The GRACE Model – Chaplain Doug Graham

The GRACE Model – by Chaplain Doug Graham

(Below is the smart phrase used in Epic to assess and score the level of spiritual-emotional distress for each letter)

Visit Summary: Situation? Background/ spiritual health history? Assessment? Response by chaplain? Recommended plan of care or referral to other discipline(s)?

BSMH GRACE Model

Spiritual-Emotional Distress Assessment

(The goal is to measure “pain” in each area)

Unable to assess:  (Total 0) –  

Scoring: 0 = No distress |1 = Low | 2 = Moderate | 3 = High Spiritual-Emotional Distress

G – God & Beliefs

Connection to God, spiritual unrest, and emotional tone toward God.
Underlying indicators: fear, anger, shame, guilt, abandonment, questioning, numbness

Tell me about your relationship with God/ the sacred/ a higher power. In light of your health needs, how is your beliefs bringing you peace or causing you to struggle? 

Score:  No distress/or unable     Low      Moderate     High distress

R – Reason for Living

Meaning, motivation, life adjustment, purpose, coping, legacy, story and significance.
Underlying indicators: hopelessness, depression, exhaustion, aimless, feels worthless

Do you believe your life has meaning and purpose, if so, what gives you meaning?

Score:  No distress/or unable     Low      Moderate     High distress

A – Allies & Support

Connections, church, family, care team, and emotional impact of relationships.
Underlying indicators: disconnection, fear of burden, resentment, regret, isolation, loneliness

Do you have support? Do you feel valued?      

Score:  No distress/or unable     Low      Moderate     High distress

C – Customs & Worship

Obstacles to spiritual practice, rituals, and emotional engagement.
Underlying indicators: avoidance, guilt, shame, emptiness, apathy, doubt, distrust

Are there parts of your faith that feel harder to practice right now?   

Score:  No distress/or unable     Low      Moderate     High distress

E – Emotions and Spiritual Struggles

Resilience, mental state, spiritual-emotional temperature, and peace in the soul.
Underlying indicators: anxiety, fear, grief, depression, lack of hope, anger, guilt, shame

What has been the heaviest thing on your heart lately?                 

Score:  No distress/or unable     Low      Moderate     High distress

Total GRACE Spiritual-Emotional Score:  __ / 15

0-Unable to assess/ no distress| 1–5 Low | 6-10 Moderate | 11-15 High distress

Summary of Patient’s Distress and Plan of Care

Based on the total GRACE score, chaplain will:

(contact patient’s faith leader/ continue providing spiritual-emotional support through regular visits/ refer to TeleChaplaincy, etc.) :

Suggestions for helping a chaplain discern the level of distress:

G – God and Beliefs

No SE Distress

Stable, secure, confident, at peace, grounded, trusting, no tension

Statements could include: “God is with me.” “I feel at peace spiritually.” “My faith is strong right now.” “I don’t feel shaken in my beliefs.”

Low SE Distress

Mild strain, concerned, processing, slightly unsettled, quietly anxious, mild worry, light discouragement.

Statements could include:  “I’ve had some moments of doubt.” “I’m thinking a lot about God right now.” “I’ve asked why… but I still believe.” “I feel a little shaken, but I’m holding on.” “I’m praying more because I need reassurance.”

Moderate SE Distress

Stressed and unstable, doubting, frustrated, conflicted, spiritually dry, wrestling, disappointed.

Statements could include:  “I’m really worried about this.” “I don’t feel close to God.” “I wonder why God would allow this to happen?”

High SE Distress

Spiritual crisis, angry at God, feels abandoned, feels condemned, feels hopeless, feels betrayed.

Statements could include:  “God has left me.” “God is against me.” “What’s the point?”

R – Reason for Living

No SE Distress

Clear sense of meaning, feels motivated, knows their purpose, grateful, fulfilled, has hope, clear identity, engaged. This person may be sick but is not disconnected.

Statements could include:  “My family gives my life meaning.” “I still have things I want to do.” “This illness doesn’t take away my purpose.” “I know why I’m here.” “I feel useful.”

Low SE Distress

Meaning intact but mildly shaken or adjusting, slowed down, reevaluating, uncertain about the future but not despairing, mild discouragement, temporary loss of motivation. Meaning is still there but making some adjustments.

Statements could include:  “I’ve been thinking about what really matters.” “This has changed my priorities.” “I’m trying to figure out what this season means.” “I still have purpose… it just looks different now.” “Some days are harder, but I’m holding on.”

Moderate SE Distress

Noticeable strain in purpose and motivation, discouraged, aimless at times, feels disconnected from support, struggling to adjust, losing direction, low motivation, identity disruption, some feelings of hopelessness, their foundation is cracking but not collapsing.

Statements could include:  “I don’t know what my role is anymore.” “I feel like I can’t do what made me who I was.” “Some days I don’t see the point.” “I’m tired of fighting.” “I don’t feel very useful.”

High SE Distress

Collapse of meaning, in crisis, hopeless, worthless, empty, futile, defeated, resigned, deep despair, loss of identity. This is more than discouragement, it is collapse.

