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February 2011 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Nolan, S. "Hope beyond (redundant) hope: how chaplains work with dying patients" Palliative Medicine 25, no. 1 (January 2011): 21-25.
SUMMARY and COMMENT: After palliative care chaplain Steve Nolan, PhD (Princess Alice Hospice, Esher, UK), encountered a clinical situation that he felt was challenging beyond his professional expertise, he sought to improve his future practice by insights from other chaplains; but he did so systematically through a qualitative research methodology. The case that generated this study was that of a patient in danger of despair when his hopes for recovery had fallen away. How might a chaplain "be with" such a patient, and how might hopefulness be encouraged albeit in some reconfigured way? Nolan's data from interviews with 19 chaplains allowed him to build a theory of "chaplain as hopeful presence" for dying patients.
"What emerged from the interviews was what the author describes as four ‘developmental moments’ in the chaplain’s being-with their patients, moments through which a chaplain may become a hopeful presence to those with whom [he/she] can work." [p. 23]
Evocative Presence:
"Chaplains begin their relationship as an evocative presence, which is rooted in the transferential response that characterizes all human contact." [p. 23] "…[C]haplains understand the way their presence as a religious person evokes positive and/or negative reactions (transferences) in their patients." [p. 22]
Accompanying Presence:
"Once the chaplain has accepted and worked with the patient’s transferential projection -- positively, by offering a sense of security or reconnection, or negatively, by deconstructing the projection -- the chaplain may become an accompanying presence, someone who can and does stay-with. As an accompanier, chaplains have no therapeutic aim or professional agenda; they do not accompany in order to do something to or for their patients so much as simply to be someone with them. ...Being physically present and emotionally available, the chaplain is in a place to experience something of the experience of the dying person, and in experiencing a degree of that experience they may give the dying person permission to experience their own experience." [p. 24]
Comforting Presence:
"As accompaniers, chaplains become a comforting presence... -- not in an anodyne, 'tea and sympathy' sense, but in the original Latin sense of confortare -- 'to strengthen.'" [p. 24] *
Hopeful Presence:
" …[C]haplains do not think specifically in terms of helping dying patients find hope. …[C]haplains aim to model a way of being-with patients that is itself a hopeful presence. Chaplains reconceptualize hope as 'hope in the present'…, and while this seems counter to common sense, it is congruent with the traditional use of 'hopefully, in the sense of to be 'in a hopeful manner'. The point is that, in the face of a terminal diagnosis, hope becomes reconfigured by presence." [pp. 24-25] "…[The patient is supported] to be hopeful, not now so much concerned with the future of desire unfulfilled, but to be a being towards life, open to connectedness and possibility." [p. 25]
In further interviews with some of his sample of chaplains, this theory seemed to fit with their own experience and hold promise for clinical application. The author notes, however, that his theory has emerged from interviews with other chaplains but "the voices of patients are volubly silent in this study" [p. 25], and further investigation should try to hear directly from terminally ill patients.
Nolan refers to "redundant hope" in his title. The particular phrase is the author's, but it is inspired by Bruce D. Rumbold's Helplessness and Hope: Pastoral Care in Terminal Illness (London: SCM Press, 1986), which identifies a "three-stage model of the way hope might develop during the trajectory of terminal illness":
Using a psychiatric account of how patients fund hope by denying their dying, Rumbold argued that as the reality of disease intrudes into denial, patients find new ways to deny and so continue to fund their hope. For example, a patient may deny initial symptoms against the hope that 'It’s just my imagination.' However, when symptoms force them into treatment, a new denial allows them to hope that 'I will recover.' Rumbold identified a point at which hope for recovery becomes redundant, and argued that, if patients are to find a form of hope beyond recovery, they need help to navigate between their now-redundant hope and the possible loss of hope. Failure of support at this point may mean patients fall away into despair. [p. 21]
Nolan's "developmental moment" in which a chaplain's "being-with" a dying patient becomes characterized by "hopeful presence" can help such a patient at a crucial juncture to reconfigure hope rather than lose hopefulness altogether.
