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July 2020 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


Hiratsuka, Y., Aoyama, M., Kaneta, T., Masukawa, K., Tagami, K., Miyashita, M. and Inoue, A. "Impressions of interfaith chaplain's activities among patients in a palliative care unit: a semi-structured interview-based qualitative study." Tohoku Journal of Experimental Medicine 251, no. 2 (June 2020): 91-96.

[Editor's Note: This is an open access article, freely available from the journal.]

SUMMARY and COMMENT: This month's article gives a picture of interfaith chaplaincy making inroads in a new cultural environment, but some of its themes should resonate with chaplains working where the discipline is commonplace yet still in need of greater understanding and acceptance. "This study is the first on interfaith chaplains in Japan" [p. 94]. It was carried out through Tohoku University Hospital [in Sendai], which has no religious affiliation, and which hired a certified interfaith chaplain in 2016.

To the best of our knowledge, no study has to date explored impressions formed by patients in palliative care units in Japan on the activities of interfaith chaplains because this role is new. A deeper understanding of these impressions, based on patients' conversations with the interfaith chaplain, may help improve the planning and implementation of end-of-life care. This study, therefore, explores this subject.

The authors explain the Japanese context: e.g., "a majority of Japanese people claim to have no religious affiliation, with less than 30% reporting a faith-based association" [p. 95, and see also p. 91]; "...but they are not atheistic either" [p. 95]; "[t]hey visit family graves on a regular basis and hold funerals...[but]...most regard the a custom, and not a religious act" [p. 95]; "people...feel some resistance to religion" [p. 95]; "monks in black robes...are seen as a 'bad omen'" [p. 95]; "[m]any Japanese people are spiritual, although they often have no opportunity for a discussion of deep spiritual issues" [p. 92]; and "most chaplains are employed in facilities with a religious background" [p. 92]. They also note that "a Japanese-style interfaith chaplain," -- rinsho-shukyo-shi -- is "educated according to the Code of Ethics of the Association of Professional Chaplains and Clinical Pastoral Education" [p. 92].

Fifteen palliative care patients, from a sample of 144 who had talked to the interfaith chaplain, participated in semi-structured, recorded interviews conducted by a nurse with research experience, before theoretical saturation of data was assessed to have been reached. The interviews lasted an average of 6 minutes and covered:

  • How was it to talk with the interfaith chaplain?
  • Were you initially resistive in talking with the interfaith chaplain?
  • Did you change your feelings and ways of thinking with talking with the interfaith chaplain?
  • Do you believe in any particular religion?
Participants had spoken with the interfaith chaplain, who is also a monk, between 2-9 times, with a mean average of 4.1.

Among the results, three main themes were identified, each with key subthemes:


      Resistance to religion --
"Three patients...reported feeling resistance to the term 'religion.' They had assumed that religion meant, not Shinto or Buddhism, but rather 'cult religion' and that it should thus be avoided." [p. 93]

      Disturbance --
"Two patients...were confused about having a 'monk' at the hospital because monks in black robes reminded them of death, as they are associated with funeral practices in Japan." [p. 93]

      No resistance --
"No patient expressed feeling resistance to subsequently talk to the interfaith chaplain once they had initially spoken." [p. 93]


      Role of interfaith chaplain --
"Ten patients...had various opinions on the importance of the interfaith chaplain. They thought that he was necessary for end-of-life care. However, before they had talked to him, they did not know what the interfaith chaplain would speak about." [p. 93]

      Relationship between the interfaith chaplain and patients --
"Nine patients...viewed their relationship with the interfaith chaplain as positive because he had sympathized with them and taken time to listen to them." [p. 94]

      Character of the interfaith chaplain himself --
"Eleven patients...felt the interfaith chaplain had attractive characteristics; they thought he was calm, pure, and intelligent. They were conscious of him as both a monk and a young man who listened to them." [p. 94]


      Religious beliefs --
"No patient reported a belief in any particular religion, although five mentioned Buddhism." [p. 94]

      View of religion --
"Six patients...who claimed to have had no religious affiliation reported having been in influenced by several religions." [p. 94]

In their discussion section, the authors highlight the finding that "results indicate that while some patients felt some initial resistance toward the concept of religion, this diminished after talking to the interfaith chaplain at the hospital" [p. 94].

