary for the design of diagnostic criteria and the applicability of this metaphor for the understanding of an integral approach to anthropological thinking in Christian spirituality, it will be notable to understand Paul’s trichotomy on our new being in Christ, and his whole notion of pneuma as central to soulfulness. Thus, the emphasis on a pneumatological approach to anthropological thinking.

Towards a base anthropology in clinical care: The trichotomy – Spirit, soul, pneuma

Traditionally pastoral care had been formulated as the care or cure of human souls (cura animarum). McNeill (1951) gave an extensive historical outline of the development of anthropological thinking in Christianity. Meiburgh (1990:122), in his article on cura animarum in the Dictionary of Pastoral Care and Counselling, pointed out how pietism’s preoccupation with the welfare of the individual soul became the seedbed for the growth of popular psychology. In her book Seelsorge, Doris Nauer puts the question of the credibility and reliability of soul care (Glaubwürdige Seelsorge) anew on the agenda of theory formation for the praxis of caregiving. In Word and World, Herbert Anderson (in Nauer 2010:68) poses the question: What ever happened to pastoral care and the rich tradition of cura animarum?

According to Davies (2001:xvi) one can render absorption of the self in an egoistic culture of consumption as “the death of the soul”. How then can we reintroduce talking about the “human soul” and the compassionate culture of cura animarum and hope care in such a culture of self-assurance and super-saturation? In fact, caregiving was already before the middle ages been rendered as an act of cure in a hospitium where the pastor acted as a “doctor of souls” (Louw 2016:54–55). The hospital in early Christianity was actually a hospice: a clinical place of hospitable care.

For a deeper insight on different Pauline terminology used for the human spirit/soul/pneuma, Dunn’s (2006: Kindle Location 55–78) exegetical work on the theological anthropology is most helpful to clarify the often-confusing anthropological terms used in theory formation for caregiving.

The anthropological impact of veiled separation from God, and unveiled access to God, is described by Paul as a shift from psychikos to pneumatikon (Dunn 2006: Kindle Location 76). Paul’s anthropological description for embodied souls with veiled separation from God, and Spirit-filled embodied souls with unveiled access to God’s presence, are found in the terms psychē and pneuma. The first Adam became a living being when God breathed the breath of life into his nostrils (Gen 2:7). The structure of Adam’s embodiment, made from the soil of the earth, was vitalized by God’s breath to become a living soul or soulish (psychikos).

Greek partitive anthropology reduced the understanding of the term psychē to the aspect of a person which is separated from the body at death to live on as an immortal soul. The Greek interpretation of word psychē has confused the understanding of the first Adam’s vitality and existence. The Hebrew understanding of psychē is based on the word nephesh (Gen 2:7),4 which designates the vitality of the entire person as a living, breathing human being (Dunn 2006: Kindle Location 76).

The concepts of psyche and pneuma, discussed in this section, join the other naturally grouped anthropological terms used by Paul. These terms include the concepts of sōma and sarx which reflect the embodiment of the soul, as well as the concepts nous and kardia reflecting the mind and heart, reiterating the ensoulment of the body. Greek thinking assigned the highest value to the nous (mind), which varies significantly from the importance assigned to the indwelling Spirit in union with the human spirit, considered as the most essential anthropological human dimension in Jewish thinking (Dunn 2006: Kindle Location 76; 1 Cor 6:17).5

Greek thinking allows for the distinction between soul (psyche) and the body. Very distinctively Paul refers to the resurrection of flesh (sarx) so that at total separation between body and ensoulment in dying and death becomes complex indeed. Albeit, in Hebrew thought the word nephesh speaks of the embodied soul as a whole person (Dunn, 2006: Kindle Location 54; 76). In addition, the Hebrew perspective considers pneuma the most prominent and deepest dimension of a person, hence the reason why the research project follows a pneumatological approach to understanding what it means to be human within the divine-human relationship and the resultant praxis of Christian ministry. It opens up new dimension for the understanding of the link between the pastoral praxis and the notion of hope and meaning giving in caregiving.