For this reader, Nolan's theory of chaplain-as-hopeful-presence seems clinically valuable, but the major contribution of his article may be to raise awareness of the idea that hope can be rooted in the present and in a manner of living in the present. The health care literature is dominated by conceptualizations of hope that are strongly future-oriented, to the point that some risk describing what might better be called "wishing" [--see Related Items of Interest, §I, below, regarding Paul Pruyser's work]. Future-oriented hope is often brittle, especially in crisis situations (e.g.: as with a patient "hoping" for particular test results), but present-oriented hope is a resiliently open attitude about the potential of life (e.g.: as with a patient "hoping" that she is learning as much as she can about being a child-of-God through her experience of illness). Chaplains serving all populations, not just palliative care groups, should find much in Nolan's article to consider in their work.
* NOTE: The first sentence of the section on Comforting Presence [p. 24] contains an obvious misprint (omitted in this summary), but the general meaning is clear.
Suggestions for the Use of the Article for Discussion in CPE:
The article is well-suited for all CPE groups, and even for supervisory education students (interested in theory). It is brief but thought-provoking; and it models a research-minded approach to problem-solving and personal initiative in continuing professional education and growth. CPE students might be challenged to think of how research questions can emerge from their real-life clinical experience, and how even peer consultation can be pursued as a systematic study. Discussion could easily be guided by the elements of the theory of chaplain-as-hopeful-presence and the four "developmental moments" [--see pp. 23-25], beginning with the phenomenon of patient transference regarding the chaplain [--see pp. 22 and 23-24]. The theory is nicely summarized in the first paragraph of the Conclusion [p. 25], which could be read aloud at the outset, before looking at each of the "developmental moments" in detail. Students may also want to think about the concept of "being-with" as a very active understanding of presence. Of course, the article easily opens up the subject of hope, and discussion should include the role of the present and the future in patients' hoping, especially in end-of-life circumstances. Supervisory students will likely want to follow Nolan's bibliographic leads to explore the bases of his theory, and there they will find more books than articles. One article noted, though, is Kaye Herth's "Fostering hope in terminally ill people," [--see Related Items of Interest, §III, below], and Herth is an especially important author, because she has created a widely-used measure: The Herth Hope Scale (and the abbreviated Herth Hope Index), which may be useful in students' original research.
Related Items of Interest:
I. Nolan references in his bibliography a number of works that would be good for further reading, yet one name of potential interest for background reading that is not listed is that of the clinical psychologist Paul Pruyser, who is known to many clergy for his classic book, The Minister as Diagnostician (1976), but who also wrote in 1963 a seminal article on hope.
Pruyser, P. "The phenomenology and dynamics of hoping." Journal for the Scientific Study of Religion 3, no. 1 (Autumn 1963): 86-96. [This philosophically-minded article includes a delineation of the concept of hoping from that of wishing, desiring, or optimism. He wrote this while at the Menninger Foundation and draws notably upon the work of Karl Menninger (--see §II, below) as well as that of the philosopher and Christian existentialist Gabriel Marcel (--especially Marcel's Homo Viator: Introduction to a Metaphysic of Hope, trans. by Emma Craufurd; Chicago, H. Regnery Co., 1951).
For a brief summary of Pryuser's perspective on hope, see also his entry, "Hope and Despair," in Hunter, R. J., ed., Dictionary of Pastoral Care and Counseling (Nashville, TN: Abingdon Press, 1990; pp. 532-534). Pruyser de-emphasizes the concept's often-implicit future-orientation and opts for more of a present-centered view, seemingly going further in this way than Menninger [--see §II, below] in delineating hope as a clinical concept. He views hope as a general and existential condition with subdued ego feelings, without the expectation implicit in desire or the self-assertiveness and interest in prediction characteristic of optimism. He particularly distinguishes hoping from wishing: for example, hoping is characterized by quiescence (rather than by impulsiveness and urgency), it is "relaxed" (rather then restless), it has a sense of surrender to transcendence and benign forces (rather than a sense of control), it is broadly focused with an open-ended sense of the future (rather than narrowly focused with concrete goals in mind), and it involves a "process" view of reality, with a sense of patience in change (rather then a focus on sudden change and gratification). NOTE: Pruyser also revisits this topic in "Maintaining hope in adversity," Pastoral Psychology 35, no. 2 (Fall 1986): 120-131.
