Winter 2009 Newsletter
On-Line Newsletter Volume 7, Number 2
Published January 28, 2009
Edited by Chaplain John Ehman, Network Convener
Network members are encouraged to submit articles for upcoming issues.
The Newsletter is published three times a year: Fall, Winter, and Spring-Summer.
The Spring-Summer 2009 issue is scheduled to be published in May.
Table of Contents
- Research Meeting and Workshops at the Spiritual Care Collaborative Summit
- A Practical Tool for Evaluating Students in the CPE Application Process
- Article on Neural Circuitry, with Implications for Pastoral Care --Review by Kyle D. Johnson
- Can We Measure Good Chaplaincy? -- Essays from a Project on Professional Chaplains and Health Care Quality Improvement
- New Overviews of Research by Harold Koenig, MD
- Convener's Report of the Network Meeting in Richmond, October 24, 2008
1. Research Meeting and Workshops at the Spiritual Care Collaborative Summit
A research meeting will be part of the 2009 Spiritual Care Collaborative Summit (February 1st-4th, in Orlando, FL) on Tuesday, February 3rd at 12:00. Please check at the conference for the room assignment. This will be an opportunity for our Network to connect with researchers from other organizations and disciplines.
There will also be four workshops presented by members and associates of our Network:
- "An Outlandish Idea: Evidence-Based Spiritual Care Practices," by John J. Gleason and Yoke Lye Lim Kwong (Monday, February 2nd at 1:30) --click here for workshop handout
- "Self-Assessed Spiritual Skills of Healthcare Professionals," by Gordon J. Hilsman, Frederick A. MacCornak, and Juan C. Iregui (Monday, February 2nd at 3:30) --click here for workshop handout
- "Working Collaboratively to Provide for Spiritual Care of Trauma Patients," by Shannon R. Borchert, David Acuna, and Gina M. Berg-Copas (Monday, February 2nd at 3:30)
- "Evidence-Based Spiritual Care: Desirable? Feasible? How Do We Get There?" by George Fitchett, Michele Ledoux Sakurai, Daniel H. Grossoehme, Thomas St. James O'Connor, and Barbara Brumleve (Tuesday, February 3rd at 2:00) --click here for workshop handout
In addition, there will be a number of other research-related workshops, including: "Spirituality and Suicide: Bereavement Support and Prevention," by Kenneth P. Mottram; "Do Psychiatrists Hold Similar Views toward Spiritual or Religious Beliefs as Dr. Freud?" by Hayden Bush; "A Womanist Pastoral Theological Model for Pastoral Counseling with African American Clergywomen in Black Church Leadership," by April C. Wells; "The Grief Born of Injustice," by Melissa M. Kelly; "Seeing Hospital Chaplaincy through a Sociologist's Eyes," by Wendy Cadge; "The Power of Lament to Create a Village of Care," by Pat Seale and Deborah Everett; "Integrating Spirituality and Healing: An Active Approach within the Continuum of Spiritual Care," by Patricia Megregian and Sheila Wang; "Excellence in Interdisciplinary Care: Social Work and Spiritual Care Partnering to Effect Change," by Linda F. Piotrowski and Donna L. Soltura; and "Supporting Adult Caregivers Grieving Children: In the Hospital and Beyond," by Beverly M. Beltramo. See the conference web page for the workshop schedule and the handouts.
2. A Practical Tool for Evaluating Students in the CPE Application Process [--comment by Network Convener, John Ehman]
At our 2008 Network meeting in Richmond, Virginia, Peter Holland (Avera Health, Sioux Falls, SD) mentioned a research project that he and Vic Lehman had once developed with the Dakota Subregion Research Team. The idea was to develop a tool that could bring greater objectivity to the process of assessing students applying for CPE, and that might also produce data that could be trended to explore patterns/biases among interviewers. The project materials were made available to supervisors in the ACPE's North Central Region, but Dr. Holland reports that little had been done with it in recent years. However, I asked permission to share the basic methodological elements of the project in our Newsletter, because this work is an example of the creativity with which supervisors are trying to bring research modalities to bear upon the ACPE educational process.