The interfaith chaplain was able to comfort some patients by allowing them to talk about their feelings, and by "listening" intently to them; no negative outcome was reported by the patients after intervention by the interfaith chaplain. They also found it helpful that he had more time to talk to them than the doctors and nurses, who were often too busy to listen. Based on the interview data, the patients who had felt an initial resistance toward the chaplain claimed that this lessened once they conversed. "This is a palliative care ward, so I knew that he was the one who listened to patients in distress." "I did not tell others about my illness, but for the first time, I was able to talk to someone else." [p. 95]
They go on to note that the initial hesitancy to speak with an interfaith chaplain may come not only from the some resistance to religion but from the association of monks with death and from the simple concern of talking to someone with whom they are unfamiliar. These dynamics seem to this chaplain reader to be broadly pertinent to interfaith chaplaincy as a discipline, characterizing difficulties of overcoming negative assumptions and fears that stand between chaplains and patients whose actual experience usually turns out to be (unexpectedly for them) very positive. How can we get patients to give us a chance to be of help to them? At Tohoku University Hospital,
Information pamphlets about the interfaith chaplain, who was also a monk, were available to patients and visitors in the patients' rooms. Doctors and nurses also provided patients with information about the interfaith chaplain's activities: that he could listen to patients and help relieve them. [p. 92]
Pointing up the "listening" aspect may be especially valuable to opening patients to the possibility of the interfaith chaplain's helpfulness. One of the patients in the study said, "I was relieved by [him] listening to me, although my disease would not heal and the problem would not be solved" [p. 94]. The authors hint at how the interfaith chaplain's apparent dress -- in a monk's robe -- could be a complication to how patients may imagine a visit to be, but they do not explore this.

This is admittedly a small study with several limitations, not the least of which is the brevity of the interviews, even though these were ended only when it was "thought that the relevant themes had been sufficiently saturated" [p. 95]. For its immediate purposes, the fact that only one chaplain was involved in the intervention may not be problematic. The article gives a window onto the emerging role of chaplaincy in Japan, where the discipline requires a somewhat subtle delineation from the culture's traditional paradigm of clergy. (The authors' distinction between interfaith chaplains and "conventional chaplains" [p. 95] may strike some non-Japanese readers as odd.) However, there seem to be some broadly generalizable themes here to stimulate discussion among chaplains regardless of national setting, including the importance of attention to "folk faith" [p. 95] existing above and beyond established religions.

A last observation: there are two lines in the article that stand out to this reader as curious. First, the description of screening for spiritual distress in other countries as a "controversy" [p. 95] seems off-target. Second, the last line of the article refers to "Japanese people who claim to have no religious affiliation" as "minority patients" [p. 95], but this seems inconsistent with the information that only 30% of Japanese people reportedly have "a faith-based association" [p. 95]. This may be a function of wording for the international audience, causing ambiguity in the meaning of the dependent clause.


Suggestions for Use of the Articles for Student Discussion: 

This article could spark discussion for any level of chaplaincy students, and might even invite remote participation by some Japanese chaplain as part of the increasingly common use of virtual meeting platforms in the wake of the COVID19 pandemic. But even without a Japanese participant, students in the US and elsewhere could start by talking about a glimpse of chaplaincy in another cultural context. Does this make them any more aware of culture-specific aspects of their own setting? Can they name quickly some cultural norms and dynamics that surround them that they expect would shift dramatically if they moved to another country? How might this sensitize them to cultural diversity within their own institution? Regarding the study itself, can the students relate to a few of the quotes from patients on pp. 93-94, perhaps especially for the theme of Opinion about the Interfaith Chaplain? The group could talk about patients' preconceptions of chaplains and how they deal with these, including the association of chaplains with death. How have the students experienced patients who at first were concerned about speaking with a chaplain but then became very engaged during the visit? One major idea of the study is that of an interfaith chaplain working with non-religious patients. How do the students themselves tend to do this? The interfaith chaplain in the study was a monk who apparently wore a robe. What may be the plusses and minuses of how the students dress professionally? Since the full value of a study lies not just in what information it offers but in what questions it generates for future inquiry, what questions are prompted in the students' minds by the present study?


