1/4/2006 Vol. 2, No. 23

Professional Practice

Chaplain Mark LaRocca-Pitts, PhD, on transforming anxiety into hope

Assessing Hope: The 4-F’s of Spiritual Assessment

The chaplain, as a member of the healthcare team, helps patients “mobilize and actualize their spiritual resources in such a way that they contribute to their own healing process.”[1] As a part of this process, the chaplain will conduct a spiritual assessment. One form of spiritual assessment is called “the 4- F’s”: facts, feelings, family 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. When sickness occurs, this web may be disturbed or disrupted thereby affecting a person’s spiritual sense of wholeness. By asking patients about the “facts”of their illness, about how they are “feeling,”about their “family,”and about their “faith,”the chaplain is able to assess whether or not the patient’s relational web is fueled by anxiety or hope.

If the assessment reveals in a particular area a sense of hope, 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.

Though patient acuity, patient load, and increasingly shorter lengths of stays often limit the chaplain’s ability to assess and intervene effectively, the chaplain can still use the assessment to increase the patient’s awareness of her or his spiritual strengths and weaknesses and to indicate how these might contribute to or detract from healing. If circumstances allow for a more concerted intervention, then the chaplain and the patient have various options.

For example, if the patient is experiencing anxiety in relation to the “facts”of his or her illness, whether these “facts”be medical, financial, clinical, or ethical, then the chaplain may address those for which he or she is qualified and then make appropriate referrals to other members of the healthcare team for follow up. If the patient’s anxiety is in relation to his or her “feelings,”then the chaplain may explore and help normalize these feelings as they relate to the illness process, and then, if needed, make referrals as appropriate to healthcare team members or outside agencies. If anxiety is found in the patient’s “family”or social support system, then the chaplain may help the patient determine where the dysfunction lies and the possible genesis and resolution of this dysfunction and again make referrals as appropriate. Finally, if the anxiety is found in relation to the patient’s “faith,”then the chaplain may help the patient explore the patient’s faith as it relates to the illness process and then encourage and possibly assist the patient in using his or her faith in the healing process. In this area the chaplain will also make referrals, as needed and as requested, to the patient’s particular faith community for appropriate follow up.

The goal of this form of spiritual assessment and intervention is to transform those areas in which the patient experiences anxiety into areas of hope for the patient. Hope has tremendous healing power for the patient. Though the transforming of anxiety to hope is one therapeutic area in which the chaplain contributes to the patient’s healing process, all who help the patient maintain hope in the face of a critical health crisis provide spiritual care for the patient.

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

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Advocacy

Dr. George A. Langhorne on communities that share a common commitment

Just What is COMISS?

The COMISS Network –the Network on Ministry in specialized settings –was founded as the Council on Ministry in Specialized Settings in June of 1979. The organization has been known as the Council, the Congress, the Coalition, and the Network on Ministry in Specialized Settings, or less formally, The COMISS Network.

The COMISS Network is the product of many years of interfaith cooperation in the development and delivery of pastoral services to persons in a variety of specialized ministry settings, including hospice, chaplaincies in health care facilities, correctional institutions, mental health settings, pastoral counseling, the armed forces, business settings, industrial settings, clinical pastoral education, the National Conference on Ministry to the Armed Forces, denominations and faith groups which endorse military, civilian chaplains and pastoral counselors across the country, and the Department of Veterans Affairs.

The Vision of the COMISS Network is to be a pre-eminent network, a collective voice for the preparation and practice of spiritual care through chaplaincy and pastoral counseling.

The Mission of COMISS Network as a network of professional organizations, institutions, and faith communities is to promote and support collaboration among its membership and is the collective voice of advocacy to a variety of constituencies on behalf of the Network. COMISS Network is a forum for dialogue and collaborative action among five distinct pastoral care and counseling communities:

1. Professional Certification Organizations, which certify professional board chaplains and pastoral counselors to perform ministry activities in specialized settings.

2. Professional Accreditation Organizations, which accredit programs to train clergy (lay people) on their way to becoming professional chaplains or pastoral counselors.

3. Religious Endorsing Bodies, which endorse professional chaplains and pastoral
counselors to perform ministry in specialized settings.