Our being human as embodied sanctuary: The eschatological dimension in biblical anthropology

The ontological shift from being psychikos to pneumatikos speaks of eternal life in Christ. The eternal aspect of new beings introduces an eschatological theme which is best demonstrated by means of Paul’s Adam Christology. The identity of the earthly Adam is seen as the psychikos or old creation, whereas the identity of reborn Christians relates to a new creation in Christ as the last Adam. The eschatological tension is experienced in the overlap of these two identities as the transformation into new spiritual embodiment is eagerly awaited at promised Parousia. This overlap with the resulting eschatological tension of already and not-yet, is demonstrated in the following figure, as adapted from Dunn’s illustration (Dunn2006:475):

Figure 1: The eschatological perspective of already and not-yet

Applied to the spiritual praxis of caregiving, and the notion of healing and wholeness, the implication of the notion of a new creation, i.e., when human beings are aware of their new identities and status in Christ, and when they experience the empowering presence of the Spirit, is that humans are strengthened by the eschatological hope of Christ’s return and the consummation of the new creation due to what can be called a theologia resurrectionis (Louw 2015:340–352). Trusting in God’s faithfulness to fulfil his promise of eternal life secures a hopeful future and a meaningful orientation in life events.

Self-awareness considering the new creaturely identity, secures a hopeful present (Kapic 2017). Eschatological hope brings the future into the everyday experience of believers, easing the eschatological tension between the old and new identities. Hope thrives when believers live in the awareness of their identities as new creatures in Christ. Hope is secured by faith in the faithfulness of God for the fulfilment of his promises regarding Christ’s return. Such a future hope provides courage and assurance within the experience of the eschatological tension in the already-but-not-yet aspects of salvation.

What can be derived from the previous outline and argumentation is that diagnosis and spiritual assessment should be portrayed against the paradigmatic and theological paradigm of eschatological thinking. What could be the impact of such a paradigmatic background in theory formation for a pastoral anthropology and diagnostic approach in clinical care?

The first theological field to be researched is the interplay between God-images and a spiritual orientation to human suffering and ailments in general. The basic assumption is that diagnosis in a spiritual assessment is in the first place about the challenge of probing the appropriateness of a patients understanding of God (conceptualization of God in terms of vital existential contexts and traumatic experiences).

The notion of appropriate God-images in a spiritual and pastoral diagnostic

Louw (2015:273–302) argues patients’ metaphorical image of God shapes their understanding of God’s engagement in suffering and existential realities. According to Louw, God-images could identify the quality of soulfulness and the character and appropriateness of Christian spirituality. Superimposing Louw’s description of appropriate and inappropriate interpretations of biblical metaphors of God (Louw 2015:432–435) over an adapted model of the Circumplex Model (Walsh 2003:514–541; Plutchik and Conte 1997; Olsen, Russell & Sprenkle 1989), yielded a useful graphical representation of the relational conceptualization of the power (sovereignty) and distance (intimacy/closeness) in terms of human perceptions of God.

Our basic point of departure will be, that the appropriateness/inappropriateness of God-images is not a doctrinal or confessional or even ecclesial matter, but a relational matter, i.e. how an understanding and experience of God in a difficult setting of life contribute to hope and meaning so that our sense of value, being acknowledged and sense of belongingness and dignity become safeguarded. All these issues can be related to the question how our spiritual relationship to God (fellowship and communion) impacts on our relationships with fellow human beings. In order to understand the hermeneutical dynamics of relational interaction, and to depict it in terms of a diagrammatic portrayal, a circumplex model is rendered as most appropriate and effective in the design of a diagnostic chart.

