Article

Definitional ceremonies: Narrative practices for psychologists to inform interdisciplinary teams’ understanding of children’s spirituality in pediatric settings

Kelsey Moore1, Victoria Talwar1 and Linda Moxley-Haegert2

AbstractIn pediatric settings, parents and children often seek spiritual and religious support from their healthcare provider, as they try to find meaning in their illness. Narrative practices, such as definitional ceremonies, can provide a unique framework for psychologists to explore children’s spirituality and its role in the midst of illness. In addition, definitional ceremonies can be used as a means for psychologists to inform interdisciplinary teams’ understanding of children’s spirituality and its relevance in pediatric treatment settings. In this article, our objectives are to (a) provide a brief overview of the literature on children’s spirituality, (b) review some of the literature on childhood cancer patients’ spirituality, (c) highlight the importance of whole-person care for diverse pediatric patients, and (d) introduce definitional ceremonies as appropriate narrative practices that psychologists can use to both guide their therapy and inform interdisciplinary teams’ understanding of children’s spirituality.

Keywordscancer, definitional ceremonies, narrative therapy, pediatrics, spirituality

1McGill University, Canada2Montreal Children’s Hospital, Canada

Corresponding author:Kelsey Moore, McGill University, 3700 McTavish, Montreal, QC H3A 1Y2, Canada.Email: kelsey.moore@mail.mcgill.ca

Journal of Health Psychology1–15© The Author(s) 2015Reprints and permissions:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1359105314566610hpq.sagepub.com

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North America’s healthcare system is comprised of professionals and patients of diverse cultural, spiritual, and religious backgrounds (Richards and Bergin, 2000). In pediatric settings, parents and children sometimes seek spiritual and religious support from their healthcare provider, as they try to find meaning in their illness (Barnes et al., 2000; VandeCreek et al., 2007). Children’s perspectives on illness, suffering, and coping can be shaped by ideas of the divine, making children’s spirituality of “direct relevance to pediatric practice, and child well-being” (Barnes et al., 2000: 900). Spirituality can also provide a framework for positive coping strategies, such as finding purpose and meaning in illness (Mahoney et al., 2001). However, healthcare professionals often lack the training to appropriately explore the role spirituality may play in children’s experiences with illness (Houskamp et al., 2004). In order to provide children with the best holistic care in diverse pediatric hospital settings, psychologists can use specific narrative practices, such as definitional ceremonies, to inform interdisciplinary teams’ understanding of children’s spirituality.

Myerhoff (1978, 1982) coined the term definitional ceremonies to capture the storytelling performances that were shared by an elderly Jewish population that emigrated from Eastern Europe to Southern California to escape Nazi persecution. After losing most of their family members in the Holocaust and moving to a new country, many elders felt isolated and experienced a loss of identity. Definitional ceremonies allowed the Jewish elders to express their stories in the presence of outsider witnesses—that is, people of their own community and people who were not aware of the community members’ religion, culture, and the loss they experienced by having to leave their country from fear of death. In these forums, the elderly Jewish people had “the opportunity to reappear on their own terms in the eyes of community

members and in the eyes of the outsiders who were invited to participate” (White, 2007: 180–181). In definitional ceremonies, the outsider witnesses are encouraged to retell components of the story that struck them in a special way and reflect on how their own perspectives were challenged or changed as a result of hearing the narratives. In hearing the outsider witnesses’ reflections, the Jewish elders’ stories were validated and they had the opportunity to hear how their narratives affected others. According to Myerhoff (1978), definitional ceremonies allowed these Jewish elders to assign meaning to their lives and make sense of adversity and loss. In the 1980s, the founders of narrative therapy, Michael White and David Epston, adopted definitional ceremonies as therapeutic practices used in narrative therapy (White and Epston, 1990; White, 2007).[AQ1]

Like the Jewish elders who settled in a new country, children with illness are in an unfamiliar environment (e.g. pediatric hospital) and often interact with people who can be perceived as outsiders (e.g. interdisciplinary team members)—people who have not directly experienced their illness and struggle for survival. Children are often not given the opportunity to appear “on their own terms” (White, 2007: 181) in the eyes of their psychologists and their interdisciplinary teams, especially when considering the role spirituality may play in their lives. Indeed, valuable insight gained by the psychologist and interdisciplinary team members in a definitional ceremony could be brought into children’s treatment practices to provide children with more holistic care. To date, there is little literature providing psychologists with a guiding framework to explore children’s spirituality in pediatric settings (Thayer, 2009; Wendel, 2003). Furthermore, there is no known published literature clearly making the link between narrative therapy’s definitional ceremonies and children’s spirituality in pediatric hospital settings.