4. Professional Pastoral Care Organizations, which exist as groups of chaplains and/or other pastoral care professionals whose work focuses on ministry in specialized settings.

5. Chaplain and Pastoral Care Counselor Employing Organizations, which utilize the services of chaplains or pastoral counselors certified by one of the certifying organizations of the COMISS Network.

These five distinct communities share a common commitment to the value of religious faith/cultural differences and beliefs in the shaping of the individual and community life. In addition, they share a common will to make available appropriate ministry, counseling in specialized settings, ministry counseling characterized by the highest levels of professionalism, loving service, mutual trust, mutual support, integrity, and justice.

The COMISS Network reaffirmed its vision and mission during its annual meeting in December, 2005. The objectives of the COMISS Network are:

1. To provide a forum for dialogue among those who share a similar mission.

2. To develop shared program/resources in order to increase collaboration and reduce duplication among members.

3. To advocate regarding professionalism in standards and service in the provision of professional faith-based care and counseling.

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Education & Research

Elder Diane Walker Stocker on companioning those in need

Take My Hand: Reflections of a Resident Chaplain

I recognized him at the far end of the hallway. I was surprised, but I shouldn’t have been, to see him on the Intermediate Care floor. Mr. Jones* and his wife have been faithful companions to their comatose son who has been in the ICU for sometime and has been moved because his immediate crises have been resolved. Some of his caregivers doubt he will awaken; at thirty, he is “nursing home bound.”Mr. and Mrs. Jones believe that God will heal their son. Each time I hear their hope I silently send up a request that it be answered as they envision it. But today Mr. Jones looks tired; his shoulders droop; his countenance is gray. The verse from Tommy Dorsey’s** song drifts in my mind “I am tired, I am weak, I am worn.”. . . We meet. Before I can speak, he begins –“I wish you would come by to see my wife. B had a bad night. I am so tired, so tired.”I place my hand on his shoulder. We walk a ways down the hall together.

I reach my destination and find another “companion”who has been moved from ICU. Traumatic experiences in Vietnam, coupled with many subsequent years of poor life choices, have greatly complicated his health issues. He cannot talk but writes almost undecipherable notes to his step-son –“they are trying to kill me, kill me,”he scribbles. No amount of assurance can assuage his fears. His son questions where his step-father is mentally; we wonder together if the sounds of the helicopters bringing in patients have triggered memories of wartime nightmares. The son is glad to have a listening ear. We go into an empty room to sit. He pours out his fears and frustrations. He is worried –about his step-father, his family, his health. He knows that he needs to rest but feels there is no respite –“Lead me on, let me stand.”I listen. I do something I rarely do; I tell him that he must go home and rest. He finally agrees: “yes that is best.”He wipes his eyes. I offer a blessing as we shake hands.

This dutiful step-son reminds me so much of the mother I spoke with just the day before. R and I sit at the end of a hallway. She unburdens herself of her fears for J, her young adult son who has been hospitalized over a month and has a long road ahead of him. They live out of town. It hurts her that other family members have “deserted”her; she feels alone in her faithfulness to him and she fears for his recovery. “Through the storm, through the night lead me on to the light.”Eventually, I turn the conversation to her needs. “Just pray for me,”she says. “How shall I pray?”I ask. Tears cascade down her cheeks. She asks for strength to carry on –physical strength; her greatest fear is that she will get sick and there will be no one to care for her son. We hold hands and call upon the Lord and Giver of Life to sustain her.

My heart goes out to my companions. I feel the tiredness that seeps out of them. Perhaps I am attuned to it because I feel it in my own life. I am just completing the third unit of my residency. The long hours and intense situations coupled with the grief over the recent death of my own mother are taxing my physical, emotional, and spiritual resources. Some days I wonder what I have to give. I have found the place that I cannot navigate by myself –I, too, walk through a valley of the shadow of death. Yet I am comforted by the sure and firm assurance that God is my companion and calls me to be a companion to others along the sometimes rocky way. I hear the words again –“Take my hand, precious Lord, lead me home”–and I realize –I am home –here in this holy space some call a hospital –walking the halls, entering a room, extending my hand to a “companion.”

*The family name has been changed.
** “Precious Lord”was written in 1932 by Tommy Dorsey, a black gospel composer, after the death of his wife and infant son.

