The Current Crisis in Healthcare Chaplaincy and Spiritual Care(An Extended Review of Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy George Fitchett & Steve Nolan, Editors)
Raymond J. Lawrence
I The Patient
Angela is a blonde, blue-eyed, petite 17-year-old who, after a family argument, lost control of her car on an icy road and suffered a severed upper spine. She was paralyzed from the neck down, with no prospect of remedial treatment, suddenly an almost certain lifelong quadriplegic.
The female Catholic chaplain visited her for four “rapport-building visits” and then used the Spiritual Assessment Tool designed by the spirituality guru, Christine Puchalski. The Spiritual Assessment Tool recommends putting the following questions to the patient:
- Do you have spiritual or religious beliefs that help you cope during this time?
What importance do your beliefs have for you at this time?
Are you a member of a religious or spiritual community?
Are there any particular spiritual or religious activities important to your well-being while you are in the hospital?
On reading this list of four, my first thought was that if I were a patient suffering from such a catastrophic, life altering event, and a chaplain came asking me such questions, I would call security and have them removed from my room. My second fantasy was that if in the unlikely event I had any spirit left in me I might play with the chaplain and reply to the first question, "Yes. My god is a large cosmic cat who is coming soon to deliver me from this nightmare, and take me to cat heaven."
The basic Puchalski theology is that religion is something like a Swiss Army Knife, a little tool with many uses that often comes in handy in a pinch. That's what you get when you turn a physician into an expert on pastoral care and counseling.
Next, the chaplain used what she calls her own specially devised "Spiritual Assessment Tool" that leads to discussions of how patients feel centered or anchored, called or motivated, whether they feel connected to relationships beyond themselves, and contribute to the good of the world and/or the good of others in grand or small ways. It is not clear why the chaplain needed two sets of so-called Spiritual Assessment Tools. One seems about as inhumane as the other. The chaplain wrote that she weaves the questions into conversations, presumably in order that the patient will not feel surveyed.
Angela, it turned out, was a member of a small Protestant church and had not been attending or engaging in any religious practices. But now she was praying several times a day and having the Bible read to her. Obviously she could not lift the book to read on her own.
For the first days after her accident, Angela was in denial, expecting to go home soon. Her mother, too, was in denial, promising her that if Angela prayed hard enough, God would give her a miracle. And of course, the chaplain was asked by Angela to pray for that same miracle, which she did. (What are chaplains for anyway?)
The chaplain thought Angela to be coping adequately in the early days after the accident, though she thought Angela to be unaware of the likely permanence of the injury. But it would have been clear to any clinical observer that Angela was in massive denial. During this period the chaplain discussed with Angela how God was working in her life. The chaplain believed that God is always with us, especially in our deepest darkness. That Angela has just been made a quadriplegic but that God is with her is the ultimate non sequitur driven by denial.
Angela's pastor came to visit, but the chaplain reported that Angela does not relate to him.
Into the second week of hospitalization Angela's illusions, hopes, and prayers began to fade. She stopped caring for herself, refused to work with the psychologist, and stopped eating and drinking. The chaplain nevertheless persevered in her visits, laying aside her "spiritual resources" agenda and most of her pious defense of God, and finally began to listen quietly to Angela's despair. "I have lost everything! Absolutely everything!" was her cry. And so it seems. Who in the world would not feel exactly the same way? The chaplain finds the emotional barrage a bit disorienting and difficult to bear, but she is for a space of time blessedly quiet, finally. The chaplain silently comforts herself (but not Angela, thank God!) with the belief that God is with us always, even in our deepest darkness. And it appears that the chaplain blessedly and to her credit stayed relatively quiet with Angela in her despair, if only for a while.
The chaplain then thinks to herself, "Angela has lost her spiritual center." (The meaning "spiritual center" is not exegeted.) Certainly Angela has lost the will to live. Certainly we can agree that Angela has experienced a horrifying life-altering blow at age 17, a blow from which she will likely never much recover, and as a result, it is not even clear that she will recover the will to live. What else does the chaplain need to know? And if Angela could find a "spiritual center" would her anguish be over?
The next phase of the relationship between Angela and the chaplain is full of discussion topics about the power of prayer, the power of God, whether God actually reached down and broke Angela's neck, or not, as well as the discussion of several biblical texts introduced by the chaplain. The chaplain is increasingly propelled into a catechetical mode. It's as if she were instructing a potential novice in the mysteries of the Christian faith. And the chaplain's lines in the verbatim sections become significantly longer than the patient's, usually an indicator of a chaplain's dysfunction. Pastoral counseling has collapsed and the chaplain has morphed into a catechist or propagandist. The chaplain says to the patient, for example:
"I believe that God's will for us is always related to what is truly good for us, but that in the middle of a painful situation, especially one as painful as yours, it's hard to find the good. With time, though, we might see it."
Yes, perhaps. And with time we might not see it. My thought in first reading this was the wish to be able to send this Pollyanna chaplain down to the underworld to give that bit of pious wisdom to all the dead from Auschwitz. She could report back, "It's hard to see the good in those deaths, but we know it must be there, because God is good."
The chaplain, as pocket philosopher, has lost her way.
"Suffering is so hard to understand," says the chaplain, in a further display of banality. And then she expresses surprise and dismay that Angela thinks that God actually reached down and severed her spine. Why wouldn't Angela think that? Omnipotence means the power to do anything.
Discussions ensue as to whether God is responsible for the accident and injury. The chaplain seems to do most of the talking, and is very protective of God's innocence, as is typical of religious authorities.
