Prepared for the Wayne E. Oates Institute for their website discussion of spirituality

The contemporary scene

Common ground? Common language? To many, at least since the fateful day of permanent change, September 11, 2001, the idea of a point of commonality seems worthy, but impossible. Where does one begin? How can we find a sense of community and communion as diverse peoples when we are so remote in our understanding and consumed with our sense of helplessness, defenselessness and rage?

Where do we begin? As a chaplain the role of prophetic voice has both been claimed by me and placed upon me. Of course it is not a solo performance; it is often a terrifying responsibility. The other day, in response to the start of our new "war," I sat at my computer wondering how to address pastorally and spiritually our 2200 employees and 400 physicians? What word was needed to be spoken and heard? How does one address a diverse population that, on the medical staff alone, includes 75 Muslims (someone from every country now thrust into the news by recent events). There is an equal number of Hindus, a significant Jewish presence, a diversity within the Christian tradition and many who, while fiercely loyal to spiritual care and our partnership on the team, insist that God and religion are meaningless, marks of weakness or foolishness. We have 180 religious communities in the county, including the traditions mentioned above along with Baha'i and Buddhism. We also have a cultural diversity in a county that is 36% minority, largely Spanish speaking, but also has strong representation from the Philippines, Korea, Laos and Poland. Is there a common ground with a common language?

It was time to revisit my task and identity as a spiritual caregiver, generally, and specifically in the role as a chaplain. What can I bring to the mix we call the common ground and dialog in health care? It is the process all of us go through. Then came the sonic booms. The hospital neighborhood shook. We felt as if the terror had come through explosions. We calmed when we learned that the sonic booms were from military aircraft in the area. The tension returned when we were told that they were called out because of a disturbance on a domestic flight. That was Tuesday. It happened again yesterday. More exposure to the mystery of life, humanity and terrorism … given new meaning for us because we work in a hospital only 25 miles from O'Hare.

These are the times in which we work and it is important to start there if we are to grasp what is the spiritual journey for our patients. The anecdotal information that introduced this essay first point to our need to approach any discussion of spirituality and spiritual care with a keen awareness of our issues, our beliefs, our values and how all of that does or does not fit into our specific work. Many times we abuse spirituality by trying to fit it into a medical model that seems more familiar to us or that otherwise suits our time constraints. If we are to be honest in our discussion of spiritual dialog as an essential ingredient in our professional menu then it must start not with the patient, but with ourselves. What are our spiritual definitions. How do we express our values and do they have something to say to who we and what we do as professionals? Finally, we must begin to take mystery more seriously. Medicine is an art, not a science, albeit approached scientifically. Few things draw us more quickly into mystery, into the challenge of finding meaning when it is not readily apparent to us, then both the surprises and the day-to-day that we call contemporary health care. It is in mystery that we can find meaning, purpose and hope.

The patient's context and story

The background information cited above introduces us to healthcare professionals and the struggles faced to find common language and meaning, It also introduces us to the patients. The patients are very familiar with the struggle. It is what it has always meant what it is to be a patient.

As a side note because it needs to be said, we dare not forget that, while we are for a time a guest in a patient's space, story and experience around the medical concern that brings us to them, they are still very much part of the larger world view and are concerned about the same issues that concern us. In other words, patients watch CNN, too, and now must balance the experience of medicine and medical care, while also addressing the same despair, helpless and anger that can accompany the lives of caregivers since September 11.

A big difference for the patient is that he or she has already experienced a different "September 11th experience." The drunk driver that plows into their car. A child born with complications and severe risk factors. A limb broken. Violence experienced. An addictive disorder. A gunshot wound. A tumor requiring surgery. Chemotherapy. Symptoms that can accompany aging. An emotional crisis. All of those "September 11th experiences" force the patient into a new life setting, a new wilderness, with new feelings, a new intensity of feelings, procedures, the lack of procedures to offer, pain, financial concerns, a rearrangement of life and life priorities or a terminal condition rewrite the rule book. The playing field has been redefined, and it is a new world requiring new definitions, new clarity, new markers. To be a patient is to be thrust into what is, at best, a new spiritual challenge and what could become a serious spiritual crisis. What does it mean to be dying? What does it mean to learn that your spouse may not leave the hospital alive? What does it mean to hear terms like CHF or AMI? How will I cope? Is there hope? Am I still valued and loved? Just as these can become the common ground of experience for all of us with the current events in the world so are they the common ground for patients in our various settings and it is where we must, again as a guest, enter their stories, meet them in their wilderness locations, and, aware of mystery in our own lives, willingly explore these issues with them. That is the start of spiritual care and spiritual care is the work that all of us do if we are to be quality, holistic caregivers.