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In this article, we will describe how psychologists can better understand the role of children’s spirituality in pediatric settings by using definitional ceremonies. We will explore how these narrative practices can be used by psychologists to inform interdisciplinary teams’ understanding of the role of children’s spirituality, and in particular, its role in the lives of childhood cancer patients. In this article, interdisciplinary teams refers to professionals from multiple disciplines (e.g., medicine, psychology, social work) working together in pediatric settings. Our objectives are to (a) provide a brief overview of the literature on children’s spirituality, (b) review some of the literature on childhood cancer patients’ spirituality, (c) highlight the importance of whole-person care for diverse pediatric patients, and (d) introduce definitional ceremonies as appropriate narrative practices that psychologists can use to inform interdisciplinary teams’ understanding of children’s spirituality.

Religiosity and spiritualityReligiosity and spirituality are often used interchangeably, as both of these constructs concern the meaning and value of life, moral order, and belief systems (Hill and Pargament, 2003). Given the scope of these terms, they are poorly operationalized in the literature. For instance, Roehlkepartain et al. (2006) note that despite the growth in research on religiosity and spirituality, a consensus on these terms has yet to be achieved. Religiosity is often defined as traditions, practices, rituals, and belief systems that are tied to a specific community (Bullock et al., 2012). Spirituality is typically described as the recognition of a sacred higher power and the individual journey toward transcendent reality (Benson et al., 2012). Spirituality is considered a broader construct than religiosity because of its overarching nature and because it is not tied to a specific community or institution. For

most children and adults, there is an overlap between religion and spirituality (Benson et al., 2003). Specifically, children do not tend to make “sharp distinctions between religion and spirituality” (Barnes et al., 2000). Developing a rigorous set of definitions based on previous literature is warranted, but beyond the scope of this article. The purpose of this article is not to make clear distinctions between religiosity and spirituality, but to contribute to our understanding of how to encourage children’s unique narrative (whether it be “spiritual” or “religious” in nature) by using definitional ceremonies.

Theories of children’s spiritual developmentIn order to better understand the role spirituality may play in the lives of childhood cancer patients, it is necessary to outline some of the main theories of spiritual development. In the literature, spirituality often is defined as continually evolving and maturing given that an individual’s experience of spirituality changes with development (e.g. Coles, 1990; Fowler, 1981; Houskamp et al., 2004). Fowler presents one of the most highly conceptualized faith-development theory. Fowler’s Faith Development Theory chronicles the development of children’s spirituality in relation to Jean Piaget’s theory of cognitive development, Laurence Kohlberg’s theory of moral development, and Erik Erikson’s theory of psychosocial development. Fowler’s theory, as discussed by Parker (2011), consists of seven stages of spiritual development. As children pass through these spiritual developmental stages, they progress from concrete to abstract thinking. In other words, as children develop, they are able to engage with their spirituality at a more sophisticated level.

While Fowler (1981) proposes that conceptions of spirituality evolve from the anthropomorphic to the abstract as children

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develop, this theory has been contested (e.g. Barrett and Richert, 2003; Kelemen, 2004). Kelemen (2004) deviates from traditional developmental theory and proposes that children are intuitive theists; they naturally view the world as a product of intelligent design. Barrett and Richert (2003) also diverge from Fowler’s theory of spirituality and propose a preparedness hypothesis, which challenges the traditional anthropomorphic view of spirituality. Barrett and Richert argue that children have early cognitive biases that allow for the ability to think about the metaphysical characteristics of the divine. Even very young children have the cognitive faculties to understand the abstract nature of the divine, given that children may use different cognitive functions when thinking and reasoning about supernatural concepts. Johnson and Boyatzis (2006) propose that young children have intuitive spiritual understanding that is scaffolded by reflexive thought and through familial, social, and cultural interactions.

Similarly, Woolley and Phelps (2001) propose that children may have a more sophisticated understanding of prayer than was once thought. Woolley and Phelps found that children’s beliefs in the mental–physical causality involved in praying increased with age, whereas their belief in the mental–physical causality associated with wishing decreased with age. Although research on children’s spirituality is still in its early stages, findings suggest that children may have much more developed spiritual lives than was once thought, which may be important to consider in pediatric settings.

