12/21/2005 Vol. 2, No. 22

Professional Practice

The Rev. Dr. Steven D. Irwin on the best and worst of society

Perilous Journeys

The distance from work to my home is about 14 miles. On an emergency call at three o’clock in the morning I’ve made it in 12 minutes. In rush hour traffic it usually takes about 45 to 50 minutes. Time varies, as does anxiety depending on traffic flow, fellow travelers and the needs of each driver to arrive at his or her destination.

Yesterday the trip was different. With ice covered roads in an area of the country where neither people nor roads are prepared for such conditions travel changes. My average speed was reduced to 10 miles per hour. My mental and emotional status was also different. Anxiety increased, fear at times when fellow sojourners drove too fast or attempted to stop at the last minute with little success, even anger at city trucks meant to make travel easier but just becoming another obstacle.

I also witnessed the best and worst of society. Complete strangers stopped to help each other. A car would spin out of control and a stranger would offer a cell phone or a push. A car slid into a ditch and a truck with a winch pulled him back onto the road. While some stopped, others drove by for reasons that I could only guess at. I also witnessed a few that chose to ignore the needs of other by driving too fast, running red lights, weaving in and out of slow moving cars.

There was a time when another generation was asked to make a difficult journey. The gospels say that:

In those days Caesar Augustus issued a decree that a census should be taken of the entire Roman world. (This was the first census that took place while Careens was governor of Syria.) And everyone went to his own town to register. So Joseph also went up from the town of Nazareth in Galilee to Judea, to Bethlehem the town of David, because he belonged to the house and line of David. He went there to register with Mary, who was pledged to be married to him and was expecting a child. (Luke 2:1-5)

We are not told much more about that journey from the story itself. I looked at a map yesterday and it looks like the two towns are separated by about 75 miles as the crow flies. In reality they are divided by what is known as the hill country, which is made of rocks and filled with trees followed by sections of arid desert. More rocks and many more hills with well-worn paths that are not very wide in some sections add to the journey.

I can only imagine what it was like to make such a journey. Neither walking nor riding a donkey sounds too comfortable for a woman who is nine months pregnant. I see some folks offering help and others turning a blind eye. I imagine some angry with the slow travelers causing their journey to become longer while others understood and offered words of kindness and comfort. Some may have stopped to help while others blew by when the path was wide enough; some may not even have waited for the path to widen.

Joseph and Mary had no idea what their next hours and days held for them or for the world. Travelers who stopped to help never knew whom they were helping. Travelers who blew by, ignored, or even hindered never knew what their ignoring meant. I think of Matthew’s (25:40) reminder that “I tell you the truth, whatever you did for one of the least of these brothers [or sisters] of mine, you did for me.”

This time of year many of us of the Christian tradition find ourselves journeying toward the arrival of the Christ child. Our journey may be slow and arduous. Our journey may be too fast for our own safety. We may stop and help those we see in need or we may blow by. We may feel guilt or anger or anxiety as we travel. We may stop to see the beauty even in the midst of the danger. I encourage each of us to ask “How am I preparing for the arrival as I journey toward Christmas?”

Do you have thoughts about professional practice you’d like to share with your colleagues? Send an e-mail info@PlainViews.org.

Advocacy

The Rev. Dr. Larry J. Austin on recognizing our worth

On Losing Your Soul

I recently attended a funeral for a young man who had just turned 16. He died in a car accident after a football game. As my wife and I sat in the church and listened to the pastor, my mind wandered to a former supervisor of mine who asked if I would ever find enough excitement to stay in the ministry? I remember saying with no hesitation, “Lord, yes, there is a tremendous amount of excitement in the hospital ministry.”

Well, I have reflected quite a bit these last few days and wanted to let people know that my excitement for ministry is still there. I am quite aware that if I ever get out of this line of work, it will be because the pain of the ministry got me first, long before the lack of excitement.

Over the years I have had the wonderful opportunity to work in an environment that has allowed me to do participate in people’s lives in a significant way. As much as I have tried to stay distant by reveling in the excitement of the hospital ministry I find that I keep getting drawn back to the intimacy, vulnerability and pain of the human encounter in the midst of crisis. To paraphrase the Gospel story found in Matthew 10:28, we should not fear the ones who can kill the body but we should fear the one who steals the soul.