Spirituality - definitions

One of the dilemmas in today's healthcare setting is the rush to get things done. We are fitting people into DRG's, standards and averages rather than bringing our offerings to the "altar" which is their story and their experience. We can't fit spirituality into some one-size-fits-all definition or practice so that we can fit it into what works best for us! We must keep our definitions clear, but always allow room for the one or two new ones that may come from the patient.

Liz Budd Ellmann, in an article on workplace spirituality gives this definition of spirituality from the work of Dr. Stephen Sundborg, SJ, president of Seattle University. "Spirituality is one's lived relationship with mystery." (note 1) That is a most suitable definition. Spirituality is seldom neat and tidy, hermetically sealed in a fancy package that we pull from the shelf when we have a need. John Fortunato reminds us, "Spirituality growth is more of the nature of proceeding from hunch to hunch than from conclusion to conclusion." (note 2) To be spiritual as practitioner is to acknowledge that patients are generally not where they want to be, physically, and may well feel spiritually lost. Our privilege (not "task") is to help them, through their definitions and rituals, to determine what this situation means, how to clarify that meaning and then how to live (or die) with that meaning. When we come together in our suffering, provider and patient together, there is that meeting point and that meaning. Doka and Morgan (1993) give this definition, "Spirituality is experienced at the meeting point, or as some would say, the merging point, between our self and that which we usually feel is not our self." (note 3) They cite further, "One of the strengths of belief is that it provides support and succor at a time when secular explanations are largely silent." (note 4)

Religion and spirituality are different. In some people, in some stories, they may so intermingled that it is hard to distinguish them. In others we will meet people struggling to claim their spiritual connections despite an oppressive crushing from organized religion, generally, a specific denomination, congregation, leader or congregant. Ritter and O'Neill (1996) discuss religious abuse especially as it appears in Roman Catholicism when it is expressed as an authoritarian voice and Fundamentalist Protestantism. They focus on abuse by discussing "the relationship between the deconstruction of illusions and the growth involved in finding a voice of one's own." (note 5)

Religion can abuse; so can spirituality. Here we are looking for clarity of definition. Simply put, religion moves beyond the "I" of one's personal spirituality and personal relationship with God/Higher Power/meaning to something akin to "we". It is moving beyond the construction of an individual piety to, hopefully, a community of like believers with shared understanding, practice, community support and mutual trust.

Congregations should provide clarity of teaching, liturgical or ritual expression, with sacramental or other ritual options that can become very important to patients and others struggling with life's traumas. There is a common language, process and expectations. There is give and take, which can sometimes lead to one's spirituality on an individual level in order to conform to what is either expected by the community (rightly or by perception) or some voice within that community. While people "give" as members of a community as we do within a family, it is important to state that religion exists to foster and nurture one's spirituality and should never be the oppressor of a person's individual journey. There is an enormous difference between participation, partnership, covenant and an obedience that crushes rather than feeds, that demands conformity rather than trust.

Spiritual care is sometimes viewed as a safer approach, avoiding any discussion of religion. That does serve a practical purpose in an age where many are generally suspicious of organized religion, where the prophetic voice of the religious community has been somewhat limited by society, and where many are finally feeling safe to explore a spiritual pathway that may be very different from that which is normal or standard for a community and that may or may not involve God or some expression of deity. It is still about meaning, purpose and connection.

Spiritual care touches all of the human experience and all of medicine (including the work of allied health professionals) because it is the care of the soul, of this meaning , of how we do or do not make decisions, and often how we express feelings like hopeful, fearful, guilty, shameful, etc. That is spirituality and this spiritual care becomes the responsibility of all of us. It is our "delving into the sacred," or, stated otherwise, "that which makes work in health care (and that includes housekeepers, volunteers, engineers, cooks, accountants …) 'sacred'." We are meeting people in their vulnerability and witnessing their discovery and acceptance of meaning.

There is no turf demarcation in spiritual care. There is diversity in terms of skills and what we can bring to the situation. The chaplains are the specialists in spiritual care. My preference, despite some new diversity perspectives, is to suggest that pastoral care is the work of the specialists. Our concern here is to say that spiritual care is the work of all of us. Stated another way, "None of us are excused from spiritual care." In other articles and discussions we need to explore developing our comfort level around "the tough God questions," and how to assess more clearly and supportively. It is also important to understand the fourfold work of chaplains and other religious leaders, (note 6) but for now we simply state that all of us must engage in the work of meeting people in their quest for common and sacred ground.