Children’s spirituality and illnessBarnes et al. (2000) maintain that spirituality plays an integral part in children’s development, providing children with a moral framework and inner resources and, thus,

should be considered in pediatric healthcare settings. Others have examined how children use spirituality to cope with critical challenges, such as living with illness (Benore et al., 2008; Cotton et al., 2009; Pendleton et al., 2002) since the presence of illness in childhood can affect physical, psychological, and behavioral development (Suris et al., 2008). For instance, Coles (1990) found that when faced with illness, family tragedy, or political strife, children often turned to their spirituality to make sense of the adversity. When individuals are faced with threats to their own mortality, spiritual practices can become more salient and intense (e.g. Baldacchino et al., 2012).

Regnerus (2003) reviewed literature surrounding adolescents and their spiritual and religious coping and found that spirituality had positive effects on health and well-being. However, children’s spirituality and its influence on social and emotional health have been beyond the scope of the majority of studies (Barnes et al., 2000; Houskamp et al., 2004). Indeed, spirituality may facilitate or impede children’s social–emotional adjustment. For example, children who view suffering as an expected part of life that can be remedied by divine intervention may be better able to tolerate negative life events. Conversely, if children hold beliefs that suffering is punishment for sinful behavior, then their tolerance for negative life events might be affected (e.g. Mahoney et al., 2001). Children’s families and religious communities play an important role in how particular religious or spiritual traditions are interpreted and how they will influence children’s lives (Barnes et al., 2000). Thus, understanding a child’s unique spiritual narrative is imperative to more fully appreciate the role of spirituality in that child’s life, especially when a child is faced with a serious illness.

Childhood cancer and spirituality

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In North America, cancer is considered one of the most prevalent causes of death for children below 19 years (American Cancer Society, 2014; Statistics Canada, 2009). Children diagnosed with cancer share a common experience of frequent and lengthy hospital admissions (e.g. for chemotherapy, neutropenia), painful medical procedures (e.g. lumbar punctures, blood samples), and uncertain treatment protocols. Although cancer prognoses have improved dramatically in the past 20 years (Canadian Cancer Society’s Steering Committee on Cancer Statistics, 2012), a diagnosis of cancer often elicits fears of mortality because of the potentially fatal outcomes sometimes associated with the disease.

Despite there being a “compelling need to reexamine the relationship between medical care and the more subtle, deeply human spiritual aspects of life” (Jonas et al., 2012: 361), there exists little research on spirituality in the lives of children with cancer diagnoses (Morse and O’Rourke, 2009). Some researchers suggest that children’s recourse to spirituality during cancer treatments is found to be positive and adaptive. For example, Kamper et al. (2010) examined children with cancer and their responses to a spirituality questionnaire; they found that 78 percent of children reported thinking or doing things that made them feel closer to God. Kamper et al. propose that children’s care may be improved if they are given the opportunity to express their spirituality. Woodgate and Degner (2003) explored families’ sense of the spiritual throughout the cancer experience by using longitudinal qualitative interviews. Using the qualitative data, they found that families engaged in a “keeping the spirit alive discourse” (p. 108) even throughout difficult cancer treatments. Similarly, Weekes and Kagan (1994) carried out interviews with adolescent cancer survivors. Based on identified themes, adolescents found meaning and purpose throughout their cancer care experience.

In using thriving theory as a guiding framework, Parry and Chesler (2005) used in-

depth interviews with 50 childhood cancer survivors and qualitatively examined themes related to thriving. According to Parry and Chesler, thriving involves two main components: (a) the presence of adversity and (b) positive growth or adaptation in response to the adversity. Thus, the researchers looked for themes, such as positive change, in the children’s narratives. A compelling finding was the “meta-narrative of psycho-spiritual growth” (p. 1065). According to these researchers, children discussed more spiritual dimensions of growth (e.g. finding meaning in cancer) as opposed to religious dimensions of growth (e.g. attending a religious service).