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Spiritual Development

The Rev. Rob A. Ruff on the weight of a burden

“…two pastors from the hospital…”

My pager went off one morning
the numbers it displayed directed me to call my office
The message I received was that
Helen needs you stat
Why would my colleague need me
so urgently?
I wondered as I walked to her office
(and why do we non-medical types
so enjoy talking like doctors?)

Something terrible has happened Helen told me
her voice quivering,
breaking,
with emotion
There’s been a death
A young man
The son of a doctor here

The Medical Examiner had paged Helen
who was on-call
to ask if the chaplain would
break the bad news to the doctor (and
break his heart in the process I thought)

I know them Helen told me
This doctor and his son
I met the son years ago when he was a patient here
and also then met the father, the doctor

How strange it is, I said,
that you, who know them, are the one called
on this day of the young man’s demise
to share the awful news with the father, the doctor
whom you’d met those many years back

Would you go with me? Helen asked
The pleading look in her eyes described that there was no other answer except
Yes, absolutely, I will

So off we went the two of us to the doctor’s office
Off we went as if like children hand in hand to keep each other safe
As if Someone Dear having fastened a belt around us
was taking us where we did not expect
did not want
to go that morning.

We reached the office and announced to the doctor’s secretary
that we needed to speak with him urgently
When two chaplains need to speak with you urgently
they are not brining good news
I thought ruefully to myself
He’s seeing a patient, said the secretary,
then he’ll be right here

We stood in the hallway
waiting nervously
the burden of the bad news not yet shared
not yet broken
weighing on our hearts

At last he appeared
in white lab coat of course
Older than I’d imagined

Helen spoke first
as we’d arranged
I’m Helen, a chaplain, here
we met years ago when your son was a patient
I met you too then
we’ve come today with some bad news
I’m sorry to tell you that your son has died

He sat down
The weight of the burden lifted from us -
the awful news having been broken -
and moved to him
pushing him into his office chair
It must have stunned him as well for he asked,
Did you just tell me that my son has died?

Yes, I did, Helen says softly
I’m so sorry for your loss, I said
What else is there to say?

He did not cry, at first
but told us of his son:
his troubles and struggles
his triumphs and joys

He cried a bit as he phoned another son
to share the painful news
and to make plans for meeting at the doctor’s house
where together they would tell his wife, the mother

Helen and I stepped out of the office
as the doctor spoke by phone with his loved ones
He told them how he heard the news:
Two pastors from the hospital came to tell me

I noticed that he didn’t say
two chaplains
but rather
two pastors
from the hospital
came to tell me

That fits, I thought
(Although I generally much prefer the former
to the latter)
for we were
two arms of the church
and of the hospital
come this painful day
to embrace him

I almost went into the ministry
the good doctor told us as we parted from him
but I chose medicine instead
I realized I was too soft-hearted to do what you do

A soft heart is a strength
not a weakness
for what we do
I thought to myself
as we walked back
the two of us
as if like children hand in hand to keep each other safe
wiping away the tears
which help us move beyond such things
our hearts aching for him

His colleague, featured prominently in the poem, is Helen Wells O’Brien, an ordained Mennonite minister and Board Certified Chaplain. Helen is a staff chaplain, specializing in pediatrics, who serves both Regions Hospital and Gillette Children’s Specialty Hospital. Helen is married and is the proud mother of two sons.

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.

Theology, Science, and The First Amendment
Intelligent Design, Darwin, And Religious Freedom
Part 1: Constitutional Issues

Spiritual care providers witness events both rationally inexplicable and awesomely concrete. This may equip them to mediate the confused furor over the December 20 decision in Kitzmiller v. Dover Area School District prohibiting teaching Intelligent Design (ID) in public school science classes.[1]

Kitzmiller does not question the existence of God or the theological validity of ID. Kitzmiller does not prohibit discussing God or ID in public schools, nor does it denigrate family values and the importance of passing onto children a family’s religious beliefs. Kitzmiller does not hold that Darwin’s theory of evolution is perfect nor does it “controvert that ID should continue to be studied, debated, and discussed.”[2]

Kitzmiller does hold, based on six weeks of testimony by scientists for both Plaintiffs and Defendants, that ID is not a science and “that ID cannot uncouple itself from its creationist, and thus religious, antecedents”and concludes “that it is unconstitutional to teach ID as an alternative to evolution in a public school science classroom.”[3]

Understanding the constitutional underpinnings of Kitzmiller is requisite to discussing the heartfelt positions held by religious people on all sides of this controversy.