Relationality in a circumplex model

Relational dimensions have been named differently in the various circumplex models, depending on the context.6 See for example how Brueggemann in his hermeneutical approach uses an axial schema to describe the far agenda vertically and the near agenda as horizontally. The far (vertical) and near (horizontal) agendas represent the social dimensions of power and trust within relationships that act as indicators of related emotions within the spaces created by the axes (Brueggemann 2010:53). Brueggemann’s axial presentation fits well within the relational dimensions inherent in the various Circumplex models (Walsh 2003:514–541; Plutchik & Conte 1997; Olsen, Russell & Sprenkle 1989).

Furthermore, the horizontal axis in the various circumplex models relate to the perceived relational distance or nearness. Terms such as closeness, cohesion, or simply distance, have been used to describe the horizontal axis. The horizontal axis generally represents relational distance or closeness indicative of the quality of trust. Attachment style research associates the distance dimension with trust. Distance relates to the perception of God’s trustworthiness. How faithful is God to his promises and how safe is it to be near God? It also hinges on the quality of faith and trust in God’s gracious promises regarding his being there where we are (Ex 3:14). These conceptualizations (distance and nearness) are suggested as possible criteria in the clinical assessment of God-images, in conjunction with aspects represented on the vertical axis of the currently applied Circumplex model.

The vertical axis demonstrates the power distribution by means of role representation, levels of functioning, and the quality of responsibility. The vertical axis has been named according to the context of the relevant research and ranges between concepts of adaptability, flexibility, agency, or power. Power relates inter alia to the perception of God’s rules, will, responsibilities, and role in the divine-human relationship. According to his sovereignty, how powerful or weak does the human perceive God to be? How rigid, flexible, or uncertain are his rules? How does he respond when humans break the rules? In combining the power and distance axes in the context of this hypothesis, it is possible to attain the following graphical perspective on possible ways in which humans could image God.

The following diagram broadly represents images of God based on biblical metaphors such as “creator” (the provisional, cosmic, and environmental dimension), “king” (monarchic and juridical tradition), “Adam” (the human and embodied/flesh tradition) and “priest” (the caring, mediating and comforting tradition). The diagrammatic presentation of biblical metaphors aimed to aid the diagnostic process in clinical practice and to guide treatment.

Figure 2: Metaphoric conceptualizations of God

For the purposes of this study, the central circle represents an appropriate conceptualization of God in terms of his ḥēsēd (grace and compassion). The wider circle represents a space where human perceptions of God shifts from God as creator and ruler, to created beings. In the spaces of the wider circle, perceptions of God are distorted. Distorted perceptions of God’s power and distance lead humans to establishing their own norms and risking the danger of mismanaging God’s resources for self-gain (God as Superman or imposing Technocrat). The mismanagement of resources for the benefit of a few is disempowering and increases oppressive suffering. Inappropriate distribution of resources creates space for the development of inhumane relational divisions and oppression. Moving further outward into spaces of increased distance and separation from God’s will and ways, other entities are established as gods. Imposter gods claim power for themselves and usurp resources for personal gain or for selected members only. Where imposter gods establish their rule, these distorted conceptualizations of God do not reflect God’s nature and being. These distorted images pose harm to humans and obstruct wholeness. Brokenness7 is found in the wake of independence from God and illegitimately claimed power.

With reference to the appropriateness/inappropriateness of God-images, it should be taken into consideration that it is not possible to separate the quadrants, representing biblical metaphors of God, with crystal clarity. The value of this seemingly rather schematic depiction and analytical exercise can be found in observing the impact of specific metaphoric conceptualization of God on health. Ultimately, patients will interpret their situation in accordance with the paradigms shaped by the relevant God-image. Within the divine-human relationship, human self-understanding is associated with interpretations of encounters with God. As already argued, the role of the sanctuary as a space for divine-human encounters was an important focus of the study.

The sanctuary represents the metaphoric body for God and the human body is interpreted as the residence for God’s indwelling Spirit. The concepts of a sanctuary building and sanctuary body as dwelling places for God, were analogously integrated to shape the framework for a theological anthropology. The following section presents the sanctuary model as a theological anthropological framework on which to base diagnosis in clinical practice.