Hendricks-Ferguson (2006) explored the relationship between spiritual well-being and phases of cancer survivorship (i.e. time elapsed following diagnosis) experienced by adolescents. The phases of survivorship were categorized into four time points: (a) 1 year since diagnosis, (b) 1–2 years since diagnosis, (c) 2–3 years since diagnosis, and (d) 3 or more years since diagnosis. Hendricks-Ferguson found that overall spiritual well-being was greater at the first two time points. Furthermore, adolescents reported higher scores for existential well-being at the first time point compared to the third time point. Hendricks-Ferguson suggests that future researchers ought to examine spiritual well-being not only during treatment, but across various phases of survivorship.

In recent years, researchers have demonstrated increased interest in spirituality in hospital settings (Smith and McSherry, 2004) since religious traditions and spiritual practices may shape children’s understanding of illness, suffering, and death (Barnes et al., 2000). Indeed, children’s spirituality is becoming of greater interest to healthcare providers, which will likely elicit more quantitative research in this area. Given the existing research on children with chronic illness and spirituality (e.g. Benore et al., 2008) and the literature concerning children with cancer and spirituality (e.g. Morse and

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O’Rourke, 2009), it is clear that spirituality often plays a significant and positive role in the lives of children with illness; thus, specific therapeutic practices are warranted to appropriately guide therapy.

The contribution of definitional ceremonies in pediatric settingsDefinitional ceremonies may be appropriate practices for psychologists to use in pediatric settings with childhood cancer patients. We will discuss how definitional ceremonies can be used to (a) promote whole-person care, (b) explore children’s spiritual narratives from diverse faith backgrounds, and (c) encourage children’s narratives, allowing their voices to be heard.

Whole-person carePuchalski (2012) suggests that

inquiring about a cancer patient’s spirituality also correlates with a whole-person healthcare model that shifts care from a focus on disease cure to one that addresses how an individual cancer patient defines wellness in the context of the disease experience. (p. 51)

Questions related to spirituality tend to arise with cancer more than any other chronic illness, as the uncertain evolution of the disease may often provoke spiritual questioning (Baldacchino et al., 2012). Many researchers have shown that integrating spirituality into patient care promotes holistic care and respect for patients (e.g. Balboni et al., 2007; Ferrell, 2007; Skalla and McCoy, 2006).[AQ2]

In a seminal work on children’s spirituality, Coles (1990) posited that when children are coping with an illness, their spirituality is often discounted since adults often do not seriously consider the real impact children’s beliefs can have on how they understand their experiences. Moreover, adults often do not

recognize children’s ability to reflect on their own lives and to find meaning in their experiences. Through interviews with children, Coles indicated that when children are faced with adversity (e.g. pain, accidents, danger), they were able to reflect on how the experience affected their life and their spirituality. Thayer (2009) has suggested that spirituality could be essential in promoting self-worth, as the belief in a deity is independent of academic or athletic accomplishments; this is especially important when children are ill and may not be able to perform to their pre-diagnostic ability. The spiritual lives of children may often be dismissed in pediatric settings, despite being an essential part of their overall wellness.

Indeed, there exist chaplains and pastoral care professionals who typically fulfill the role of exploring faith-based issues with patients in pediatric hospital settings. In a study by Cadge et al. (2011), physicians and chaplains were interviewed about the role of the chaplain in large academic hospitals. While physicians perceived chaplains as integral members of interdisciplinary teams, often involved in rituals and support around death, chaplains viewed their role as contributing to holistic care and healing. In a study by Feudtner et al. (2003), pastoral care professionals from 77 pediatric care sites were surveyed about their perceptions of the spiritual care needs of hospitalized children and their families, in addition to any barriers they feel impede spiritual care. Feudtner et al. (2003) found that pastoral care professionals reported that they felt their hospitals provided 60 percent of what they deemed as “ideal spiritual care.” One barrier highlighted by the respondents was inadequate training of healthcare professionals in detecting spiritual needs of patients and insufficient staffing in pastoral care. Definitional ceremonies may prove to be a unique way to make interdisciplinary team members more aware of children’s spirituality and the role it may play during their illness. In turn, healthcare professionals may become

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more attuned and sensitive to the importance of spirituality in the lives of children and may be more likely to detect children’s spiritual needs in the future.

Professionals that comprise interdisciplinary teams may vary depending on the pediatric setting; typically, teams consist of social workers, psychologists, pastoral care workers, child life specialists, physicians, nurses, and music and art therapists. The objective of this article is not to determine which team members may be more adept in understanding the role spirituality may play in during illness. Instead, the goal of this article is to highlight definitional ceremonies as a possible therapeutic practice for psychologists and a way to incorporate members of an interdisciplinary team. In turn, interdisciplinary team members will have the opportunity to listen to a pediatric cancer patient’s narrative as a team instead of individual professionals. Each team member’s reflection on the narrative can contribute to the team’s understanding of the child’s spirituality and its role in his or her illness and may lead to better collaboration with respect to psychosocial treatment in the future.