Related Items of Interest:

I.  Our article's authors give a very brief description of the development of chaplaincy in light of the Great East Japan Earthquake of 2011 [--see p. 92]. For a deeper background on chaplaincy in Japan and this earthquake, see the inaugural issue (September 1, 2012) of the Practical Religious Studies Newsletter of the Department of Practical Religious Studies of the Graduate School of Arts and Letters at Tohoku University, available online. And, for more on chaplaincy in Japan, see:

Benedict, T. O. "Practicing spiritual care in the Japanese hospice." Japanese Journal of Religious Studies 45, no. 1 (2018): 175-200. [(Abstract:) This article introduces how spiritual care is practiced in Japanese hospices to fit the needs of nonreligious patients. It suggests that Japanese chaplains often go beyond helping patients vocalize spiritual pain and addressing anxieties through counseling, religious support, or being a sympathetic presence. Rather, much of spiritual care is also conducted in the margins of daily care, and through special group events or even prosaic activities --an approach that elicits less resistance by Japanese patients. This article will also discuss how examining the practice of spiritual care helps to problematize terms like "secular" or "post-secular" in Japanese society and point out the ways in which spiritual care is being marshaled by contemporary religious groups, chaplains, the media, and religious studies scholars to help valorize the role religion can play in Japanese society by emphasizing its psychotherapeutic contributions.] [This article is available freely online from the Nanzan Institute for Religion and Culture.]

Berman, M. "Religion overcoming religions: suffering, secularism, and the training of interfaith chaplains in Japan." American Ethnologist 45, no. 2 (May 2018): 228-240. [(Abstract:) Interfaith chaplains responded to the suffering caused by the 2011 earthquake and tsunami in Japan by providing "care for the heart" in municipal funeral halls, temporary housing units, and hospitals. To gain access to those government-run spaces, however, chaplains had to suppress outward signs of their particular religious traditions, including prayers and Buddhist robes. They were neither remunerated for their labor nor allowed to proselytize. Gathering around suffering, suppressing religious differences to recognize suffering, and sharing suffering led chaplains to create a form of religion that they called "religion overcoming religions." Ironically, this form of public religion exhausted the particular religions that formerly sustained their compassionate work, thus reproducing the alienation that their engagement with suffering is meant to overcome.]

Kasai, K. "Introducing chaplaincy to Japanese society: a religious practice in public space." Journal of Religion in Japan 5, nos. 2-3 (2016): 246-262. [(Abstract:) This paper examines the meaning of the introduction of Clinical Pastoral Education (CPE) to Japan, as an example of one of the religious activities accepted in public space in a secular Japanese society. For over half a century, Christian clerics have tried to introduce the idea of chaplaincy to Japan, and Buddhists have attempted to develop a Buddhist form of hospice palliative care. The Japan Society for Spiritual Care was established in 2007 and began an accreditation process of ecumenically designed "spiritual caregivers," bringing interested parties together in Japan for education, peer support, and continuous training in spiritual care. The outpouring of national grief in response to accidents or natural disasters encouraged sponsors to create CPE training institutions at some universities. Challenging the Japanese understanding of the separation of religion and state, the introduction of chaplaincy can be seen as a case of religious practice that is accepted in public space.]

Taniyama, Y. "Significance of interfaith chaplains (rinsho-shukyo-shi)." Paper presented at the 3rd United Nations World Conference on Disaster Risk Reduction in Sendai (Japan): Disaster and the Role of Religious Practitioners, March 14-18, 2015. [The conference was sponsored by the Department of Practical Religious Studies at Tohoku University. This paper is available online as one of three presented on March 17, 2015.]