It takes courage to be a chaplain to people in awful situations. A patient’s pain will affect you in a cumulative sense. The longer you are in the business the more personal pain you will feel. After a day of working in terrible situations, even when they are people you barely know, you will go home tired and exhausted, and try to distance yourself from the situations of the day, only to realize you have to go back to work the next day.

Patients will give us compliments for our being there with them in difficult times and we will get embarrassed and discount their compliments by denying that we did anything important. We let others discount our worth because our narratives do not have the weight of scientific research.

We contribute to our own pain by the failure to recognize the worth of what we do, and our failure to confront those who discount the profession and the person doesn’t help either. And finally, if you are not careful your pain will sneak up on you and steal your soul.

Do you have thoughts about advocacy you’d like to share with your colleagues? Send an e-mail to info@PlainViews.org.

Education & Research

The Rev. Dr. Glenn A. Robitaille on thinking before you touch

Boundaries and Touch in Pastoral Interventions

Bonnie is a 54-year-old mother whose son recently committed suicide. She presented as labile, confused, and filled with guilt over failed opportunities to rescue her son from the clutches of his demanding and punitive father. With some gentle prodding, she began to unpack the failures of the last decade that saw her leave her abusive husband and return to Canada, leaving her two children behind with him in the United States. Her reasons for making this decision seemed sound at the time but, with the benefit of hindsight, she was face to face with the possibility that she secured her own peace at the expense of the life of her son. Nursing staff, psychiatrists, social workers and the entire multidisciplinary team all affirmed that, given the details of her circumstance, she had little choice but the one she made; but that was little consolation now that her son was dead.

Clinicians have long argued about the appropriateness of touch as part of therapeutic intervention. The impulse to comfort a grieving mother with a hug is instinctive for many pastoral professionals and, at times, may be the right therapeutic response. What would you do if you were interviewing Bonnie?

What clinicians must understand in providing such responses is that touch changes the intervention. Depending on the needs, perspectives and personality of the subject, it could change the relationship in a variety of ways. For some it could evoke resistance. Not all people are comfortable with touch, and something as simple as a pat on the shoulder could shut down an individual who is protective of his or her personal space, or could be interpreted as condescending. Individuals who have experienced physical violations may be distracted from the work you are trying to do with them. They may wonder what you are trying to accomplish by touching them. Are you trying to gain power in the relationship? Are you attracted to them? Or are you simply a caring person expressing genuine compassion? Conversely, personality-disordered individuals often manipulate normal human emotion to blur boundaries and create unhealthy dependence on others. Is the subject truly in need of touch, or is he/she angling to be rescued and vulnerable to forming an unhealthy attachment.

At the same time, touch can be a powerful way to bridge isolation and to communicate warmth. How does one determine when touch is therapeutic and when it is not? I have found two principles to be helpful.

First, knowledge always precedes praxis where touch is concerned. Reflex responses based on our own preferences and projections reflect our needs and not those of our subject. If we do not spend the appropriate time collecting data and assessing it, we are left with assumption and guess work. The time we spend communicating through sensitive questions, mirroring, and restating, builds a foundation of trust. Hurting people need to know that we are hearing what they are saying and that we are willing to listen.

Secondly, good boundary recognition must be evident. Subjects who press boundaries or who lack appropriate boundary awareness are never candidates for touch. The risk of changing the focus of the intervention is too high in such cases. At all times, pastoral professionals must protect their roles as spiritual care providers as primary. Before we shift the relationship to a new level of intimacy, it is important that we insure that this primary function is not compromised.

Do you have thoughts about education & research you’d like to share with your colleagues? Send an e-mail to info@PlainViews.org.

Spiritual Development

Rabbi Charles P. Rabinowitz on dealing with winter's darkness

A Winter Meditation

In the midst of illness, depression, caregiving or bereavement, this winter season presents challenges to anyone who accompanies people spiritually. The other members of our clinical care teams are challenged as well. As the days turn shorter and colder, we go to work in the dark, and return to our homes in the dark. Is it our imagination or the heavier stresses at work that makes it seem that everyone else around us is more joyful than ourselves?

As families gather together, emotional baggage triggers, past losses and grief may resurface, which need to be reflected and reframed. During our drives in darkness, we recognize painfully our broken life stories and psychosocial pieces. We have a deeper and warmer need to be healed, repaired, and made whole once again.[1]

On each continent, it is interesting how religions and cultures have found a means to deal with the winter darkness and its psychosocial and spiritual aspects: Jews with Hanukah, Christians with Christmas, African Americans with Kwanza. All bring light to turn away the darkness inside and outside our homes. On NPR I heard a wonderful story about end-of-year visiting rituals that are performed all around the world.