II. Another important background work on hope in the clinical setting is The Vital Balance: The Life Process in Mental Health and Illness, by the eminent physician Karl Meninger, with Martin Mayman and Paul Pruyser (New York: Viking Press, 1963). See especially pp. 380-400 regarding hope, part of the larger section on "Intangibles." This narrative -- and at times very personal -- overview looks at hope with a sense of transcendence (borrowing from Christian tradition) and defines it in the clinical context as consisting of "positive expectations in a studied situation which go beyond the visible facts" [p. 386] Menninger sought to distinguish hope from such things as optimism, and he thus stands early on in a trend to create a differential assessment of hope in health care that might lead to greater and greater conceptual precision. Some of the basis of Menninger's perspective may be found in his Academic Lecture on "Hope," in the American Journal of Psychiatry [vol. 116, no. 6 (December 1959): 481-491].
III. Nolan mentions the nursing researcher Kaye Herth [p. 25] for her 1990 article, "Fostering hope in terminally-ill people" [--see below]. Herth's work is largely congruent with Nolan's perspective, and her Herth Hope Index and Herth Hope Scale is are major instruments for hope research. For more on her work, see:
Cutcliffe, J. R. and Herth K. "The concept of hope in nursing 1: its origins, background and nature." British Journal of Nursing 11, no. 12 (Jun 27-Jul 10, 2002): 832-840. [This is the first of a series of six articles intended to "explore the nature of hope, review the existing theoretical and empirical work in several discrete areas of nursing, and provide case studies to illustrate the role that hope plays in clinical situations." (abstract, p. 832) Other articles in the series are: "Hope and mental health nursing" (vol. 11, no. 13, pp. 885-889 and 891-893); "Hope and palliative care nursing" (vol. 11, no. 14, pp. 977-983); "Hope and gerontological nursing" (vol. 11, no. 17, pp. 1148-1156); "Hope and critical care nursing" (vol. 11, no. 18, pp. 1190-1195); and "Research/education/policy/practice" (vol. 11, no. 21, pp. 1404-1411).]
Farran, C. J., Herth, K. A. and Popovich, J. M. Hope and Hopelessness: Critical Clinical Constructs. Thousand Oaks, CA: Sage Publications, 1995. [This book is an excellent resource on hope, containing a broad overview of the concept and its clinical (especially psychological) assessment, critical summaries of various assessment questionnaires, and the questionnaires themselves. The book is divided into three sections: Part 1: Conceptual and Theoretical Issues (Hope: An Overview of the Construct; and Hopelessness: An Overview of the Construct), Part 2: Assessment and Interventions in Hope and Hopelessness (Critique of Existing Measures; Assessment in the Clinical Setting; and Interventions in the Clinical Setting), and Part 3: Research on Hope and Hopelessness (Quantitative Research Conducted on Hope and Hopelessness; Qualitative Research Conducted on Hope and Hopelessness; and Directions for Future Research).]
Herth, K. "Abbreviated instrument to measure hope: development and psychometric evaluation." Journal of Advanced Nursing 17, no. 10 (October 1992): 1251-1259. [(Abstract:) The purpose of this research was to develop and evaluate psychometrically an abbreviated instrument to assess hope in adults in clinical settings. The Herth Hope Index (HHI), a 12-item adapted version of the Herth Hope Scale (HHS), was tested with a convenience sample of 172 ill adults. Alpha coefficient was 0.97 with a 2-week test-retest reliability of 0.91. Criterion-related validity was established by correlating the HHI with the parent HHS (r = 0.92), the Existential Well-Being Scale (r = 0.84) and the Nowotny Hope Scale (r = 0.81). Divergent validity with the Hopelessness Scale was established (r = -0.73). Construct validity was supported through the factorial isolation of three factors: (a) temporality and future; (b) positive readiness and expectancy; (c) interconnectedness. These three factors accounted for 41% of the total variance in the measure.]