In an unpublished report within the North Central region, Dr. Holland has described the goal of the project:
Many of us who do ACPE CPE interviews, know that we assess students based on our trained observation and informed intuition. We also read intake interviews, that have been conducted by other supervisors, and wonder if their equally subjective, intuitive assessments would correspond to ours.
In the past few years, ACPE CPE has introduced an outcomes based assessment of the ACPE CPE experience, which suggests there is a place for more objectivity in the official evaluation process.
When supervisors review intake interviews, at the end of the unit, it is often possible to discern themes that emerged in the supervisory process, but which were also recognized, even in rudimentary form, in the intake interview.
As a result of these three factors, we in the Dakota Subregion wondered if it would be possible to better predict outcomes of ACPE CPE from intake interview data. We also wondered if it would be possible to forge a contract for learning, out of the intake interview and its findings.
As we became more practical, we wondered if it would be possible to introduce more objectivity into the intake interview process. A discussion of possibilities led to the suggestion that we produce a research project to test the hypothesis that it would be possible.
The goal has been to approach the tension between the subjective judgment of the supervisor and the objective assessment of the students' readiness for ACPE CPE. That has led us to produce a Practical Assessment Tool with which to more objectively evaluate student admissions materials. This Tool would help validate the more subjective intuitive and observational findings, serve an an organizing factor for the admissions data, assist in identifying and overcoming supervisor biases, and aid the supervisor in being more reliable to themselves. The combination of informed intuition, trained observation and using this practical assessment tool will then provide more confidence for supervisors in projecting when students truly are ready for ACPE CPE. It is our hypothesis that, once refined through our research pilot project, this tool will greatly aid in predicting student readiness for ACPE CPE.
The research group decided to build their method on Howard McClusky's "Margin of Life" theory, which operates on the concepts of a person's power and load: in ACPE terms, these two concepts would represent students' ability to learn and need to learn --counterbalancing qualities, the assessment of which is critical to supervisors' decisions about CPE applicants. Ten areas for power/load assessment were specified by the research group:
- Presence - personal appearance and poise during interview
- Personal History - family background and religious history
- Educational Readiness - motivation and openness to learning
- Ability to Learn in a CPE Setting - learning style, education issues, understanding of the process of education
- Personal Vision - educational goals and expectations of CPE
- People Skills - ability to relate to people, openness in sharing feelings, sensitivity, and level of maturity
- Previous CPE Experience - type and usefulness of experience, growth areas identified
- Previous Pastoral Experience - type and usefulness of experience, growth areas identified
- Personal Resources Available - finances, support network, health
- Existing Commitments - living situation, job, community commitments
The tool that emerged from this research project, including an explanation of the "Margin of Life" formula, is available through the History & Research section of the North Central Region's website (www.ncracpe.org/hist_research.htm). See: ND Supervisor's Research Project: Student Readiness for CPE Assessment Tools, available as a PDF or Word document --note that each of these files contains two draft versions of the tool.
In addition to the tool available via the ncracpe.org site, an earlier draft focused on the assessment of individual student application materials. A version of that draft is available as a PDF by clicking HERE.
Supervisors and researchers may debate the areas of assessment in this tool, the utilization of "Margin of Life" theory, or the feasibility of such an assessment strategy for CPE students; but these nevertheless all seem to be productive topics for discussion. The question remains: How can we better examine the process by which students are assessed when applying for and completing CPE, and how might we apply research modalities to this task? Network members are invited to comment on the tool(s) presented here and offer other tools that may stir dialogue and encourage instrument development.
Peter Holland may be contacted at email@example.com.