As a communal event, each culture goes from house to house with song and a strong sense of covenantal community. Each visited family is expected to bring something to eat out to their neighbors at their doors. In Africa, South America, Europe and here, when those families don’t have something to share, the community brings to them in the days that follow gifts of food and drink that are left anonymously at the door. These holiday rituals celebrate the rays of hope and light that are found even on the darkest of days. The physical darkness of the year becomes a metaphor for the darkness that envelops individuals at times of illness and loss. These simple rituals produce little acts of loving kindness, world repair, and unrecognized miracles that touch our inner warmth of hope and light.

My friend Rabbi Simkha Weintraub teaches us so well that:

“Rather than curse the darkness,
we seek to fan the sparks of light-
to find blessing where we can,
locate community where it may exist,
to treasure moments of joy where we may.
A person can’t be asked
to suddenly ‘jump’to 8 lights of joy,
but we can help each other build from 1 to 8.”[2]

As the modern Psalmist Debbie Perlman, who used her own suffering to reframe the world, wrote:

“Almighty and Marvelous One.
You call us to take up the light,
To push aside our spirits’darkness
For Your Name’s sake.

At this season, the miracles appeared.
At this season, we must work for miracles.

You open Your hand
Not to pour the light upon our heads,
But to offer it as a beacon
That we might grasp it and move forward.

You open Your hand in this dark season
As we warm each other and praise Your Name.”[3]

So as we celebrate our multifaith and multicultural strengths together, may we be able to conclude our prayer as Rabbi Alexandria did each day:

“May it be Your Will,
O Eternal our G-d,
To station us in an illumined corner,
And not let our heart be sick
Nor our eyes darkened.”(Berakhot 17a) [4]

AMEN.

[1] A rewording and reflection based on the opening paragraphs in The National Center for Jewish Healing’s Hanukkah: Lights in the Darkness. 2004, 1.
[2] Ibid, 4.
[3] Ibid, 4. See Debbie Perlman, Flames to Heaven: New Psalms for Healing & Praise, Wilmette, IL: Rad Publishers, 75. She was a modern psalmist with a powerful voice.
[4] Ibid, 2.

Do you have thoughts about spiritual development you’d like to share with your colleagues? Send an e-mail of any length to info@PlainViews.org.

EthicsWalk

EthicsWalk addresses spiritual care as an ethical enterprise. It explores why relationships between spiritual care providers and those they serve need protection, and examines what that protection entails. PlainViews invites our readers to share their responses to each EthicsWalk column, which will be published in the following issue.

If you’d like to respond to EthicsWalk, please send a comment of no more than 100 words. You can use the e-form below (click on "hearing from you," link) or submit your commentary to the editors in the body of an e-mail (or as a Microsoft Word attachment) sent to Info@PlainViews.org. Please put the phrase “EthicsWalk” in your subject line.

We look forward to hearing from you.

The Gift of Declining Presents

Should spiritual care providers accept gifts from those served?[1] Would Eid al-Fitr, Christmas, Hanukkah, and Kwanzaa pose exceptions to general prohibition? Are these questions, considered in CaseConference #2, those of Scrooge or professional ethics? Reader responses to the CaseConference are wise. Similar ones end this column.

Chaplaincy Ethics Codes are silent about gifts. Institutional policies fill the gap but often don’t clarify the humane reasoning. Most professional and industrial Codes of Ethics and Advisory Opinions prohibit or narrowly restrict the giving or receipt of gifts. Concerns about actual or perceived bribery or extortion[2] drive many.

Government regulations covering holidays, as well as other times of year,[3] prohibit employees from making gifts to supervisors or donations to causes on behalf of superiors. All are prohibited from accepting gifts (over $10) from anyone with whom the employer does business.

What constitutes a “gift?”[4] American poet Ralph Waldo Emerson wrote, “The only true gift is a portion of thyself, Thou must bleed for me.”As noted in last month’s column, too many recipients of health services in the U.S. are involuntarily “bleeding”to pay their providers. Should gifts, albeit voluntary, be added in?