Herth, K. "Development and refinement of an instrument to measure hope." Scholarly Inquiry for Nursing Practice 5, no. 1 (1991): 39-51, with discussion on pp. 53-56. [(Abstract:) This article describes the development and psychometric evaluation of a measure designed to evaluate hope in adults, the Herth Hope Scale, which was completed by 180 cancer patients, 185 well adults, 40 well elderly and 75 elderly widow(er)s. The alpha reliability coefficients for the total scale ranged from .75 to .94 with a three-week test-retest reliability of .89 to .91. A negative correlation (r = -.69) was found between the Herth Hope Scale and the Beck Hopelessness Scale. The multidimensionality of the construct was supported through the factorial isolation of three subscales: temporality and future, positive readiness and expectancy, and interconnectedness. These three factors accounted for 58% of the total variance in the measure. With refinement, this measure should enable exploration of the antecedents and correlates of hope in diverse adult populations. Further, hope enhancing strategies could be identified and examined for their ability to alter hope states.]
Herth K. "Fostering hope in terminally-ill people." Journal of Advanced Nursing 15, no. 11 (Nov 1990): 1250-1259. [This study of a convenience sample of 30 terminally-ill adults identified 7 categories of hope-fostering strategies used by patients (i.e., interpersonal connectedness in meaningful relationships, lightheartedness in feelings of delight and playfulness, personal attributes like determination or courage or serenity, attainable aims that direct efforts at some purpose, a spiritual base in active beliefs and practices, affirmation of individual worth, and uplifting memories) and 3 hope-hindering categories (i.e., abandonment and isolation, uncontrollable pain and discomfort, and devaluation of personhood). The author points out the potential for using these findings to develop interventions to foster hope in terminally-ill people. NOTE: In 2004, this study was replicated with a British population --see: Buckley, J. and Herth, K., "Fostering hope in terminally ill patients," Nursing Standard 19, no. 10, pp. 33-41.]
Herth, K. A. "Development and implementation of a Hope Intervention Program." Oncology Nursing Forum 28, no. 6 (July 2001): 1009-1016. Erratum appears in vol. 28, no. 10, p. 1510. [The article describes and evaluates an 8-session program to enhance cancer patients' hope. The intervention revolves around four "central attributes of hope": Experiential Process, Spiritual or Transcendent Process, Rational Thought Process, and Relational Process --all constituting a Hope Process Framework. Chaplains may be especially interested in the goals of sessions 4 ("Connecting with Others," which focuses on relationships) and 5 ("Expanding the Boundaries," which looks at participants' sense of meaning in life, spiritual resources, and small joys). NOTE: This research builds upon that reported in Herth's 2000 article: "Enhancing hope in people with a first recurrence of cancer," Journal of Advanced Nursing (vol. 32, no. 6, pp. 1431-1441).]
VandeCreek, L., Nye, C. and Herth, K. "Where there is life, there is hope, and where there is hope, there is....." Journal of Religion and Health 33, no. 1 (Spring 1994): 51-59. [For this study, Herth teamed with chaplain researcher Larry VandeCreek and medical student Christina Nye. (Abstract:) Using the Herth Hope Index, we describe the level of hopefulness among hospital patients and compare it to that reported by community persons and family members in a surgical waiting room. We also correlate these results with depression and self-esteem scores. As measured by these selected instruments, the results suggest that the level of hopefulness is not significantly different among the three samples, that it is positively correlated with self-esteem and negatively associated with depression, and that, among the demographic variables, only the respondent's age and frequency of attendance at worship significantly influence hope scores. The results suggest that pastoral caregivers can encourage hopefulness among those under their care by bolstering self-esteem and giving attention to depressive symptoms. They also suggest that those who need the most pastoral support are younger adults with limited education. Pastoral caregivers can use these results, we think, to inform their work in giving pastoral care.]