Surbone and Baider (2010) provide general strategies that can be used by physicians and other health professionals to transform their care to be more attuned to patients’ spirituality. Specifically, Surbone and Baider emphasize that having patients share their spiritual narratives may be the most appropriate way to promote spiritual well-being in hospital settings:

Some patients may try to express their own spiritual preferences and needs, and may feel, or in effect are, silenced. Narratives are a common, powerful, way for patients to find a spiritual thread that connects their lives before and with cancer, and to communicate their spirituality in the clinical context. (p. 232)

Surbone and Baider (2010) maintain that cancer patients do not expect spiritual answers from their interdisciplinary team; instead,

patients want to feel the comfort in knowing that their spiritual narrative will be received without judgment or fear. Thus, a definitional ceremony, which encourages children’s spiritual narratives in front of their interdisciplinary teams, may be appropriate narrative practices to use in pediatric hospital settings.

Diverse patientsWhen exploring the use of children’s spiritual narratives in pediatric settings, it is necessary to acknowledge the cultural, religious, and spiritual diversity in North America’s healthcare system. North America is a heterogeneous continent with respect to spiritual and religious practices. For instance, as of 2008 in the United States of America, approximately 170 million adults reported an affiliation with the Christian tradition. There were reportedly two and a half million Jews, more than one million Muslims, and approximately one million Buddhists. Unitarianism and Hinduism each had half a million adherents, and thousands of individuals indicated association with other spiritual groups (U.S. Census Bureau, Statistical Abstract of the United States, 2012). In Canada, Christianity is the dominant religion with approximately 22 million adherents from different denominations. There are approximately one million Muslims. Sikhism and Hinduism each have approximately half a million adherents whereas Judaism and Buddism each have approximately 400 000 observers (Statistics Canada, 2013).

Although children from diverse faith orientations may share some common beliefs and perspectives about the divine (Moore et al., 2012), Dennis and Duncan (2012) propose that all members of an interdisciplinary team should be competent with regards to diversity and recognize patients within their unique context.

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However, given the overall societal character of North America, it is common for one family to identify with more than a single culture, religion, or spiritual practice. Fully understanding the complex dimensions of cultural identity, especially in North America where there are often a variety of cultures even within a single family, is not feasible for healthcare professionals. Indeed, interdisciplinary treatment team members could never be expected to know or understand the many idiosyncrasies in every culture, religion, and spiritual practice. Thus, encouraging children’s unique spiritual narratives is especially appropriate, considering the diverse nature of families and faith traditions. Definitional ceremonies are particularly suitable in pluralistic contexts since the theoretical framework of this approach uses a social constructivist worldview; individuals are recognized within their context and therapy is grounded in the individual’s perspective. White (2007) emphasizes that definitional ceremonies are especially appropriate for minorities and those who are marginalized. Children with cancer are a minority in relationship to other children and are often marginalized (e.g. hair loss, school absenteeism).

Listening to children’s voicesDefinitional ceremonies can be used as a means to strengthen children’s narratives in pediatric settings. Seller (2010) uses imagery from the familiar story The Little Mermaid to describe the lack of sensitivity to children’s voices that often occurs in pediatric hospital settings. In the original story authored by Hans Christian Anderson, the mermaid gives up her voice in exchange for a pair of legs; she knows that the prince would never accept her with a mermaid’s tail. Just as the Little Mermaid gives up her voice to be accepted by the prince, Seller argues that children often silence, or give up, their own voices in

pediatric settings to conform to social pressures and appease others. While Seller’s focus is pediatric autonomy in bioethical discourse, her perspective has important implications when considering children’s spiritual lives in pediatric settings.