Like most transactions between professionals and persons served, gifts are seldom a private matter. Implications abound for third parties. Hearing my Pilates teacher rave about presents from other students last week, I winced and questioned silently the possible implications (for her attention) of my practice of no gifts for professionals who enhance my life (as distinguished from people who provide newspaper, mail, and trash services). She didn’t solicit gifts, but she did accept. What does that mean for me, the non-gift giver?

If the gift has “no value”does it matter? A “no value gift”is an oxymoron for people of faith who recognize that “value”attaches by the act of giving, not purchase price. The “why”of giving is always different. The potential for real or perceived favoritism or “special closeness”is always alive. Below are suggestions for receiving the “giving”but refusing the present.

1. Follow your institution’s policy. Most prohibit anything other than hospitality tokens: cookies made by family members, bouquets patients can’t take home.

2. While declining presents, take time to thank persons for the gifts their lives provide. Help patients recognize how their life blesses others regardless of their state of diminished health.

3. In rare instances, accept a gift on behalf of the Spiritual Care Department. Specify the money or item is going to the institution (check with your supervisor or ethics committee).[5]

4. If patients persist in personalizing it, the gift might be in your honor.

5. If #1 –4 are pastorally impossible or not supported by your institution and you accept a gift, clarify how it will be used at the time you accept: “Our hospital library will appreciate this book.”[6] “I will sign this check over to Katrina relief efforts.”If the gift could have value (sentimental or monetary) to family, consult family first. If donor and family are alienated, your task is facilitating reconciliation, not brokering heirlooms.[7]

6. Substitute “spiritual care providers”for “physician”in this title from a medical journal and ponder its message: “Should Physicians Accept Gifts from Their Patients? No: gifts debase the true value of care.”[8]

This holiday season, remember to thank your colleagues and honor yourself for the gifts each of your lives bestows.

[1]“Ethics Walk,” PlainViews, 12/01/04 (vol. 1, no. 21) suggested that accepting gifts from people served is a boundary issue. One reader’s response to CaseConference #2 elaborates this point well.
[2] Bribery refers to influence on decisions or actions subsequent to and based on a gift; extortion implies a gift is required in order to obtain a favorable decision or action. Both may be reflected in individual’s increasingly lavish gifts to doormen, maitre d’s and private school teachers in large U.S. cities!
[3] For example, CFR Part 2635, Subparts B,C, & H, December 2004 “Summary of Holiday Season Gift Rules.”Such rules are the basis for the highly publicized ethics cases before several state and federal government bodies.
[4] Economists, philosophers, sociologists, anthropologists, ethicists, scholars of religion and law, have published tomes on “the gift”and “ethics of gifts in friendship and business”through out history. A delightful compendium of such is The Question of the Gift: Essays across disciplines, edited by Mark Osteen. Routledge, 2002.
[5] To avoid potential legal consequences, no contribution/gift over $250 should be negotiated or accepted by you even if you are not the direct beneficiary. The donor’s lawyer or the institution’s Planned Giving professionals should handle the transaction. Never accept or arrange for gifts of money or items of value from people receiving government assistance or in bankruptcy.
[6] Caution: If you accept one family Bible how do you decline others? How many does your institution want?
[7] I am indebted to a conversation with Rabbi David Zucker for this discussion.
[8] Weijer C. “Should Physicians Accept Gifts from Their Patients? No: gifts debase the true value of care.”Western Journal of Medicine, 2001:175:3.

CaseConference

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.

Case Conference #3 (Responses are posted below the case)

A patient had won the lottery and her children had become more interested in her money than in a relationship with their mother. The patient had changed her will, excluding her children. Several months later, the patient suffered a massive stroke. She was connected to life support –intubated and receiving artificial nutrition and hydration. Her heart was starting to fail and the doctors approached the children about signing a Do Not Resuscitate Order because they felt it would not be in the patient's best interest to call a code and try to resuscitate her. The children refused to sign the DNR, hoping that they could get a court order and have their mother declared “incompetent”so that they could challenge the will. They also threatened to sue the hospital if the hospital staff did not do everything to keep the patient alive.

After several weeks and the physical deterioration of the patient’s body to a level that the staff considered to be “inhumane,”the staff asked the chaplain to talk with the children to see if the chaplain could convince the children to sign the DNR.

Should the chaplain intercede? If so, on what grounds?
If the chaplain intercedes, what should the “goal”of that intercession be?
Is this an appropriate use of the chaplain?

