(An Extended Review of Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy George Fitchett & Steve Nolan, Editors)
NOTE: See Part I
Erica is the mother of a two-year-old girl with cancer, admitted to the ER. There are several young children at home, a grown daughter, and a new husband who doesn't understand Erica's religious affections. She describes herself as a "redneck" with a faith in Jesus that was making it possible for her to cope. God has spoken to her directly and powerfully, and she relates stories about the voices. Erica is certain that God has a plan, but she is not sure why God would speak to her. She keeps all this from her husband, who couldn't understand.
Erica had requested a chaplain when admitted to the ER. She responded negatively to the first chaplain she met, a female who was 'dressed too fancy,' unlike the present chaplain who is dressed down, in blue jeans and turtleneck. The chaplain responds to Erica's sharing of her experience of God speaking to her by relating the story of God talking to Moses.
Later Erica rants over the many misleading translations of the Bible in current circulation, arguing that only the King James Version is authentic. She is vexed specifically that the new translations do not declare Mary a "virgin." In response the chaplain offers a mini-lecture on the problems of translating ancient manuscripts. It did not seem to occur to the chaplain that Erica may have some thoughts or feelings about virginity itself, or perhaps the circumstances of her own deflowering, and thus might have become fixed on this biblical text.
It appears that every chaplain visit is ended with a prayer, and sometimes at the chaplain's own request.
The chaplain reports an intuition along the way that Erica might have a substance abuse problem that she was not disclosing. This would seem to be a good guess. In response to this supposition, the chaplain decides to divulge her own past history of substance abuse. She took this action, she says, subsequent to a message from the social work department reporting that Erica had made a request there for referral to a "Christian counselor" for help with one of her older children. The chaplain discloses her knowledge of this request by advising Erica to find a competent counselor rather than a specifically Christian one. There is no inquiry and no speculation as to why Erica went to social workers for referral, and not to the the chaplain herself. One would think this would have been an insult and a negative reflection on the pastoral relationship itself, a devaluation of the chaplain's authority and/or wisdom. Yet, that is not explored.
Erica and the chaplain appear to have some difficulty finding places to talk in private. Or perhaps Erica's need to smoke is the motivation to exit the hospital. In any case, the two of them devise a plan to move outside to a nearby street corner, and to sit on the curb while they talk and Erica smokes. It is in that context that the chaplain shares her own substance abuse history and her 12-step program experience. This is a rather poignant picture, an institutional chaplain counseling on the street, sitting on the curb. If nothing else, this chaplain is resilient.
At one point Erica's husband arrived unexpectedly in the hospital room while the chaplain was present. Erica suddenly fired four shots with a toy gun that emits plastic globs, leaving him nonplused. Erica immediately proposed to go for a private conversation with the chaplain, leaving the husband with their daughter.
The chaplain reports that every visit with Erica began and ended with a hug, and it seems to have been a serious hug at least some of the time. One such incident is described as Erica holding her baby and sobbing, throwing herself into the chaplain's arms, while the chaplain embraced them both and stroked Erica's back as she prayed
In her summary, the chaplain assesses herself in relation to this patient as eager to get religion out of the way so that spiritual care could begin, and to move the conversation to a deeper level.
She feels she became Erica's "mentor and spiritual friend."
The chaplain also contends that she has been "a transitional object" for Erica, as described by the psychoanalytic authority, D.W. Winnicott. Very few readers will have any idea what a transitional object means, or whether it promotes understanding of the pastoral role here.
The Published Critique
The co-editor's (Nolan) assessment of the case is that Erica had "a keen Christian faith," that the chaplain "models good practice in multi-professional working," and that she models "an incarnational approach." The editor also notes that while self-disclosure can be a first step towards "violating the boundaries of the therapeutic relationship," the chaplain here "offers chaplains an example of good practice in this sensitive area."
The other two critical assessments are more substantive - and more accurate. The clinical chaplain critic (Bull) seems to be mostly undecided and feeling ambivalent about this case, but he does question the chaplain's identification of herself as a Winnicotian "transitional object." He also "felt ambiguous" about the religious focus that emerged in the case. Even more telling, he felt that the chaplain "may have had her own deconstructive agenda" in her claim that her goal was "to get religion out of the way" in favor of spirituality. He also "wonders," astutely, about the chaplain's compliance with Erica's request to leave her child and husband in the room (after shooting him!) while the two of them went off to talk.