The making of a spiritual diagnosis in clinical pastoral care: indicators of wholeness in Christian lifestyles

At the beginning of the article, it was already pointed out that the trichotomy of soul, spirit and pneuma is not about and abstraction. These terms include the concepts of sōma and sarx which reflect the embodiment of the soul, as well as the concepts nous and kardia reflecting the mind and heart, reiterating the ensoulment of the body (Dunn 2006). The implication for a praxis of clinical care is that when a diagnostic chart for a spiritual assessment is deigned, a holistic approach entails that all aspects of our being human should become included, namely the human mind (thinking processes, the cognitive dimension), our emotional capacity, habitus (intention, motivation and will power), as well as the physical, biological, environmental, and material dimension of human embodiment (sōma and sarx). Thus, the reason why Chandler’s research (2014) Christian Spiritual Formation: An Integrated Approach for Personal and Relational Wholeness has been used to identify assessment indicators for the design of a diagnostic chart.

The following adaptation to Chandler’s model is proposed. Her model is designed in the shape of an interactive wheel, centred in God’s redeeming love. The adaptation is based on the same concept; but presented in the shape of a fruitful tree symbolizing the charismatic Christian lifestyle of bearing the fruit of the Spirit as Christian witness. It is hoped that the adapted grid will expound on each of the dimensions of a charismatic Christian lifestyle for ease of diagnosis.

Figure 3. Integrated Lifestyle Model: An approach to personal and relational wholeness

The following indicators could be identified, bearing in mind that a spirituality of wholeness within the paradigm of a human beings as embodied sanctuaries of God’s pneumatological presencing in our human predicament of vulnerability and suffering, includes physical, cosmic, existential as well as material dimensions. Spirituality in a sanctuary model cannot be reduced to abstract ideology, but is a concrete existential reality as exposed in the how of human attitudes (habitus – inhabitational theology). It should be noted that many indicators could indeed be identified determining the quality of our human existence in the quest for dignity, meaning and hope. However, the research decided to select indicators in accordance with their relation to both the spiritual and existential dimension of life as well as to the quality of fellowship and communion with God through the Spirit.

Physical well-being

The body as sanctuary implies a bio-physical approach to an embodied soul. The goal here is to combat the achievements ethics with its emphasis on prestige and performance. Thus, the emphasis on body care as antidote to soulful depletion.

Performance or achievement drivenness can demand more than what is reasonable from the body. Given the appropriate support, the body generally is able to self-repair. Without appropriate support or time to repair, re-generate, restore, refresh, re-energise, the body is depleted and unable to replace neurotransmitters such as serotonin. Too much of anything like smoking, drinking, medication, eating, sleeping or even exercise can be harmful to health and physical welfare. When physical activities and habits become demands, and no longer a resource, it is a good time to re-evaluate the meaning and reasons for engaging in it. Moderate exercise and relaxation techniques enhance physical well-being. Just breathing deeply can bring relief during stressful times. Grooming and self-care are also indicators of wholeness.

Mental well-being

The focus here is to become engaged in basic issues that determine the quality of human wholeness, anguish (performance anxiety) due to the fear for loss and rejection and the development of coping skills within the dread of unexpected and traumatic life events. The challenge is to develop new perspectives and attitudinal change.

Negative thoughts release chemicals (for example cortisol) that have a toxic effect on the brain and body, and in the long term can result in illness. Healthy thoughts assist in detoxing the system and can help with building memory, developing intelligence, and boosting the immune system.

Ways of maintaining mental well-being include taking responsibility for thoughts through meditating on the loving and forgiving words and ways of God under the guidance of the Spirit; remembering forgotten dreams and hopes; finding things that cause laughter and that promote playing, exercising, relaxing, and staying in touch with God’s will.

Emotional well-being

The focus here: distinction between thought and emotion, between problem identification and emotional responses.