Responses to CaseConference #3

In my facility, it would be very appropriate for me to be involved. I'm the staff liaison to the ethics committee, so it would probably pass through me on the way to the committee.

Even before the committee meets, I would meet with the family and try to mediate a resolution. I have found that such cases might involve conflicts among the children; my presence could allow them to resolve those conflicts and start to look at the best interests of their mother. An unspoken issue would be that the ethics committee could intervene if, in the opinion of our doctors and lawyers, we were not acting in the patient's best interest.

Summary:
It would be appropriate for the chaplain to intervene, but with the goal of mediating a resolution. The use of our authority could be instrumental in allowing the family members to do what is right.

Rabbi Jim Michaels
Hebrew Home of Greater Washington
Rockville, MD

Should the chaplain intercede? This is exactly a case for a chaplain to step forward as an ethicist, and then as theologian. In my institution the DNR is a physician decision that is discussed with the family. If so, on what grounds? The ethics issue, for me, is the physician asking the family to sign a DNR. Asking the family to make a medical decision is problematic. If the chaplain intercedes, what should the “goal”of that intercession be? I work with medical staff, to help foster the three poles of the ethical discussion.

Is this an appropriate use of the chaplain? The chaplain has the ability to walk on both sides of the line between institution and patient/family. Who else is better equipped than the chaplain to care for the staff as they face triangulation between family, care for the patient, and the institution.

The family becomes my tertiary customer, and as such receives necessary energy for listening and reflecting. I have no need to teach, preach, or cajole this family into compassion. I may at some point plant a seed that indicates that the will may be easier challenge than guardianship.

Roy Sanders
Director Spiritual Care/Clinical Pastoral Education
Truman Medical Center Hospital Hill
Kansas City, MO

It is hard to imagine a scenario where the chaplain had not already been involved with the patient and her family as well as her visitors during the preceding weeks. In situations like this, the patient may have been transferred to an ICU from a neurological floor at the time of her intubation. As a result, the chaplain's assigned to the floor and the particular ICU ought to be more cognizant and conversant with each other about the minute details of her condition and wishes than the scenario suggests. It is also possible that one or the other chaplain's had heard the patient or others verbalize her wishes before her condition deteriorated.

Therefore, absolutely, "Yes" the chaplain ought to intercede because, as stated, the chaplain ought to have established a pastoral relationship with the children and may also have first-hand knowledge of the patients wishes. Accordingly, that information ought to have been clarified and documented in the patient's "Progress Notes" or anther appropriate chart entry. This information might also include the patients clarification about whether she stated her medical care wishes in legal language upon the advice of a competent attorney at the time her will was drafted.

As a result, the chaplain's intercession ought to be a part of a continuing conversation with the staff, including physicians, as is the case in many ICU's, to apprise them of the facts already recorded in the patient's chart; and to reiterate to the family that their mother's wishes were stated and as such must be honored. The big "If" is "if" what I have suggested is what occurred. If it isn't then the chaplain's goal of intercession is to first understand the physician's frustration or previous efforts to obtain consent from the children and then to build a relationship with the children before attempting to convince them that it is their mother's wishes that count, not theirs!

Deacon Mike Steele, Ph.D.
St. John’s Hospital
Springfield, MO

I believe the question is wrong. Making a patient DNR does not mean they will die when the ink dries. DNR just means that if the patient’s heart stops you do not attempt to resuscitate them. As I read this case the patient would still be alive when the staff asked the chaplain to talk to the family, because if her heart had stopped before that, resuscitation would not have worked anyway. The question is wrong because you are linking DNR with death. A clearer question would be About Using medical interventions. How much medical technology do you want us to use? There are a lot of family issues and to link that with DNR is a mistake.

Gordon Putnam, M.Div.
Chaplain/Support Services Coordinator
University of Virginia Cancer Center

With due respect for the above posted positions, I do not see this as a situation best addressed by the chaplain. True, chaplaincy could help sort out family dynamics, but this case seems to me to be one of legal standings. Too bad the patient hadn't prepared an advanced directive!

Here in Delaware, when the patient is too sick to make medical decisions, a condition distinct from being incompetent, the power to make those decisions is defaulted along a prescribed chain of persons, the first being a spouse, then children, etc. Since no spouse appears in the study, the responsibility would fall to the children. But the act of changing her will suggests, perhaps even demonstrates, that the relationship between the patient and her children is conflicted and raises credibility issues about their willingness to best serve the patient's needs and the patient's desire to have them fulfill the role.