Seller states that in pediatric hospital settings, children “are afforded little opportunity to express themselves, their perspectives are seldom elicited and their values are even less often honoured” (p. 101). Seller discusses many forces of oppression that silence children’s voices, but emphasizes a study conducted by Hsiao et al. (2007), which focuses on physician–child interactions in pediatric palliative care. Through the analysis of interviews with children, Hsiao et al. found that children often feel as though their physicians are dismissing them, as evidenced by the fact that physicians often ignore children when speaking to parents. These social interactions may lead children to believe that their voice or opinion is not considered in their care. Seller (2010) explores potential clinical implications from the research of Hsiao et al. (2007) and suggests that children need a supportive healthcare environment that encourages them to share their values, perspectives, and goals with respect to their treatment plan. Definitional ceremonies can provide psychologists with structured practices to give children a vehicle to express themselves, and have their voice be heard, by those who care for them.

Definitional ceremoniesMichael White (White, 2007; White and Epston, 1990), one of the founding fathers of narrative therapy, outlines the basic tenets of narrative practices. Narrative therapy is embedded in a social constructivist worldview, meaning that individuals are recognized within their context and the therapy is grounded in the individual’s perspective (White, 2007). A main objective of narrative psychologists is to

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help patients move away from “problem saturated stories” and help them to strengthen or make “thicker” their stories of strength, resilience, and courage (White and Epston, 1990; White, 2007). Since spirituality is often perceived as a source of strength and sustenance for childhood cancer patients, a narrative therapy approach can be used to strengthen and validate children’s spiritual narratives. White (2007) argues,

of all the therapeutic practices that I have come across in the history of my career, those associated with the definitional ceremony have the potential to be the most powerful. Time and again I have observed outside witnesses retellings achieve what is quite beyond my potential to achieve in my role as a therapist. (p. 218)

Thus, definitional ceremonies may serve as a powerful and meaningful therapeutic intervention for childhood cancer patients in pediatric settings.

The therapeutic structure of definitional ceremoniesThe definitional ceremony structure consists of three distinct stages: (a) the child’s telling of the significant life story, (b) the retelling of the story by the people invited to be outsider witnesses, and (c) the child’s reflection and retelling of the outsider witnesses’ interpretations (e.g. Morgan, 2000; White, 2007). Although definitional ceremonies have been used with adults, adolescents, and children (White, 2007; White and Epston, 1990), the focus of this article is on children. Thus, for the purposes of this article, the pediatric cancer patient will be referred to as the child. Below, these three separate stages are described in more detail and applied to situations in which children turn to spirituality in their cancer experience. The psychologist facilitating the definitional ceremony must obtain consent

from all parties involved and debrief all participants upon completion of a definitional ceremony. Since not all professionals may have the same standards of confidentiality, the facilitating psychologist should define and ensure the protocol of confidentiality (White, 2007).

The psychologist, child, and the child’s family will decide who should be present and where the definitional ceremony should be held (e.g. private office space). Typically, a definitional ceremony would be most appropriate for a child who is spending a great deal of time as an in-patient, as that child is often surrounded by outsiders. At this time, the child and their family can also decide if any community members should be invited (e.g. religious leaders, neighbors, friends). As spirituality is a developmental process that is molded by both a child’s individual capacity and environment (e.g. culture, community, family; Benson et al., 2003) having members from a child’s community present may be important when considering spiritual development. The ceremony should take no more than 2 hours (i.e. in order to be feasible in a pediatric environment), and the psychologist would facilitate the definitional ceremony to ensure that appropriate time is awarded to each stage of the definitional ceremony according to their clinical judgment.

Stage I: the tellingFollowing individual or family therapy, the psychologist, child, and the child’s family may decide that a definitional ceremony is an appropriate narrative practice to explore the role of spirituality in the child’s cancer experience. In the first stage of the definitional ceremony, the psychologist interviews the child in front of an audience of outsider witnesses (e.g. child’s interdisciplinary team, family, friends, religious community). The psychologist invites the child to tell stories

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that have significant value in the child’s life and that have shaped the child’s relationships. More specifically, the psychologist may ask about times the child had spiritual experiences and how it affected the child’s perception of the situation, medical procedures, family dynamics, and other relationships.

During this time, the outsider witnesses listen to the child’s narrative without interjecting. The presence of outsider witnesses is central to the definitional ceremony process. According to Myerhoff (1982), the outsider witnesses’ role is to acknowledge and authenticate the child’s history, identity, and values. Specifically, inviting the interdisciplinary team to be outsider witnesses will prompt team members to reflect on the role of spirituality in the child’s cancer experience. The outsider witnesses can be in the same room as the psychologist and child, or they may watch the interview through a one-way mirror; this is left to the discretion of the psychologist, the child, and the child’s family. Although a child’s spirituality can be understood within the context of his or her family and community, a definitional ceremony facilitates the child’s sharing of their own personal narrative, revealing his or her unique understanding of spirituality and the role they feel it plays in his or her illness.