IV. For a very helpful (if now slightly dated) tabular summary of 13 authors' understandings of the elements involved in hope/hoping, see:
Eliott, J. and Olver, I.
"The discursive properties of 'hope': a qualitative analysis of cancer patients' speech." Qualitative Health Research 12, no. 2 (February 2002): 173-193. [See TABLE 1: Selected Review of Published Papers Delineating Elements of Hope (pp. 175-176). The article as a whole reports data from interviews with 23 oncology clinic outpatients.]
V. Other articles by Steve Nolan (not focusing on hope):
Nolan, S. "Am I a male social worker?" PlainViews 5, no. 6 (4/16/2008): http://plainviews.healthcarechaplaincy.org/archive/AR/c/v5n6/pp.html.
Nolan, S. "Chaplaincy in the United Kingdom: religious care or spiritual care?" PlainViews 5, no 2 (7/16/2008): http://plainviews.healthcarechaplaincy.org/archive/AR/c/v5n12/a.html.
Nolan, S. "In defence of the indefensible: an alternative to John Paley’s reductionist, atheistic, psychological alternative to spirituality." Nursing Philosophy 10, no. 3 (July 2009): 203-213. [John Paley has rightly observed that, while spirituality is widely discussed in the nursing literature, the discussions are uncritical and unproblematic. In an effort ‘to reconfigure the spirituality-in-nursing debate, and to position it where it belongs: in the literature on health psychology and social psychology, and not in a disciplinary cul-de-sac labelled “unfathomable mystery” ’, Paley has proposed an alternative, reductionist approach to spirituality. In this paper, I identify two critiques developed by Paley: one political, the other ‘logical’. Paley's political critique claims the concept of ‘spirituality’ has been appropriated by nursing theorists as part of an attempt to accrue professional power and jurisdiction over occupational territory. I suggest that Paley's analysis masks his own exclusivist, secularizing jurisdictional claim made at the expense of spirituality. Paley's so-called ‘logical’ critique is motivated by an intention to ‘determine what the “spirituality” terrain looks like from the naturalistic point of view’. However, noting a number of inconsistencies, I challenge his ‘logical move’ as a naďve attack on a straw man. In place of Paley's reductionism, I propose my own alternative alternative and argue (after Foucault) that ‘spirituality’ is a discourse, a non-reductionist attempt, in a post-religious society, to speak about the human condition open to the unknown. I conclude with a definition and a description of empirically congruent spirituality.]
Nolan, S. "Learning from the experience of my own lack." PlainViews 4, no. 13 (8/1/2007): http://plainviews.healthcarechaplaincy.org/archive/AR/c/v4n13/er.html.
Nolan, S. "Psychospiritual care: a paradigm (shift) of care for the spirit in a non-religious context." Journal of Heath Care Chaplaincy [Publication of the College of Health Care Chaplains, London] 7, no. 1 (Spring/Summer 2006): 12-22. [Available from the journal at www.healthcarechaplains.org/information/documents/journal_spring_2006.pdf or from the European Network of Health Care Chaplaincy Library at www.eurochaplains.org/enhcc_library/nolan2006-1.htm. (Abstract:) A pressing question for many chaplains concerns the meaning of spiritual care in a non-religious context. From different perspectives, Pattison and Walter both question the distinctive contribution of chaplains offering a generic approach to spiritual care. I suggest that using a humanistic-phenomenological definition of spirituality as ‘a way of being' allows chaplains to understand the care they offer in terms of ‘psychospiritual' care, that is a care offered on the shared terrain of spirituality and consciousness of being. I note that chaplains' distinctive contribution comes from the fact that we are familiar with this terrain, and I consider three aspects of psychospiritual care: mapping and marking, personal work and ‘hearing confession'.]