Solving this dilemma involves no spiritual or religious questions. It isn't really even about the emotional support system, which until the patient could regain sufficient health to participate in the problem's solution, is beyond repair. It is about establishing the identity of a trustworthy guardian and ensuring that the patient receives the most responsible level of care, and it is about getting the hospital de-triangulated from this nasty family feud.

This is a job for the hospital's patient advocate. At most, the chaplain could facilitate a meeting with the advocate, the patient's attorney, and other interested parties and/or offer to pray for Divine guidance if not an intervention.

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

Please check below for comments made about the last CaseConference.

Send your comments about CaseConference to info@PlainViews.org.

Reviews

Clicking here will take you to the Book Review

Macky Alston reviews the film:

The Yatra Trilogy

The term “Yatra”means “sacred journey,”and this film trilogy, instilled with Buddhist teaching, guides the viewer through the varied landscapes of Southeast Asia. For chaplains, the three documentaries in this series provide contemplative visuals of places of faith.

Filming began in 2001 and the last film of the trilogy was released in the spring of 2005. The first film, Dharma River, weaves along legendary rivers in Laos, Thailand and Burma in discovery of great Buddhist temples and mystical sites. Prajna Earth, the second in the series, transports the viewer to Cambodia, Bali and Java on a visually stunning tour of the lost spiritual civilization of Angkor in Cambodia, including the largest temple in the world, Angkor Wat. Sacred nature sites of Bali, and trance dancers in the jungles of Java, are also on the itinerary. Finally, Vajra Sky provides the viewer with an intimate look at central Tibet, and the opportunity to experience revered temples, monasteries and festivals that survive under Chinese occupation.

One has the option of viewing the film series with narration and music or with music and a chant soundtrack designed for meditation.

The Yatra Trilogy transports the viewer to remote places of stunning beauty and spirituality.

Completed: 2005
Running Time: 85 Minutes/DVD
Director/Producer: John Bush

If you are interested in purchasing this film series, you can do so on the Hartley Film Foundation Web site at www.hartleyfoundation.org. Just click on “Masterworks”on the homepage for more information. The cost for the three-part DVD series is $65.00 for a 3-DVD set.

Book Review

The Rev. George Handzo reviews:

The Corporate Culture Survival Guide

For chaplains trying to build pastoral care programs, especially in an institution new to them, organizational culture can often be an unseen and seemingly omnipotent enemy. You painstakingly research a new program that you think will add immeasurably to the institution’s care only to be told, “We don’t do things that way here”or “this isn’t a fit for this institution.”Or, worse, your proposal seems to vanish into some black hole never to be heard from again.

Edgar Schein is the generally acknowledged guru in understanding and working with corporate cultures. His book, The Corporate Culture Survival Guide, can be extremely useful for anyone trying to understand why their institution works the way it does. While it is primarily aimed at for-profit corporate managers, the language and concepts are clearly understandable by chaplains and others who don’t have an MBA.

Schein starts by explaining why understanding corporate culture is so important and some of the consequences of misunderstanding it. Again, while the examples are corporate, those illustrating organizations of different levels of maturity and mergers are easily transferable to non-profit health care. He then provides a very helpful description and in-depth discussion of corporate culture, including artifacts, espoused values and tacit assumptions followed by a chapter on how to assess culture. The second half of the book is devoted to discussing corporate culture in the setting of a start up company, a company in transformation, a mature company and a newly merged company. While these chapters are very readable, they are not as relevant as the first part of the book.

Every few pages, Schein includes sections called “Practical Implications”which are provocative questions and suggestions for the reader to consider as they apply the material to their particular setting.

While this can be a very helpful book for chaplains trying to understand and integrate with their institutional cultures, Schein presents several cautions which need to be kept in mind. The major one is that corporate culture is very difficult to change even for a CEO. Generally, the best one can do is learning to work with the corporate culture and use it to one’s advantage rather than trying to work around or through it. Lastly, analyzing corporate culture may lead one to the conclusion that this particular culture will simply not allow the transformation that one wants to make.

The Corporate Culture Survival Guide. Schein, Edgar H. (Jossey-Bass, San Francisco, 1999), 195 pp.

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