Stage II: the retellingThe second stage of the definitional ceremony is the outsider witnesses’ reflections on the child’s narrative in the child’s presence. Before attending a definitional ceremony, the outsider witnesses are briefed on four types of appropriate inquiry. White (2007) developed four levels of inquiry since he feels that they elicit the richest narrative development based on his many experiences using definitional ceremonies. In the first category of inquiry termed expression, the psychologist encourages the outsider witnesses to identify parts of the narrative that caught their attention. In the second category of inquiry

termed imagery, the psychologist invites outsider witnesses to focus on images and metaphors that emerge from the child’s narrative and what these images and metaphors say about the child’s values, purpose, hopes, and dreams. In the third category of inquiry termed resonance, the psychologist asks outsider witnesses to identify fragments of the child’s narrative that resonate with them and describe why they feel drawn to these parts. In the fourth and final category of inquiry termed transport, the psychologist prompts outsider witnesses to focus on ways in which they were moved by the child’s narrative.

White (2007) provides an example to help outsider witnesses better understand the fourth category of inquiry. White suggests to outsider witnesses that “it might help for you to think about the places that this experience has taken you that you would not have arrived at had you been out gardening or shopping at this time” (p. 195). In other words, the outsider witnesses acknowledge how the child’s narrative has reshaped their thoughts and how it will affect their future interactions with the child. For instance, by listening and reflecting on a child’s narrative, a nurse may realize that a child uses prayer to feel less anxious about a needle; a music therapist may understand the importance of a child’s religious music; and a psychiatrist may understand that spirituality plays a major role in the child’s ability to cope with the thought of mortality.

Definitional ceremonies are not performed to elicit advice, applause, or to be evaluative. In keeping with the four stages of inquiry, these ceremonies are meant to acknowledge the child’s narrative and what the child values (White, 2007). As a result, the psychologist discourages outsider witnesses from responding with superlatives (e.g. “Johnny is so wonderful”). When this occurs, the psychologist refocuses the outsider witnesses on retelling something that they found striking in the child’s narrative. The psychologist will

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also gently stop outsider witnesses who begin to engage in their own autobiography or that make comments that “go one down” (White, 2007: 208). “Going one down” is an expression used by White that refers to individuals who diminish their situation in order to elevate another (e.g. “I could have never been as strong as you”). Since a main objective of narrative therapy is to “thicken the counterplots of existence” (White, 2007: 166), the purpose of definitional ceremonies is not to focus on the presenting problem, but to strengthen narratives related to children’s spiritual lives, which are often perceived as a source of strength. The psychologist gently redirects outsider witnesses that have a tendency to focus on anguish, pain, and frustration and attempts to draw out themes of hope, values, and resilience.

Stage III: the retelling of the retellingWhile the outsider witnesses are still present, the psychologist uses the same four categories of inquiry (i.e. expression, imagery, resonance, and transport) to encourage the child to reflect on what was said by the outsider witnesses. In other words, the child is prompted to reflect on what he or she found particularly striking about the outsider witnesses’ comments. The child is also asked to reflect on the imagery that may have been evoked, as he or she listened to the outsider witnesses’ reflections. The child is asked to think about how the outsider witnesses’ perceptions may have been affected by his or her story. Having the child reflect on the outsider witnesses’ insights of the narrative can help the child consolidate the presented story, which ultimately strengthens the child’s values, beliefs, and meaning making (White, 2007).

Possible limitations of definitional ceremonies

Alternate perceptions of spiritualityWhen diagnosed with an illness, children may find it hard to reconcile their spiritual beliefs with the reality of their illness. For instance, upon receiving their cancer diagnoses, children may sometimes develop a negative view of spirituality if they see their diagnoses as contradicting the notion of an all-loving deity (Thayer, 2009). Although definitional ceremonies could still be used in these instances, individual or family psychotherapy may be more appropriate. Moreover, these children may not want their care to include any spiritual components, making it unnecessary for members of an interdisciplinary team to be particularly attuned to the child’s spiritual life. Furthermore, a family that experiences a great deal of tension with respect to their spiritual beliefs may not benefit from a definitional ceremony. Familial tension concerning spiritual beliefs could be best explored in the context of individual and family therapy. In addition, it is critical to recognize that some families who do share a united faith may feel that spirituality is a private matter and may find definitional ceremonies uncomfortable. Therefore, it is imperative that psychologists know their patients well, and propose the idea of definitional ceremonies in a manner in which patients do not feel obliged to participate.