Spiritual care - listening, assessing, caring (note 7)

Much of the discussion for this website conversation is around common ground and common language. It may be that the best that we can do is to own the important place for matters of the sacred in the lives and care of our patients and, with clear definitions bound by our attention to our own issues and needs, bring care and support to people seeking their spiritual connection. That is the ultimate task and promise of spirituality, maintaining a session of connection to God, the divine or, more simply, meaning and values, in a world (and in a health issue) determined to leave us feeling disconnected.

With these definitions, and as guests in the story of the patient, there is the work of assessment. There are many assessment tools and, when consulted on this matter, encourage each team or institution to develop those assessment tools (remember, no one-size-fits-all approach to spiritual assessment and care) which best serve a wide array of people, health issues, cultural perspectives and gender needs.

For our purposes in this brief article we focus on three words, listen, assess, care. They are interactive. Caring is expressed in how (and whether) we listen, the assessment process (done jointly with the patient) and in the ongoing care that we provide that maintains a sense of sacredness even when the wilderness' boundaries are redrawn depending on a patient's care and his or her response to that care.

Stated another way, we don't listen, discern the meaning of what we have "heard" (assess) and then develop a care plan that we think best suits the patient. It is arrogant, at least in matters that are spiritual, and is an affront to the person's own spiritual expression and determination. To listen involves a constant attention to our own values and beliefs so that, unencumbered we can begin to "hear" what the patient is telling us. We do use our professional skills, we do discern meaning in their words and we do try to develop some response that brings the skills of our practice to their needs. Spiritual care, however, is first and foremost about "being," not "doing." We don't do spiritual care. We are spiritual caregivers who, through the skill (ministry) of presence, become the guest in a person's story so that the host can articulate feelings, questions and longings and, through his or her own reflection (we serve as reflectors or guides) ask about meaning and discover its location. Clergy are guilty enough of hit-and-run ministry, zapping people with a sacrament, verse or ritual identification. It takes more time, patience and health (on our part) to stay with people in their struggles so that, self aware and self affirmed, they can walk where they must walk and rest where they must rest. Enough things have been "done" to medicine to make it easy to do hit-and-run, medicine by the book, or, as we say more often, "bottom line medicine." There are other venues for that discussion, but we mention it here because reactors will allow those flaws (albeit dangerous flaws) to corrupt who we are and what we do. Proactive caregivers will do what must be done, even rearranging priorities (but always listening to our values) to provide the sanctuary (safe place and safe person) needed by the patient to find that connection.

To assess, medically, usually means that we run tests, ask questions, discern, search and hope, this scientific process within a world called mystery. It still becomes something that we do, albeit collaboratively. In is interesting that a word check in the dictionary suggests that assess means "to sit beside," and maybe that is where our work of assessment begins. If we are to come to common ground in a person's spiritual quest, using the common language of definitions as our messengers, we must remember that the ultimate assessment is made by the patient. They discern for themselves the pathway which is their spirit and they bring that message to us. Then, collaboratively, caregiver and patient, we work for the common good of health and wellbeing.

That is assessing, and that is caring. It is also the work of all of us if we are ever to tame the beast of modern medicine and get back to the basics of quality, affordable, accessible care that puts person above machine, and restores time (taken away by other authorities) to the time which is within the person we are, for that moment in time, privileged to sit beside.

Concluding statements

1. All people are spiritual, as they define spirituality and connect with it. Not all people seek a religious context or presence.
   
   
2. Spirituality is growing in its awareness within the medical community, though it is nothing new to many of us. This is exciting, and brings great hope to patient care and even to the health and well being of the institution. We must be vigilant in keeping spirituality healthy, even "protecting" it from being lost in the convenience of the medical model.
   
   
3. Spiritual care is the privilege and responsibility of all of us. All of us are spiritual care generalists. Some of us are spiritual care specialists. At a time when we are coming to value spirituality we are seeing chaplains fired because of funding limitations and, oftentimes, short sighted, visionless administrators and leaders. Professional organizations such as The Association of Professional Chaplains and The National Association of Catholic Chaplains have much to offer the health care industry to help the industry and workplace be healthier, and to improve the care we bring to our patients. Listen to the experts and insist on a collaborative approach to spiritual care (which includes the patient).
   
   
4. Not all expressions of spirituality and religion are healthy. We must be very careful when making that assessment. That determination (unless there is an urgent risk factor) still rests with the patient, but we must remain present with the patient and offer the invitation to explore those areas of concern.
   
   
5. The United States is religiously diverse, a message that is hard to accept by many individuals and faith traditions. "Over the last thirty-five years...the United States has become the most religiously diverse nation in the world." (note 8) This has very clear implications for our already tired and struggling healthcare delivery system. It is another reminder of the importance of chaplains as our resource on spiritual and religious diversity and as the institution's liaison to the religious communities that feed into that institution.
   