The psychologist critic (Cotton) is somewhat more decisive and direct. He says the researcher in him wants to know what the definition of "spiritual care" is, and if the chaplain is off-loading religion in its favor. He certainly belled the cat on that one. I suggest he better not wait around for an answer.
We have here a very complex and troublesome clinical case, followed by three critical responses. It should be said first that the chaplain deserves credit for courageously jumping in water over her head, publicly disclosing a number of poignant and serious issues, and making herself the object of public scrutiny. She certainly should get high marks for courage. Maybe we can all learn from her mistakes as well as her commitment.
I strongly second the psychologist critic (Cotton) who asks for a definition of spiritual care that is distinct from religious or pastoral care. As I have already suggested, I believe that will be hard to come by. No one should look for it anytime soon.
As to the other clinical responses, I concur with the chaplain critic (Bull), but with less ambivalence. Contrariwise, I take issue with the co-editor's (Nolan) assessment of Erica's "keen Christian faith," and that the chaplain is a model of an incarnational faith. For the latter point, I do not know what he is talking about. The chaplain is certainly in the flesh, probably too much so, if that is what is meant by an incarnational stance. As for Erica's faith, it seems to me a borderline or even psychotic construct. Persons today often refer to God speaking to them, typically meaning "metaphorically speaking." But Erica sounds as if she is not speaking in metaphors. She suggests that she may in fact be hearing voices, in which case she would seem to qualify as psychotic, or at least borderline.
Now there is nothing wrong with being psychotic, or borderline. Anton Boisen taught us that lesson well. But the question is how to work with a person in such straits. The best answer yet is that we should listen to them, and keep listening until we can make some sense out of their irrational thought processes. My problem with Erica's chaplain is that she does not seem to recognize that she may have an exceedingly troubled woman on her hands. And the chaplain does not do much listening. She lectures on the Bible, and engages in discussion of the meaning of the Trinity. She shares her own past history of substance abuse. She prays and prays ad nauseum. She hugs. But she does not really listen in depth. She does not seem to wonder what might underlie Erica's troubling personal disorganization.
For example, what might it mean that Erica shoots her husband with the toy gun in the presence of the chaplain, and then whisks the chaplain away from her husband for a private talk? Shouldn't it be useful for the chaplain and for Erica to meet and converse jointly with the husband? Is the chaplain no more than Erica's pawn in this family drama?
I am also concerned about the extraordinary amount of physical contact that takes place between the chaplain and Erica, an issue only lightly touched upon by one of the critics, the clinical chaplain (Bull). The boundary between the two seems much too permeable. Hugs at the beginning and end of each visit, along with intimate back-rubs during prayers while Erica sobs. A male chaplain acting in such a way would place himself in grave danger in the current environment of sexual hysteria. But political issue aside, most authorities in the field consider such physical intimacy to be inhibitory to a significant pastoral or counseling relationship. I doubt that the permeable physical boundaries between Erica and the chaplain are useful in furthering the therapeutic process.
I also wonder about the wisdom of the chaplain's self-disclosure of her own history of substance abuse. As with the issue of physical contact, this seems to be the consequence of boundaries that are too permeable.
However, in spite of all I have written, I am quite struck by the articulate if somewhat skewed closing words of the chaplain writing in her own self-defense for this case:
"So I believe that the most important part of the work I will ever do is inner work, plumbing my own fears and chaos so that I will not pull away from the fears and chaos of others."
Agreed. Well said. She is eminently correct, as far as she goes. And the chaplain in this case, indeed, did not pull away from Erica's chaos.
But it's like a reverse of the old parable of falling over backwards while trying to avoid falling on one's face. It could be said that the chaplain fell on her face, but did avoid falling over backwards.
The chaplain blessedly did not pull away from Erica's chaos, but she did get swallowed up in it, and thus lost her way and abandoned her role. The chaplain must revise her philosophy of pastoral care, and resolve neither to pull away nor to get swallowed up, but to remain close and intimate, while remaining distinct and separate, and watching with a third eye...and patiently listening until some sense of meaning in the craziness begins to emerge from the patient herself. It often takes a long time.
This case is an excellent teaching instrument from which we all can learn. I do hope the chaplain can endure the critique in the service of her own learning as well.
Raymond J. Lawrence