There is an intricate connection between thoughts and emotions. Thoughts stimulate emotions and the body produces chemicals accordingly. At times, emotions can be overwhelming, and it is important to find ways of regulating thoughts. Appropriate processing of intrusive thoughts prevents either the bottling up of emotions, or uncontrolled outbursts. Uncontrolled responses escalate emotion and can end in aggression, violence, or other inappropriate behaviour.

Flooded emotions need to be released by calming activities such as walking in nature; exercising; listening to music; playing musical instruments; having a bath; swimming, or other suitable and preferred activities that promote the diffusion of emotions and can support self-control.

Authentic communion and communication with God through prayer or lament acknowledges the need for help and the hope of an appropriate and compassionate response from God. Emotions can be regulated by talking them through with God, trustworthy friends or through constructive self-talk. Self-control is not only defined by the choice to abstain from behaving in certain ways, but also the decision to act appropriately.

Welfare – material and financial well-being

Financial management reflects the personality and the worldview of individuals. Stress is promoted in instances where the pursuit of money and riches has become the motivation and goal of living. If money is considered a tool by which to accomplish meaningful goals, the focus is not on the money but on the meaning of the accomplishments. The money paradigms include the way in which the source of money is viewed. If the source of income is acknowledged as external (as a grace from God), a sense of accountability and responsibility ensues in its management. If the person’s own energy, drive and abilities are considered the source of the income it holds the possibility of severe crisis of meaning if their ability to earn money is thwarted.

Being generous to others (the art of sharing), even under severe circumstances, maintains perspective and prevents the development of a poverty mind-set. This requires trust and provides meaning. This principle was proved in concentration camps when individuals who found meaning in being generous were able to give their last piece of bread to other hungry persons despite their own state of starvation. Generosity reflects the very nature of a gracious God.

Relational well-being: Problem of prejudice and stigmatization (xenophobia) in the encounter with the other as stranger.

Broken, unhealthy and abusive relationships (exploitation, stigmatization violence) can be the cause of extreme stress or skewed perceptions on life. Unkind words and actions; betrayal; oppression; abuse or any other form of damage inflicted on individuals are harmful to health and well-being. In some instances, it is possible to restore relational trust and to become reconciled. This generally occurs when an individual takes responsibility for the harm they have caused and offers a sincere apology accompanied by changed behaviour. Repeated insincere apologies and unchanged behaviour can destroy trust and cause levels of distress that are detrimental to health and well-being.

Green spirituality – environmental factors that contribute to well-being

Noise, pollution, poor living conditions, over-crowdedness, danger, isolation, or extreme weather conditions are all contributors to environmental stress. It may not always be possible to change any, or all of these conditions, but some relief may be obtained through attitude. A constructive attitude towards unchangeable aspects of life is helpful. Regular escapes from the toxic environment into healthy areas such as the beach, forest, safe public gardens or mountain walks, are restorative.

It is particularly important to take responsibility for the care of God’s environmental and ecological resources. In this regard, Louw (2015:259–272) refers to an eco-spirituality and “green hope” as an integrative part of the healing of life (cura vitae) and the earth (cura terrae). Participating in programmes to reduce environmental pollution can be meaningful and reduce stress. The appropriate distribution of natural resources can be supportive of alleviating poverty and restoring hope. Discernment and wisdom from God’s Spirit guide the management of God’s resources under human care and promote the paradigm shift from exploiting dominionship to caring stewardship.

Indicators of circumstantial factors that contribute to well-being

Circumstances cannot always be changed. Illness can place severe restrictions on both the patient and the carers. Other types of circumstances may be alterable in the short or long term. Discerning the difference between these categories can contribute to the reduction of stress. Some relief from circumstantial stress can be achieved by altering what can be changed and accepting what cannot be altered immediately – or at all. The principle of acceptance is helpful when circumstances are unchangeable. When circumstantial stresses are attributed causatively to others, the spiritual principles of forgiveness and reconciliation can be applied for the alleviation of stress.