3. Article on Neural Circuitry, with Implications for Pastoral Care --Review by Kyle D. Johnson
[Editor's Note: Kyle Johnson has highlighted a number of articles on neurobiology for our Articles-of-the-Month (--see September 2008, April 2007, and October 2006) and is currently engaged in original research using Functional Magnetic Resonance Imaging (--see the Winter 2008 Newsletter, §2). He is currently Visiting Professor at Jarvis Christian College, Hawkins TX. Chaplain Johnson offers below a summary and comment on a recent article of interest. He may be contacted at firstname.lastname@example.org.]
Summary and Comment on: Delgado, M. R., Nearing, K. I., LeDoux, J. E., and Phelps, E. A. [New York University Center for Neural Science], "Neural circuitry underlying the regulation of conditioned fear and its relation to extinction," Neuron 59, no. 5 (September 11, 2008): 829-838.
SUMMARY: Previous animal and human research has implicated the ventral medial prefrontal cortex (vmPFC) and the amygdala in the passive extinction of learned fears. This study focused on the neural correlates underlying the use of complex cognitive strategies to regulate fear. The authors were interested in whether the dorsolateral prefrontal cortex (dlPFC) played a role in emotional regulation. The dlPFC has been implicated with other higher cognitive functions, such as executive processing and working memory, and the active maintenance of on-line information.
Prior to beginning the study, 12 participants (6 female and 6 male) were trained to use an emotional regulation technique (i.e., imagery). The study had four phases: acquisition, attend, regulate, and extinction. The study was conducted while the participants were receiving fMRI scans that used blood oxygen level dependent (BOLD) techniques to see how the participants' brains responded.
The participants were told that during the study they would see a series of squares that were either yellow or blue. In addition, they were told that a mild electrical shock on the wrist would be paired with one color. They learned to fear the color that coincided with a shock (acquisition).
An instructional word cue preceded each square. If the instructional word was, "attend," the participant was to focus on their natural feelings as to how they responded to the colored square. If the instructional word was, "reappraise," the participant was to imagine something in nature that was calming. The word cue, "reappraise," represented the regulate phase. The regulate phase's goal was the extinction of the fear of the colored square that was paired with a shock.
The fMRI scans revealed that during the "regulate phase," the dlPFC and vmPFC became more active while the amygdala's activity appeared to moderate. These results affirmed the view that the dlPFC used projections to the vmPFC, which then projected to the amygdala. These results also affirmed the use of imagery as an effective Cognitive-Behavioral Therapy (CBT) tool for treating fear.
The authors found a lateralization in the amygdala’s BOLD responses. The left amygdala’s greatest BOLD differences were between the "attend" and "regulate" phases. The right amygdala’s greatest BOLD differences were between the "acquisition" and "extinction" phases. These results confirmed earlier studies' conclusions that the right amygdala is involved with implicit fear learning while the left is involved with explicit fear learning.
COMMENT: This study affirms our evolutionary heritage with animals. The vmPFC has been established as a way that animals regulate their fear. The dlPFC appears to use this established evolutionary method to allow our higher cognitive functions an additional way to regulate our fear. Theologically, this is an affirmation of our membership in G-d’s creation.
Another lesson points to the lateralization of the amygdala. Our brains learn fear in different ways. The left amygdala appears to be involved in the verbal or instructed learning of fear. This kind of learning involves the higher cognitive functions. The person's conscious awareness is involved. The right amygdala is involved in implicit and observational learning. This learning occurs outside one’s awareness. This study is an example of both amygdalae being involved at the same time but in different ways.
Pastoral care and counseling providers may want to take note of the effectiveness of the imagery exercise as an emotion regulation strategy. The authors provide fMRI evidence of the imagery exercise's effectiveness. Nevertheless, one should not assume that one size fits all. Imagery may not work in all cases since the amygdala’s lateralization learning of fear means that not all fears are learned the same way.
Chaplains and CPE students may want to consider how such research affects one's model of the person and how an imagery exercise might be used in other ways, and what techniques might be available to help someone deal with a fear.
