We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place. Please send any cases that you would like considered for inclusion to: info@plainviews.org

We hope that this new addition will help to inform not only those who are dealing with the issue, but will enable all of our readers to learn from the experiences and perhaps mistakes of others.

PLEASE NOTE: Due to unanticipated continuing responses to both the case and the resolution of the case, added responses can be viewed in the archives. Click HERE.

CaseConference #6: (see responses below)

A chaplain consult was received to see a mental health patient, Islamic, from an Arab country, who was here studying at an American University. The referral read, “Please see pt. – pt believes he has committed the unforgivable sin of blasphemy by cursing God.”

The chaplain began by stating the reason he had been referred. The patient initially did not want to talk with the chaplain about the issue, but after a few minutes, the patient began to speak about loneliness of being in a foreign country, feeling under pressure to succeed, and breaking up with a female friend. The mental health staff felt that he has a poor concept of the depth of that relationship since the woman was clearly in relationship with another man at the time. The chaplain felt that anger at God was sometimes a result of frustration at situations in which we find ourselves. The chaplain stated that he had at times felt anger at God for some of his own life’s circumstances. From a mental health perspective, the patient was seen to be somewhat narcissistic. (“Who are you to tell God who God cannot forgive”?)

There was no Imam to consult in the community and no one to whom a referral could be made. The chaplain spoke of forgiveness from a Christian perspective and used the story of the Prodigal Son as an example that if the patient asked for forgiveness, God would grant it. The chaplain asked the patient if he could imagine forgiveness of self within the context of his Islamic faith. 

The chaplains sensed his own lack of understanding with regard to stories or illustrations of forgiveness within the Islamic tradition and also decided to look into Jewish tradition as well. While seeking assistance on the internet with regard to Islamic and Jewish beliefs, it became clear that Islamic and Jewish forgiveness not only asks that one make amends to God (which in the patient's case is helpful), but emphasis in both religions is heavily upon making right broken relationships with one’s community. Christian beliefs seem more to emphasize confessing to God about one’s sin but with less emphasis upon making things right with one’s neighbor.

How would you have handled the situation?

Would you have placed more emphasis upon the presenting diagnosis or dealt more with the underlying issues that appeared as the patient began to reveal his story?

What resources/stories from Islamic tradition might have been available to use?

Responses to CaseConference #6

I would like to hear more about "the reason for the referral" from chaplain's point of view. My first impression was that the chaplain started by saying something like, "Hi Mohamed, I have a referral to talk with you because you think you have committed the 'unforgivable sin." The rest of the case seems to be built around the chaplain taking charge of the conversation and working hard to convince the client that God will forgive. (The chaplain doesn't use Allah, which might have helped the client feel accepted)

The chaplain relies greatly on what the mental health staff has to say about the client, "he has a poor concept of . . . since the woman was ... . in a relationship;" then again "the mental heath perspective . . . narcissistic." What ever happened to patient directed conversation? The client doesn't seem to be able to really tell his story complete enough
for the chaplain to actually learn the Islamic concept of sin and forgiveness, which may or may not follow the teaching of the client's Masjid, Imam, or the Quran.

There is a reason for writing verbatim case studies in CPE, at least from my perspective. One primary reason is to explore the chaplain directed conversation vs. the patient/client directed conversation. In order for patient/client centered conversation to work the chaplain must be committed to trust that the patient is competent in discovering the
solution or "balm" for the current angst.

What about the story of Job? Did not the friends attempt to convince Job that he had blasphemed God, in this case Allah, and therefore needed to do something to get forgiven? And what did Job do, except to continue the argument with God. At the end of the story God rebuked the three friends of Job because they did not do what was right, Job was considered all the more righteous. Perhaps we chaplains can foster the argument and help the patient/client "take God to court." I think our job is to either stay silent or help the patient find words to express the anger and argument.

Finally, we have something to offer the mental health staff. This may be a teachable moment about grace and the psycho-spiritual/theological distress that happens when life pounces on learned religion. They might benefit from a little confrontation that what looks like narcissism or lack of depth may actually be the struggle to harmonize lived theology
and learned theology.

What resources/stories from Islamic tradition might have been available to use? I have a great Islamic Imam who is open to providing resources, his name is Imam Hasan. He is a BCC Chaplain and you can get his contact information through the APC directory. Or email me and I will check with him about giving out his email address.

Rev. Roy Sanders, M.Div. B.C.C. Diplomate in CPE Supervision
Director Spiritual Health / Clinical Pastoral Education
Truman Medical Center Hospital Hill

A most excellent and wise professor of pastoral counseling once told his class, "No one will allow you to care for them until you have taken the time to build empathetic common ground. Regardless of whether or not you agree with a person's presenting problem, if you do not take the time to let them know you hear what they have to say about what they think is wrong, they will not believe you care enough or honor them enough to do anything for them. If you don't have time to really listen to what they have to say, don't bother them with your theories of what is wrong with them."

The patient made it clear to the chaplain that he was not interested in discussing the issue of forgiveness with the chaplain. Maybe the patient knew that the chaplain was not equipped to help him with that concern. Maybe he had some concern that the chaplain was going to jump on the bandwagon with the therapists rather than meet him in his spiritual reality. It's hard to say because we don't have all that information.

What we have is what the chaplain had - what the patient told him. That he was lonely and struggling with being far from home. Regardless of religious differences, as a human being, that was a place where the chaplain could have met him. That was the place where the chaplain could have offered two ears and eyes of compassion. The patient told the chaplain what he needed - he needed someone to be with him to relieve the lonlieness and alienation of the moment. From the presentation, it sounds as though the chaplain simply ignored that and used words to drive the patient further into his lonliness.

Maybe the chaplain would want to explore why he was so driven to talk so much and listen so little with this patient.

Director, Spiritual Care and Religious Services
Washington County Hospital
Hagerstown, Maryland

In reading the patient's account of his situation, I become increasingly aware of his sense of isolation and my curiosity questions how the experience of isolation plays out in his religious crisis. Being so alone in the world, might any of us not find ourselves feeling abandoned by God? I think that it would be helpful to look deeper into the nature of his disconnectedness. I might try to formulate some clusters of questions that could open dialogue and promote insight.

To explore his social situation I might use this line of inquiry. How is it that this person has come to this alien place? How has he maintained connections with family, friends and religious community back home? What is the quality of these connections?

He might also benefit from exploring the relationship between his personal story and the greater story of his faith. If he were a character in one of Islam's epic tales, who would he be? What was the character's fate? How did or how might redemption have happened for this character? How might the patient find his way through this crisis using the tale as a roadmap?

An inquiry into his self-care practices might form around these questions. Has the patient been able to meet his daily obligations as a Muslim? How could the hospital and staff support his daily practice?

The key lies with the patient's ability to recognize his dilemma in a way that also invites him to call on his religious resources in a more positive way. It is not the Chaplain's task to relieve him of his distress by supplying a sufficiently potent counter curse. Instead, the Chaplain should seek to empower the patient as the expert on his religion and encourage him to broaden the scope of his currently over-limiting practice.

Keith Goheen, MDiv
Chaplain
Beebe Medical Center
Lewes, DE USA

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