Then in the midst of the sermonizing and religious education a ray of hope breaks in. Angela says, out of the blue, that it always helps when Josh visits. Josh is another rehab patient Angela's age who has similar injuries. Angela has found a new friend, one her age and in a predicament like her own. Then Angela asks the chaplain to assist her in blowing her nose, something she of course cannot do for herself. Angela cannot even hold a tissue. Next she asks the chaplain to wash her face, and afterward says, "That feels better, so much better. Thank you." We have the first recorded inkling of Angela's recovered will to live, faint as it may be. Angela dismisses the chaplain and asks that she return tomorrow. In her departure the chaplain of course feels the need to offer yet one more prayer.
In due course Angela is discharged to a long-term treatment center. Her family is unable to care for her and seemingly little interested. We never hear about her further.
II The Critique
The published critiques were quite weak.
The Editor's (Steve Nolan) critique merely summarizes, adding nothing.
The Psychologist critic (Sian Cotton) points out that the chaplain aims to "be a sign of God's incarnational love" and to help Angela establish a relationship with God that would "center and sustain her" in the future. He calls the chaplain's interventions and clinical choices "spot on." He also claims that the chaplain's "spiritual care transformed and assisted Angela." He does add, appropriately, that the chaplain might have explored Angela's parental abandonment, along with her other losses resulting from her accident. His one assertion, that I heartily concur with, was that this was "one of the most emotionally...powerful" stories he has ever read. On balance, the psychologist critic failed in his assignment. He was far from "spot on."
The Chaplain critic (Alister W. Bull) was the strongest of the three. He felt ambivalent about the religious focus that emerged in this case, as well as in the previous two cases. He charges that the chaplain often took the lead in introducing religious language and constructs with which they were familiar. I wish he had been less ambivalent and more direct, but nevertheless I say "bravo to the chaplain critic!"
III Author's Notes
Clinical pastoral criticism in the U.S., coming as it does out of the Boisen movement, is a tradition of strong clinical criticism. The critics in this case hardly qualify as strong. Except for the one offered by the chaplain critic, the critiques of this case were almost useless.
Overall Angela's chaplain assumed too much of the role of God's little defense attorney. She should already know that that's a role, ever since Job, that no one should undertake under any circumstances. How could anyone defend the turning of a lively 17-year-old girl into a quadriplegic? Who would even want to? But who can put God in the dock? It's a case one cannot win.
The proper posture of a clinical chaplain is agnostic, regardless of the chaplain's own personal beliefs and allegiances. The clinical role demands it. In this era, chaplains present themselves to persons of many different faiths, and faiths within faiths as well as persons of no faith at all. A proper clinician does not represent any specific religion or tradition if the chaplain wants to remain a clinician. Indoctrination and proselytizing do not belong in the clinical setting. The chaplain in this case was continually promoting her own pious beliefs. That is not acceptable.
I think we must be suspicious of the chaplain's cavalier dismissal of Angela's own congregational minister on the grounds that Angela didn't relate to him. Angela was in no condition to relate to anyone for much of her time in the hospital. Unless there are clear contraindications— and there may be— the chaplain should encourage the connection between the minister and Angela. One visit can hardly be determinative. Angela has only meager support from her family. The chance that any minister might take an interest in her should be valued on its face. We have to be suspicious that discounting- the minister is rooted in the half millennium of hostility between Catholics and Protestants, and wonder in this case if the chaplain's own Catholicism was skewing her assessment of Angela's Protestant minister. The minister and the chaplain were, after all, in a competitive role during Angela's hospitalization. Suspicion is warranted.
The one point in the case that was clearly redemptive, in my view, was Angela's reporting that it always helps when the 17-year-old Josh, a quadriplegic like herself, comes to visit. Mirabile dictu, she has found a boy for a friend, a boy immobilized like herself, and in that she has found, perhaps, even the will to live. Then she asked the chaplain to help her blow her nose and then to wash her face. "That feels better, so much better. Thank you," she said, and then asked the chaplain to return the next day. The quadriplegic 17-year-old Angela has found a will to live, if only for that moment. It's enough to make a grown man weep.
Buried in all the chaplain's religiosity and talkativeness, Angela must have sensed that there was a compassionate human being in there, human enough to be asked to blow her nose and wash her face.
This case demonstrates that we can be instruments of healing sometimes even when our skills abandon us and our awareness is dim. Perhaps it is a matter of simply being human, utterly human: blowing the nose and washing the face of a young quadriplegic girl who has just met a boy she likes.
I do conclude that the chaplain in this case was ultimately a blessing to Angela—but in spite of herself. It was a very close thing. The chaplain made a revelatory confession in her concluding paragraph, stating, "I entered Angela's darkness while keeping my eyes on the light of hope." This tells me that the chaplain's own countertransference was so strong that she could hardly bear staying focused on the patient. For her own protection—and sanity, perhaps—she piled high her religious teaching and her piety as a defense against the horror of Angela's predicament. But enough humanity broke through her anxiety, enabling the chaplain to reach Angela. Perhaps one day she will be able to do much more.
The fact that the chaplain in this case now is teaching other chaplains as well as medical students and psychiatric residents about the work of chaplaincy should sound the alarm to any who care about the profession. I do wish this chaplain would get into advanced clinical pastoral training that is psychodynamically oriented, in the Boisen tradition. Her heart seems to be right, but her practice is very much lacking.
I do wonder what eventually happened in Angela's life, and in Josh's. They are now in their mid-twenties. If they are alive. I fear the worst.
Editor's Note: This is the third article of a series written by Dr. Lawrence critiquing the clinical case studies found in An Extended Review of Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy by George Fitchett & Steve Nolan, Editors). Additional articles on the subject will be published on the Pastoral Report.