Statements could include:  “What’s the point?” “My life doesn’t matter anymore.” “I’m just a burden.” “There’s nothing left for me.” “I don’t see a future.” “Everyone would be better off without me.”

A – Allies & Support

No SE Distress

Connected, supported, valued, loved, accepted, secure. Sickness has not impaired their safety net.

Statements could include:“My family is here for me.” “I have people I can call.” “My church has been checking on me.” “I don’t feel alone.” “I know I matter to people.”

Low SE Distress

Support present but slightly shaken, slight family drama, feeling the distance, slightly isolated, a little overlooked, quietly lonely at times, mild loneliness, concerned to be a burden.

Statements could include: “They’re busy, but they care.” “I wish more people could visit.” “It’s not the same as before.” “I don’t want to bother anyone.” “I have support, it’s just harder right now.”

Moderate SE Distress

Noticeable strain in relationships, lack of support, resentful, overlooked, isolated, unsupported, increased loneliness, withdrawal, suspicious or hurt, feeling undervalued. Support maybe present but the patient doesn’t feel it.

Statements could include: “People stopped coming.” “I don’t think anyone really understands.” “I don’t want to be a burden.” “They’ve got their own lives.” “I feel alone most of the time.”

High SE Distress

Relational brokenness, profound isolation, abandoned, rejected, invisible, unwanted, disconnected, bitter, deeply lonely, relational grief, emotional shutdown. This is not only loneliness but relational collapse.

Statements could include: “No one cares.” “I have no one.” “They’re better off without me.” “I’m a burden.” “I don’t matter.” “I’ve pushed everyone away.”

C – Customs & Worship

No SE Distress

Spiritual practices intact and meaningful, engaged, connected, consistent.

Statements could include: “I’m praying daily.” “Scripture brings me comfort.” “I feel close to God when I worship.” “My faith practices are steady.” “Communion, prayer, church matter to me.”

Low SE Distress

Practices slightly disrupted but not abandoned, inconsistent, distracted, less emotionally engaged, mild spiritual dryness, occasional guilt.

Statements could include:“It’s harder to concentrate when I pray.”“I haven’t been as consistent.”“I still believe, I’m just tired.”“I don’t feel as connected as I used to with my spiritual practices.”

Moderate SE Distress

Spiritual practices feel heavy, conflicted, or avoided, feels guilty, frustrated, doubting, numb toward worship/church, shame, apathy, loss of joy in worship, reluctant.

Statements could include: “I don’t feel anything when I pray.” “I’ve stopped reading Scripture.” “Church feels different now.” “I don’t know what to say to God anymore.” “I feel guilty because I’m not practicing like I should.”

High SE Distress

Withdrawal, rejection of spiritual practices, shut down, cynical, disillusioned, spiritually empty, detached, shame, distrust of faith community, moral injury.

Statements could include:“Prayer doesn’t work.” “I don’t trust religious people.”“I feel like a hypocrite.”“I don’t want anything to do with church.”

E – Emotions & Spiritual Struggles

No SE Distress

Emotionally steady, resilient, grounded, calm, peaceful, hopeful, stable.

Statements could include: “Of course I have concerns, but I’m at peace.” “I feel steady even in this.” “I have hard moments, but they pass.”

Low SE Distress

Heaviness present but contained, worried, processing, sad at times, concerned, mild anxiety, some discouragement.

Statements could include: “I’ve been thinking a lot.” “It weighs on me sometimes.” “Some days are harder.” “I get anxious sometimes.” “I’m trying to stay positive.”

Moderate SE Distress

Emotional strain affecting functioning, overwhelmed, drained, anxious most days, tearful, very sad, irritable, burdened, discouraged, difficultly coping, reduced resilience.

Statements could include: “It’s constantly on my mind.” “I can’t shut it off.” “I’m exhausted emotionally.” “I feel stuck.” “I’m not sleeping well.” “I’m losing hope some days.”

High SE Distress

Emotional collapse or crisis, feelings of hopelessness, despairing, numb, ashamed, angry at self, deeply fearful or anxious, severe grief, defeated, emotional shutdown, loss of internal peace, possible suicidal thoughts/feelings.

Statements could include: “I don’t see a way forward.” “I feel empty.” “I’m falling apart.” “I can’t handle this.” “I feel like a failure.” “Nothing helps.” “I wish it would just end.”

Summary guideline for each level of distress:

Low Spiritual-Emotional Distress
The patient shows mild concern or temporary strain, but their faith, meaning, relationships, practices, and emotional stability remain intact. They are coping and adjusting, even if the situation is heavy.

Moderate Spiritual-Emotional Distress
The patient shows clear spiritual or emotional struggle that is affecting their sense of meaning, connection, or coping. They feel strained, discouraged, or unsettled, but some hope, belief, or support is still present.

High Spiritual-Emotional Distress
The patient shows deep disruption or collapse in their sense of meaning, connection, faith, or emotional stability. They may express despair, abandonment, worthlessness, or profound isolation, indicating a spiritual or existential crisis.

More condensed form:

Low: coping with mild signs of concern

Moderate: struggling and strained

High: overwhelmed or collapsing

–

–