The First Amendment guarantees freedom of religious belief according to personal conscience without interference or influence by governmental entities.[4] Such entities cannot include or exclude anyone based on religious belief.[5] The nation’s founders, themselves people of faith, did not seek to remove God from public discourse but to “preclude government from conveying or attempting to convey a message that religion or a particular religious belief is favored or preferred.”[6]

The most challenging forum for balancing First Amendment establishment concerns and free exercise rights[7] is public schools. Students are captive audiences vulnerable to the authority of teachers’words.

Two tests for constitutional permissibility are applied when a policy which could implicate religion is proposed for a governmental entity. In the “endorsement”test, a hypothetical reasonable observer[8] looks at the evidence “to ascertain whether the policy ‘in fact conveys a message of endorsement or disapproval’of religion, irrespective of what the government might have intended by it.”[9]

The Lemon test asks of such policy: (1) does it reflect a clearly secular legislative purpose; (2) have a primary effect that neither advances nor inhibits religion; (3) avoid excessive entanglements with religion.[10]

Establishment and endorsement tests promote justice and hospitality –virtues in the three Biblical religions. As the Supreme Court observed:

School sponsorship of a religious message is impermissible because it sends the ancillary message to members of the audience who are nonadherents ‘that they are outsiders, not full members of the political community, and an accompanying message to adherents that they are insiders, favored members of the political community.[11]

Families and faith communities have the absolute right to include or exclude anyone from their gatherings for any reason. Individuals and faith communities have the absolute right themselves to be included, and feel included in any government entity without prejudice because of religious belief (or disbelief).[12] This does not permit, however, the governmental entity to provide a forum for expression of particular religious convictions.

Next month’s column enumerates findings specific to Kitzmiller. The following month suggests discussion points by analogy with other religious doctrines which defy but coexist with secular and scientific theories.

I welcome any comments you might want to submit in response to these articles.

[1] Tammy Kitzmiller, et al. v. Dover Area School District, et al., U.S. District Court for the Middle District of Pennsylvania, Case No. 04cv2688, Judge John E. Jones III, December 20, 2005.
[2] Id. 137
[3] Id.
[4] Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; Amendment I, U.S. Constitution (1791). The Fourteenth Amendment applies the Constitution to the States and hence to public schools which are arms of state government.
[5] Belief is absolutely protected; practice is not in all circumstances.
[6] County of Allegheny v. ACLU, 492 U.S. 573 (1989)
[7] One of the first such cases anticipates Kitzmiller: the 1925 challenge to teaching evolution in public schools, the so called Scopes “monkey trail.”
[8] Someone who knows the history of the disputed policy/action, the history of the community and the broader social and historical context in which the policy/action arose.
[9] Lynch v. Donnelly, 465 U.S. 668, 690 (1984) quoted in Kitzmiller at 17. The endorsement test has been applied in cases addressing school prayer, vouchers, religious student clubs meeting on school property, government aid to parochial schools, university funding of religious newspapers, etc.
[10] Lemon v. Kurtzman, 403 U.S. 602 (1971), court struck down R.I. plan to use state funds to pay parochial-school teachers only teaching secular subjects and meeting state license requirements.
[11] Id., 688 quoted in Kitzmiller at 11.
[12] For example, unlike compulsory secularization of public schools in France, the U.S. Court has upheld the rights of Muslim women to cover their heads and Jewish men to wear the yarmulke in government work and education forums.

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 Resolution

The chaplain, who had been regularly visiting with the patient and helping the staff and doctors cope with the situation, called the two children. They had not visited their mother for several weeks. The chaplain asked them to come in to a meeting. They initially declined but the chaplain insisted and they acquiesced. The chaplain arranged for them to meet in the mother’s room in the ICU. Because it was a small community hospital and there was no patient advocate, the chaplain, who was also the co-chair of the bioethics committee, was asked to mediate this situation.