Allowing pressures to dominate decision making can add to stress as bad decisions have to be managed in addition to the stress load. Appropriate support in the alleviation of circumstantial stress includes seeking calm and helpful advisors when important life decisions are at hand. Making use of supportive resources requires wisdom and discernment and, therefore, depend on seeking God’s guidance (the advantage of wisdom counselling, Schipani 2003).

Interculturality – cultural factors that contribute to well-being

Culture, from the Latin colo (to nurture and to nurse) (Louw 2015:172–179) can be defined as a group of people held together by shared values, beliefs, customs, norms, morals, products, or interests. These common interests in groups are adopted through socialisation and become the standards by which the group is defined. The adopted standards are generally captured in the contemporary art, music, symbols, icons, and other creative acts.

Cultural standards are not always suited to all members of a group. Membership to a group is not always voluntary such as belonging to a family, ethnic or race group. People do not choose to be born into such a group. Cultural pressures place expectations and requirements on individuals to conform. These pressures are often unspoken and can be experienced as demanding compliance without seeking consent. Non-compliance can be perceived as disrespectful or rebellious. However, heartfelt compliance can produce a sense of belonging and unity.

Temperance and mortality – Indicators of time as a resource contributing to wellness

Efficient time management potentially reduces stress. Matching the job to the time available can be a challenge. The job at hand can often be stretched or shrunk to fit the time available at the cost of either boredom or strain. Resetting goals to a more manageable timeline can be helpful. Filling up time with busy-ness, to avoid thinking about problems, can increase stress levels as it may result in the suppression of emotions and possibly lead to burnout. It is in this regard that the previous mentioned eschatological view on the tension between already and not-yet can help to discover the dimension of the immortal value of our being human and the perspective of the resurrection as a kind of spiritual victory over death and dying.

Ethos, ritual, communion, and communality – Indicators of spiritual well-being

The human spirit, being the receptor and communicator within the spiritual realm, gathers information from the senses, the conscience and from God’s Spirit. Spiritual well-being relates to the way in which a person acknowledges their spirituality and accept the guidance of the indwelling Spirit of God, i.e., starting to live according to the charisma of the Spirit: the fruit of the Holy Spirit and the willingness to be guided by the Sprit in decision making (our inner, renewed conscience as regulated by codes of conduct as stipulated in the law and the beatitudes).

Conclusion

Spiritual well-being is regulated by the understanding and interpretation of meaning in life (the principle of telos directed by sacrificial love and diaconical outreach, servitude, to suffering people in need). Meaning is a deeply spiritual concept that has the potential of equipping a person with endurance under the most severe circumstances. Spiritual well-being is reliant on knowing God’s will and spending time in communion and communication with God in honest prayer and displaying the charisma of the Spirit.

Despite the specific Christian focus in this study, the above indicators for the design of a diagnostic chart in spiritual assessment (see Integrated Lifestyle Model, figure 3), include options for the spiritual care of all patients. The diagnostic chart is, therefore, inclusive, and not religiously exclusive. It is applicable to all world views and religious traditions that incorporate wisdom thinking in their belief system. This is perspective is important because the clinical setting inherently includes patients from varied denominations, secular beliefs, and patients from different religions. As mentioned previously, the clinical setting suggests the presence of some patients who suffer from toxic spirituality due to oppressive and enslaving spiritual powers. Despite the particularly Christian focus in this study, the sanctuary design is anthropologically inclusive of all humans. In essence, the sanctuary design indicates spirituality as an ontic and anthropological reality.

It is recommended that clinical pastoral training includes the responsible and appropriate application of the diagnostic tools associated with the sanctuary framework. The diagnostic tool is not intended for either labelling or judging patients. The motivation for this project is embedded in the hope of movement from brokenness to wholeness. It is suggested that the compassionate presence of God be embodied by the therapist in the journey alongside the patients towards spiritual wholeness. In this regard, the notion of a charitable and co-suffering God could be rendered as most appropriate to patients exposed to severe questions regarding the presence or absence of God in the praxis of clinical care.

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