Possible challenges within interdisciplinary teamsOrganizing an interdisciplinary team to attend a definitional ceremony may be seen as a challenge to orchestrate and a drain of resources for the sake of only one patient. However, Carey and Russell (2003) argue that the impact of even one definitional ceremony can be therapeutic for all of those involved, including the outsider witnesses. Furthermore, it can be a time when the child’s voice is fully heard in an interdisciplinary setting, instead of the psychologist representing the child’s

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thoughts and feelings at team meetings. As opposed to being a burden, these ceremonies are often enriching for the outsider witnesses themselves, leading to more holistic care. The sharing by the interdisciplinary team members, resulting from their experience as outsider witnesses, can lead to greater team cohesion and can substantively inform the team members’ understanding of how the child’s spiritual life interacts with illness. While definitional ceremonies do require organization and the time of many professionals, the benefits may outweigh the costs.

Psychologists should be wary of the possibility of discrimination against religious and spiritual beliefs. Narrative-oriented psychologists are trained to approach individual stories in an accepting and nonjudgmental way (White, 2007; White and Epston, 1990). Thus, the definitional ceremony should ideally be lead by a therapist with narrative therapy training. Psychologists should preface the definitional ceremony with a conversation with the outsider witnesses about discrimination, prejudice, and micro-aggressions, and the importance of respecting views that may not be widely held. According to White (2007), the validation that comes from outsider witnesses can be quite powerful and therapeutic and can go beyond that of what a psychologist is capable of doing alone. White (2007) admits that there can be some discomfort and awkwardness experienced by the therapist when beginning to practice definitional ceremonies, but this discomfort, which usually stems from this unconventional therapeutic approach, usually dissipates once the benefits of these practices become evident.

Developmentally appropriate stages of inquiryPsychologists using definitional ceremonies must be sure to propose questions within each stage of inquiry that are developmentally

appropriate. In addition, psychologists should familiarize themselves with the literature concerning children’s spiritual development. Psychologists should be careful not to assume that younger children do not have complex spiritual experiences, given that some researchers propose that children may have a more sophisticated understanding of prayer than was once thought (Barrett and Richert, 2003; Woolley et al., 2011; Woolley and Phelps, 2001). Indeed, in order to facilitate effective definitional ceremonies, psychologists should have a thorough understanding of the tenets that underline narrative therapy and a solid knowledge of developmental psychology.

Limitations of definitional ceremoniesAlthough there is increasing evidence for the usefulness of narrative therapy approaches (e.g. Busch, 2007; Marlowe, 2010), a major limitation is that there is little known empirical research that shows that definitional ceremonies are an effective therapeutic intervention. Although broad narrative practices have been proven to be effective in a few cases with adults (Vromans and Schweitzer, 2010) and children (Seymour and Epston, 1989), the use of definitional ceremonies, especially with childhood cancer patients, remains largely unexplored. In a case study, Leahy et al. (2012) examined themes that emerged when using definitional ceremonies with an adult having stuttering problems. Leahy et al. found that the adult was able to move away from her problem story (i.e. stuttering) and through definitional ceremonies, found her strengths and developed a positive perception of self. However, Leahy et al. recognize that the outcomes gleaned from their case study are not generalizable and provide little support for definitional ceremonies with children. Clinical research should be designed in a way that is

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unobtrusive, while providing important information on children’s spiritual lives and the effectiveness of using definitional ceremonies. Such research could then be used to guide clinical interventions and inform future practice.

ConclusionIn this article, definitional ceremonies were proposed as a new way of equipping psychologists and interdisciplinary teams with a unique and structured narrative framework to better understand children’s spiritual needs in pediatric settings. There is a clear and compelling need for a therapeutic framework to guide psychologists and to inform interdisciplinary teams’ understanding of spirituality of children. Narrative therapy’s definitional ceremonies can provide appropriate practices for psychologists to encourage and strengthen children’s spiritual narratives, facilitate interdisciplinary teams’ understanding of children’s spirituality in coping with illness, and contribute to more holistic care.

Funding[AQ3]This research article received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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