Nolan, S. "Taking the piss? A self-reflexive analysis on Jung's question about 'psychotherapists or clergy'." Psychodynamic Practice 16, no. 3 (August 2010): 313-321. [(Abstract:) Working as a hospice chaplain I have experienced myself as the object of patients' transference. This has been uncomfortable and has left me feeling unrepresented by my identity as a clergyman. Training as a counsellor/therapist has increased my awareness about my own countertransference and, although this has been equally uncomfortable, the awareness has enabled me to self-reflexively analyze my identity as a clergyman. The trigger for my self-reflexive analysis was the response of a fellow student to my unguarded use of the word 'piss'. I use the theory of Fairbairn to respond to a question posed by Jung.]
Nolan, S. "'The experiencing of experience': a pragmatic reassessment of Rogerian phenomenology." European Journal of Psychotherapy and Counselling 10, no. 4 (2008): 323–339. [(Abstract:) Aspects of Person-Centred counselling/psychotherapy have been taken by some to support to the idea that Rogers identified with phenomenology as a philosophical approach. While in his search for ‘a new science’ Rogers does come to regard phenomenological methods as, if ‘not the best tool of research’, a ‘tool appropriate to some kinds of situations’, he never explicitly advocates a phenomenological approach in therapeutic practice. This paper suggests that those who propose a ‘Phenomenological Rogers’ do so because, ironically, they read him with phenomenological preconceptions. Instead, this paper proposes that by reading Rogers phenomenologically, and so allowing his perspective to emerge from the reading, it is possible to recover Rogers’ philosophical indebtedness to John Dewey and the tradition of American Pragmatism. The paper examines the extent to which Rogers shares Dewey’s philosophical interest in experience and shows how he saw the process of therapy in terms of enabling ‘the experiencing of experience’ in the client. The paper argues that Rogers’ philosophical debt to Dewey and American Pragmatism offers to account for why he developed his ideas and practice as he did and provides a better understanding of the logic underwriting his conditions of therapeutic change, the coherent and ‘logically intertwined’ ‘core’ therapeutic conditions. (NOTE: There are bibliographic variations of this journal's name, but the official citation of the article may be found at http://www.informaworld.com/smpp/content~db=all~content=a906645824.)]
Nolan, S. "'This chapel is a sanctuary': another place or a place for the other?" International Journal of Public Theology 2, no. 3 (2008): 313-327. [(Abstract:) Tabloid reporting about the removal of crosses from hospital chapels and the banning of Bibles on wards highlights a perception that English cultural identity is under threat by concessions made to minority groups, often characterized as 'political correctness gone mad'. A claim frequently made is that Britain is 'a Christian country', and this article argues that this idea, and its corollary that it is natural and right for Christian symbolism to have precedence in the sacred/spiritual spaces of healthcare institutions, acts as what Lacan and Žižek term a 'master-signifier'. As such, I argue that the marginalization of cultural representation—the symbolizing of cultural/religious values that legitimates the presence of minority religions/cultures—is an important factor contributing to the inequality of access to healthcare in general and palliative care in particular.]
Nolan, S. "To say 'Good bye': to say 'Hello'." Journal of Heath Care Chaplaincy [Publication of the College of Health Care Chaplains, London] 8, no. 2 (Autumn 2007): 5-11. [(Abstract:) Two services were conducted with the aim of supporting staff and volunteers to deal with their experiences around a hospice redevelopment project. This paper presents those services, which were constructed in a way that attempted to be inclusive and respect the generic spirituality integrity of all who were taking part, while at the same time maintaining the integrity of the chaplain (a practicing Christian).]
Nolan, S. "Writing for publication: a rough guide for chaplains." The Journal of Health Care Chaplaincy [Publication of the College of Health Care Chaplains, London] 9, nos. 1-2 (Spring-Summer 2008): http://www.healthcarechaplains.org/information/documents/journal_autumn_2008.pdf. [NOTE: This is a theme issue on research, with Steve Nolan as the guest editor.]
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