RELATED MATERIAL: For an excellent book chapter on the cognitive neuroscience of emotion and the amygdala’s role in learning fear, see: Gazzaniga, M. S., Ivry, R. B., Mangun, G. R., and Steven, M. S., "Emotion," pp. 364-387 in Cognitive Neuroscience: The Biology of the Mind (3rd ed.) , New York: W. W. Norton & Company, 2009. Articles on how fear is learned: Phelps, E. A., "Emotion and cognition: insights from studies of the human amygdala," Annual Review of Psychology 57 (2006): 27-53; Olsson, A. and Phelps, E. A., "Social learning of fear," Nature Neuroscience 10, no. 9 (September 2007): 1095-1102; and Rauch, S. L., Shin, L. M., and Phelps, E. A., "Neurocircuitry models of Posttraumatic Stress Disorder and extinction: human neuroimaging research--past, present, and future," Biological Psychiatry 60, no. 4 (August 15, 2006): 376-382. For an article on how amygdala damage affects one’s ability to respond to fear, see: Funayama, E. S., Grillon, C. G., Davis, M. and Phelps, E. A., "A double dissociation in the affective modulation of startle in humans: effects of unilateral temporal lobectomy," Journal of Cognitive Neuroscience 13, no. 6 (August 15, 2001): 1-10. Finally, for two articles on Cognitive Emotion Regulation Strategies, see: Schroevers, M. K., Kraaij, V. and Garnefski, N., "Goal disturbance, cognitive coping strategies, and psychological adjustment to different types of stressful life event," Personality and Individual Differences 43, no. 2 (July 2007): 413-423; and Garnefski, N. V., Van Den Kommer, T., Kraaij, V., Teerds, J., Legerstee, J. and Onstein, E., "The relationship between cognitive emotion regulation strategies and emotional problems: comparison between a clinical and a non-clinical sample," European Journal of Personality 16, no. 5 (September/October 2002): 403-420.
4. Can We Measure Good Chaplaincy? -- Essays from a Project on Professional Chaplains and Health Care Quality Improvement
The Hastings Center published in its November-December 2008 issue of Hastings Center Report (vol. 38, no. 6), a set of essays that are available separately (and repaginated) online under the title, Can We Measure Good Chaplaincy? A New Professional Identity Is Tied to Quality Improvement [PDF]. The essays, which "examine the 'professionalizing' profession of chaplaincy, the goal of patient-centered care, and the special challenges of defining, measuring, and improving quality in less-standardized areas of health care delivery" [--from the introductory statement by Gregory E. Kaebnick (no page number)] are:
This is a product of a research project, Professional Chaplains and Health Care Quality Improvement, by The Hastings Center in collaboration with The HealthCare Chaplaincy.
- "What Are We Doing Here? Chaplains in Contemporary Health Care," by Martha R. Jacobs
- "Ethical Grounding for a Profession of Hospital Chaplaincy," by Margaret E. Mohrmann
- "Lost in Translation: Using Sociology to Help Define Chaplaincy’s Role in Health Care," by Raymond de Vries, Nancy Berlinger, and Wendy Cadge
- "Chaplaincy and Clinical Ethics: A Common Set of Questions," by Martin L. Smith
- "The Nature of Chaplaincy and the Goals of QI: Patient-Centered Care as Professional Responsibility," by Nancy Berlinger
Project Co-Director, Nancy Berlinger, has written to our Network that an empirical component of the project -- a focus group study involving 39 chaplains in 4 cities -- will be the basis for several journal articles that are currently in process. As information becomes available, news will be posted on our Network website.
5. New Overviews of Research by Harold Koenig, MD
Harold Koenig, MD, Co-Director of the Center for Spirituality, Theology and Health at Duke University, and one of leading voices and researchers in the field of spirituality & health, presented on "Religion, Spirituality and Public Health:
Research, Applications, and Recommendations," in testimony before the U.S. House Of Representatives' Committee on Science and Technology--Subcommittee on Research and Science Education, September 18, 2008. Dr. Koenig's testimony is available online [PDF] from the Committee on Science and Technology. This is an excellent overview, with more of an eye toward issues of public health than is normally found in the literature.