When the children arrived, the chaplain explained to them that since their mother had not left any advance directives, the hospital was, by law, continuing to do everything to keep their mother alive. The chaplain then asked them to look at their mother and to consider whether or not what was being done to maintain her “life”was what they wanted. They were shocked with the deterioration of her body and the level of medications that she was receiving to keep her heart going. She had already been coded and revived four times. From looking at their mother, it was clear to them that she was not going to “wake up”and change her will, nor could the court have her declared incompetent, since the judge would not be able to ask her any questions to determine her state of mind at the time that she changed the will. The chaplain was then able to get them to talk about what had caused the family rift in the first place and facilitated the beginning of saying goodbye to their mother. They then signed a DNR. The patient’s heart stopped the next day. No code was called.

Case Conference #3

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?

Please check below for comments made about the last CaseConference.

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Reviews

Clicking here will take you to the Book Review

Macky Alston reviews the DVD:

The Tibetan Book of the Dead

An ancient guiding source, The Tibetan Book of the Dead remains essential to the Buddhist culture of the Himalayas.

Narrated by Leonard Cohen, this enlightening two-part DVD explores the sacred text through the deaths of two Buddhists, an elderly man and a middle-age man with a wife and young children. The spectacular cinematography and narrative threads provide a moving account of how Buddhists deal with grief. For chaplains involved in end-of-life care, the film is a wonderful way to inspire individuals of all faiths in thoughtful discussion of death and afterlife.

The first DVD chapter contains history of The Tibetan Book of the Dead, with riveting footage of the rites and liturgies for a deceased elder and an interview with the Dalai Lama on the book’s meaning and importance. The second chapter, entitled “The Great Liberation,”follows an old lama and his novice monk as they guide a Himalayan villager into the afterlife using readings from The Tibetan Book of the Dead.

The soul’s 49-day journey towards rebirth is envisioned through rarely seen Buddhist rituals.

Complete: 1994
Running Time: 90 Minutes
Directors: Hiroki Mota, Yukari Hayashi and Barrie Angus McLean
Producers: Atsunori Kawamura and David Verrall

If you are interested in purchasing this DVD, 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 is $24.98.

Book Review

The Rev. Sue Wintz reviews:

Spiritual Lemons: Biblical Women, Irreverent Laughter, and Righteous Rage and The God Between Us: A Spirituality of Relationships

Books that explore biblical stories are often filled with devotional material that highlights the faithful qualities of men and women who faced life changing events and obstacles with confidence and faith. Lyn Brakeman, an Episcopal priest, pastoral counselor, and spiritual director, goes another direction in her books Spiritual Lemons: Biblical Women, Irreverent Laughter, and Righteous Rage and The God Between Us: A Spirituality of Relationships.

Brakeman describes her studies as the “underbelly”of spirituality. She focuses instead on the scandals of Scripture: Sarah laughing in God’s face, Susanna confronting the Bible itself, and other mostly feminine images of “the God Between”. She describes her choice of method as midrash which encourages one to seek, search, and demand in order to courageously bear witness to spiritual fruit that can come from unpopular and difficult feelings. By doing so, she opens the door for readers to acknowledge and embrace them just as the Holy does.

She opens each chapter by applying the concept of midrash to a particular biblical story that invites the reader to consider each character and their experience in an authentic and often challenging way. The character’s interaction with the Divine is often described as “God-in-the name of the person”rather than “God said”in order to emphasize that God’s voice comes from within rather than outside of oneself. At the end of each chapter is a brief commentary that lifts up the contemporary issue and provide questions for reflection and prayer.

The stories and reflections could be of potential use in interventions with patients, particularly in long-term or group settings. Even more importantly, these books are useful for professional chaplains and pastoral counselors as well as CPE and counseling students for personal reflection. Even more, they are useful to invite professionals to glimpse more closely many of the spiritual dilemmas that patients, clients, and families wrestle with. They invite us to step into the “underbelly”of emotions and struggles that are not always clean or easily addressed in professional practice.

Spiritual Lemons: Biblical Women, Irreverent Laughter, and Righteous Rage. Brakeman, Lyn. (Augsburg Books, Philadelphia, PA, 2005). 126 pp.
The God Between Us: A Spirituality of Relationships. Brakeman, Lyn. (Innisfree Press, Inc. Philadelphia, PA, 2001). 157 pp.

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