As professional chaplains we need to be in dialogue with each other about what we do, how we do it, and why we do it a certain way and how these practices benefit our patients. The ultimate goal of MyPractice is to build a consensus about what constitutes “good practice” and eventually establish “Standards of Practice” for chaplains. As with quality improvements in our institutions, this is an ongoing process in order to improve our practice.

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Responses to The Four Fs: Profiling Spiritual Well-Being

(For the Practice that is being discussed, please scroll down for original article)

Thanks to Mark LaRocca-Pitts for his Four F practice of spiritual assessment.

I took the article for discussion to our monthly meeting of Pastoral Care Volunteers to talk about what content this would provide for the way we do our work. They felt that using it would help our practice by highlighting the content of the patients conversation, and helping to define the primary subject in need of follow up by either the chaplain, another volunteer, or a social worker, nurses specialist or physician.

I quickly had the back side of the contact cards revised and now have the new ones available for use.

Rev. George Burn M Div, BCC
Director of Pastoral Care
Mount Nittany Medical Center
State College, PA

As a clinical chaplain, having at my disposal a proven filter such as the Four Fs schema provides categories to organize my actions and reflections. I have concern that a too rigid application of the prescribed approach to the sacred ground of another's spiritual well-being may hinder one from being fully present. An agenda may emerge within the chaplain to seek something identifiable to possibly comfort themselves and ease their own internal anxiety about the many unknowns of a pastoral visit. The Four Fs methodology is a viable, practical schema. Clinical chaplains should be mindful that the "doing" part of this model can possibly fog up the "being" part required in the moment. An even-handed approach with this tool is to use it carefully and wisely to avoid the unintended task of asking "20-questions" which leaves us with information about topics-but not the subject-the person we are caring for.

The Rev. John Simon, M.Div., M.T.S., BCC
Director of Pastoral Care
Vassar Brothers Medical Center
Poughkeepsie, NY

I appreciated Mark LaRocca-Pitts’ contribution to the investigation on assessment. This may be the key area where we, as a profession, need a standard of practice because assessment is where it all starts. Without it there is no plan and no help to the patient. Mark’s contribution also affirmed for me that there is so much great practice out there in our field that may be passed down by oral tradition as this system has been but is too seldom published.

It also reminded me of a system I have been part of creating which has some similarities to this one. Some years ago, I was asked to be the pastoral care presence on a guidelines panel for the National Comprehensive Cancer Network (NCCN) which, at the time, had guidelines for the treatment of almost any kind of cancer, but no guidelines for psychosocial/spiritual issues. We chose an approach that is roughly the reverse of what Mark presented. Rather than begin with attributes (feelings, facts, etc) and then look for where the anxiety lies, we chose to begin with the feeling. We chose “distress” as the universal feeling because it seemed ubiquitous, but also non-stigmatizing. This “distress’ is likely identical to the “anxiety” in Mark’s system. Patients specify their level of distress by indicating its intensity on a thermometer modeled after the 1-10 pain scale. The thermometer has now been normed against accepted anxiety and depression scales. Those with high distress can indicate the source(s) of their anxiety from a problem list that includes physical, emotional, social, and spiritual options. This list is the analogue to Mark’s four Fs. These choices drive to whom the patient is referred.

The strengths of this system are that it is a quick, integrated measure than can drive referrals to the whole psychosocial/spiritual team. It is meant to be administered on the patient’s first contact with the system. It also quickly identifies need based on level of distress. From a spiritual care perspective, the problem list is weak. Evidence needs to be developed for what the spiritual/religious problems should be. The guidelines are reviewed once a year and new evidence is considered. Anyone who wishes to contribute to the evolution of these guidelines is welcome to send material to me or to the guidelines chair who is listed on the web site. The guidelines can be viewed under the supportive care section at www.nccn.org.

Rev. George Handzo
Vice President,
Pastoral Care Leadership & Practice
The HealthCare Chaplaincy
New York, NY

The Four Fs: Profiling Spiritual Well-Being

At the core of my practice is a short and memorable screening tool that profiles a person’s spiritual well being and that can be used to form part of a more complex spiritual assessment.[1] This tool is called the “Four-Fs,” which corresponds to Facts, Feelings, Family/Friends and Faith.

As spiritual beings, humans are nested in a web of relationships, connections and understandings that include ideas, other people, one’s own self, nature, and possibly God, or a higher power.[2] When sickness occurs, this web may be disturbed or disrupted thereby affecting a person’s spiritual well- being. By asking a patient about the “facts” of their illness, about how they are “feeling,” about their “family,” and about their “faith,” the chaplain is able to delineate the patient’s spiritual well-being in terms of, for example, anxiety or hope.

If the patient is experiencing anxiety in relation to the “facts” of their illness, whether they be medical, financial, clinical, or ethical, then the chaplain may address those for which he or she is qualified and make referrals to other disciplines as needed. If the patient’s anxiety is in relation to their “feelings,” then the chaplain may explore and help normalize these feelings as they relate to the illness process. If anxiety is found in the patient’s “family” or social support system, then the chaplain may help the patient determine where the anxiety lies and the possible genesis and resolution of this anxiety. Finally, if the anxiety is found in relation to the patient’s “faith,” then the chaplain may help the patient explore their faith resources as a resource for successful coping.

If the assessment reveals hope in a particular area, then this area is spiritually well and can be utilized as a spiritual strength. If the assessment reveals in another area an anxiety-producing relationship, connection, or understanding, then this area indicates spiritual distress or a spiritual weakness. Rarely does the patient experience anxiety in all four areas and often strengths in one area may offset weakness in another. The more overall hope the patient has the more likely the patient will have a favorable outcome.[3]

The strength of this tool lies in its ability to be utilized conversationally. Inquiries concerning facts, feelings, family/friends and faith can form a natural part of any pastoral conversation. The Four-Fs also provide topics around which the chaplain can organize the pastoral conversation. The art consists in using this tool to discover clinically relevant information for delineating a spiritual profile that may then be used to develop a pastoral care plan with appropriate interventions and agreed upon outcomes.

I have used this tool since learning it from Dr. Uwe Scharf at Duke University Medical Center some eight years ago. Dr. Scharf, who is now Director of Pastoral Care at Johns Hopkins, continues to teach this tool to his CPE students who find it “very helpful.” Dr. Scharf, however, learned the Four-Fs from a chaplain resident at Baptist Hospital in Winston-Salem in 1997. This chaplain resident, Rennie Adcock, is now the Chaplain at the Kate B. Reynolds Hospice Home in Winston-Salem. Chaplain Adcock reports he still uses this tool and has in fact added a fifth F, Follow-Up.

Footnotes:

[1] As an example of where a “spiritual profile” forms part of a larger, more thorough spiritual assessment, see Larry VandeCreek & Arthur Lucas (eds.), The Discipline for Pastoral Care Giving (Haworth Pastoral Press: New York, 2001).

[2] Mark LaRocca-Pitts, “Walking the Wards as a Spiritual Specialist,” Harvard Divinity Bulletin, 32:3 (Summer, 2004), p. 29.

[3] See Andrew Lester, Hope in Pastoral Care and Counseling (Louisville, KY: Westminster John Knox Press, 1995). See also, Gowri Anandarajah & Ellen Hight, “Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment,” American Family Physician, 63:1 (Jan. 1, 2001), pp. 81-88.

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