Dr. Koenig subsequently reworked this testimony for a December 3, 2008 conference in Washington on Religious Practice and Health: What the Research Says. The presentation, titled "Religious Practices and Health: Overview," is also available online (from the Heritage Foundation). Such a recent overview by an eminent authority should not be overlooked just because it has not been published in a journal.
6. Convener's Report of the Network Meeting in Richmond, October 24, 2008
The Network met on October 24, 2009 at 12:15 PM at the Omni Richmond Hotel, as part of the national ACPE conference. Among business items: Institutional dies were increased to $50/year, though individual dues will remain at $20/year. ACPE President Bill Scrivener addressed the meeting and supported suggestions that the ACPE central office help promote the Network by facilitating an e-mail "blast" announcement to all organization members and by exploring options for greater visibility on the ACPE website. He also suggested that the Network itself investigate foundation funding. There was general discussion about our own website, and John Ehman noted design changes to the logo and home page, along with the addition of a new section on the Ideal Intervention Project. John DeVelder brought up the idea of advertising revenue from our website, as it seems to receive 50-150 hits a day from a distinctive target audience. The upcoming Spiritual Care Collaborative Summit in Orlando, FL (February 1-4, 2009) should give an opportunity to raise awareness of our Network in other chaplaincy organizations, and Martin Montonye volunteered to represent our Network at the research meeting there on February 3rd at Noon.
Much of the meeting was devoted to discussion of members' projects and interests. Among the reports: Jack Gleason and Henry Heffernan updated the group on the Ideal Intervention Project, its new information and resource section on our website, and their upcoming Spiritual Care Collaborative Summit workshop [--noted in §1, above]. Fr. Heffernan made special mention of a document from Mowat Research in Great Britain, "The Potential for Efficacy of Healthcare Chaplaincy and Spiritual Care Provision in the NHS (UK)," available at www.mowatresearch.co.uk/uploaded_documents/Feb%2027%202008%20final%20chaplains%20review.pdf.
On the topic of research into the educational process for chaplains, Peter Holland spoke about his pilot research seeking to develop a scheme for student readiness for CPE [--see §2, above]. He also commented on the use of standardized patients for education for an interdisciplinary palliative care team. The idea of standardized patients has been explored by other Network members, notably Lex Tartaglia and Diane Dodd McCue at Virginia Commonwealth University [--for more on this, see the Winter 2007 Newsletter, and for more on their work in general, see the Fall 2007 Newsletter and the Spring 2008 Newsletter]. Martin Montonye raised the idea of simulation labs, and he suggested also the possibility of research into the CPE certification process by taping certification meetings.
Gordon Hilsman reported his continuing work identifying patient needs and chaplains' "spiritual skills." He also plans to present his latest findings at the upcoming Spiritual Care Collaborative Summit [--noted in §1, above]. (For more on his past research, see content from his poster presentation at our Hawaii conference: Spiritual Needs in Patients' Words and Patient Needs, Chaplain Functions, and Outcomes for Study.) Lex Tartaglia commented on research at VCU's Program in Patient Counseling on the role of chaplains in early intervention in discussions of organ donation. Martin Montonye noted research analyzing 30,000 pastoral visits indicating that the way chaplains report data says more about the chaplains than the patients.
Regarding bibliographic work, Shannon Borchert has completed a literature review on spiritual care for the Society of Care, and Leonard Hummel, Professor of Pastoral Theology at Lutheran Theological Seminary at Gettysburg, and Visiting Scholar with The HealthCare Chaplaincy, recently compiled a Cultural Bibliography for Chaplains. Also, John Ehman's annual bibliographies are available through the Hospital of the University of Pennsylvania's Pastoral Care site (www.uphs.upenn.edu/pastoral/resed/bibindex.html), and literature resources regarding ethics during a pandemic emergency have been compiled at www.PandemicEthics.org.