   
6. Ritual remains crucial in health care. Chaplains are ritual specialists (the "priestly function") of chaplains, but ritual is the concern of all of us. Ritual serves to give us a visible and measurable way to say, to others and to ourselves, "Something has happened," and "What does this mean?"
   
   
7. Until we come to terms with a concept of the soul of the workplace and the soul of the industry (i.e., "hospital" and "health care industry") we will continue to fall short on all of the issues that confront health care today, including new and demanding ethical issues, new diseases, need for new medications, terrorism, violence, staff shortages (which are increasing in many places) and financial limits. We must rediscover the sacredness of being a healthcare professional and a healthcare institution. If we are truly to render optimal for our patients it must be concurrent with the resolution of these very complicated problems that challenge the heart and quality of healthcare delivery.
   
   

Concluding questions:

What are your definitions and experiences of spirituality, religion and spiritual care? Are they truly integrated into your story/journey and, from that, integrated into your professional practice?

How is diversity understood in your practice and workplace and what are its implications for how you provide spiritual care?

Understanding spiritual care as presence, do you have a collaborative approach to spiritual care and the assessment skills necessary to best serve the needs of your patients?

How do ritual and religious practice fit into your professional work?

Do you have chaplains available to you, personally and professionally? Are they properly trained, supervised and integrated into the mainstream of the institution and your practice? Do you properly utilize them? Do you also remember to support them?

How can you use the emerging new standards for JCAHO to your advantage to enhance the spiritual care that you are providing?

How are you doing, spiritually? Where is your common ground (meaning) in this mystery we call life?

End notes

1. Ellmann, L. Tending to Spirituality in the Workplace. Presence: The Journal of Spiritual Directors International v. 7, n. 2, June, 2001, p. 47.
   
2. Fortunato, J. (1987) AIDS: The Spiritual Dilemma. p. 14.
   
3. Doka, K. and Morgan, J. (1993) Death & Spirituality. P. 52
   
4. Ibid., p. 11.
   
5. Ritter and O'Neill (1996), p. p. xii
   
6. Gilbert (2002), pp. 22-26.
   
7. Ibid., p. 28-35.
   
8. Howell, L. A New Religious America: Defining Our Faith By Roots, Not Borders. Cathedral Age, v. LXXVII, n. 3, Fall, 2001, p. 17.

Recommended reading

Carr, W. (1997) Handbook of Pastoral Studies. London: SPCK.
Cox, G. and Fundis, R., ed. (1992) Spiritual, Ethical and Pastoral Aspects of Death and Bereavement. Amityville: Baywood.
Doka, K. and Morgan, J. (1993) Death and Spirituality. Amityville: Baywood.
Evans, A. (1999) The Healing Church: Practical Programs for Health Ministries. Cleveland: Pilgrim.
Fortunato, J. (1987) AIDS: The Spiritual Dilemma. San Francisco: Harper & Row.
Friedman, D. (2001) Jewish Pastoral Care: A Practical Handbook. Woodstock: Jewish Lights.
Gilbert, R., ed. (2002) Healthcare & Spirituality: Listening, Assessing, Caring. Amityville: Baywood.
Harvey, J. (2000) Give Sorrow Words: Perspectives on Loss and Trauma. New York: Brunner/Mazel.
Larson, D., Swyers, J., McCullough, M., ed. (1997) Scientific Research on Spirituality and Health: A Consensus Report. Rockville; NIHR.
McBride, J.L. (1998) Spiritual Crisis: Surviving Trauma to the Soul. Binghamton: Haworth.
Oates, W. (1970) When Religion Gets Sick. Philadelphia: Westminster.
Ritter, K. and O'Neill, C. (1996) Righteous Religion: Unmasking the Illusions of Fundamentalism and Authoritarian Catholicism. Binghamton: Haworth.
Roukema, R. (1997) The Soul in Distress: What Every Pastoral Counselor Should Know about Emotional and Mental Illness. Binghamton: Haworth.
Steere, D. (1997) Spiritual Presence in Psychotherapy: A Guide for Caregivers. New York: Brunner/Mazel.
Storey, P. (1997) UNIPAC Two: Alleviating Psychological and Spiritual Pain in the Terminally Ill. Gainesville: AAHPM.
Wilcock, P. (1997) Spiritual Care of Dying and Bereaved People. Harrisburg: Morehouse.
Zurheide, J. When Faith is Tested: Pastoral Responses to Suffering and Tragic Death. Minneapolis: Fortress.