II.  For a perspective from Buddhist chaplains working in the United States, see:

Komura, F. "Spiritual care as an embodiment of Buddhist loving-kindness and compassion teachings: a Buddhist chaplain's perspective." pp. 607-625 in Thich Duc Thien and Thich Nhat Tu, eds., Buddhist Approach to Harmonious Families, Healthcare and Sustainable Societies, Vietnam Buddhist University Publications, April 16, 2019. [This essay on how spiritual care offered by Buddhist chaplains can be regarded as an embodiment of Buddhist loving-kindness and compassion teachings is written by a chaplain who completed Clinical Pastoral Education at Kuawkini Hospital in Honolulu, HI, Johns Hopkins Hospital in Baltimore, MD and the Hospital of the University of the Pennsylvania in Philadelphia, PA. It includes observations about the place of chaplaincy in Japan.] [The entire text of Buddhist Approach to Harmonious Families, Healthcare and Sustainable Societies, including this chapter, is available freely online as a PDF from the website of the 16th United Nations Day of Vesak Celebrations 2019.]

Stikeleather, D. V. "Strategic presence: the effect of the Tibetan Buddhist chaplain's presence on the family's process during end of life medical feeding decisions." Unpublished Master of Divinity Thesis, Naropa University Boulder, Colorado, April 15, 2010. [Silence is mentioned at many points, but see especially those in the section headed by the term (pp. 17-19): e.g., "Silence speaks volumes about attention to another person. It creates a presence that allows the other to flourish in the resultant space. ...[S]ilence fills the space with presence, the presence of companionship. Elizabeth Kubler-Ross speaks of a 'time when it is too late for words... it is the time for the therapy of silence with the patient.' ...Judith Lief points out another use of silence: 'When we sit quietly with another person, we gradually become more aware of that person's presence. We begin to accept and appreciate him. Those two qualities, awareness and acceptance, are the ground of kindness. ... Margaret Mohrmann describes a patient visit where there were no words, but only tears...."] [Available online.]


III.  Our authors comment about the importance of the image of "monks in black robes" [p. 93]. Remember that the interfaith chaplain in the study was also a monk. Our January 2018 Article of the Month, addressed "Handling stereotypes of religious professionals...," by hospice chaplains in the US Midwest, and one of the themes there was choice of clothing.

Lindholm, K. "Handling stereotypes of religious professionals: strategies hospice chaplains use when interacting with patients and families." Journal of Pastoral Care and Counseling 71, no. 4 (December 2017): 284-290. [(Abstract:) Stereotypes of religious professionals can create barriers for those who provide spiritual/pastoral care. Through interviews and journal entries, hospice chaplains ( n = 45) identified the following stereotypes that affected their work: chaplains as people whom others try to impress, who only talk about spiritual and religious topics, who are male, and who try to convert others. Participants reported using a variety of communication strategies to counteract stereotypes and make meaningful connections with the people they serve.]


IV.  This month's article speaks to the issue of increasing spiritual support to palliative care patients. For more on that broad topic, see for example:

Gomez-Castillo, B. J., Hirsch, R., Groninger, H., Baker, K., Cheng, M. J., Phillips, J., Pollack, J. and Berger, A. M. "Increasing the number of outpatients receiving spiritual assessment: a Pain and Palliative Care Service quality improvement project." Journal of Pain and Symptom Management 50, no. 5 (November 2015): 724-729. [(Abstract:) BACKGROUND: Spirituality is a patient need that requires special attention from the Pain and Palliative Care Service team. This quality improvement project aimed to provide spiritual assessment for all new outpatients with serious life-altering illnesses. MEASURES: Percentage of new outpatients receiving spiritual assessment (Faith, Importance/Influence, Community, Address/Action in care, psychosocial evaluation, chaplain consults) at baseline and postinterventions. INTERVENTION: Interventions included encouraging clinicians to incorporate adequate spiritual assessment into patient care and implementing chaplain covisits for all initial outpatient visits. OUTCOMES: The quality improvement interventions increased spiritual assessment (baseline vs. postinterventions): chaplain covisits (25.5% vs. 50%), Faith, Importance/Influence, Community, Address/Action in care completion (49% vs. 72%), and psychosocial evaluation (89% vs. 94%). CONCLUSIONS/LESSONS LEARNED: Improved spiritual assessment in an outpatient palliative care clinic setting can occur with a multidisciplinary approach. This project also identifies data collection and documentation processes that can be targeted for improvement.] [This was our November 2015 Article-of-the-Month.]

Klop, H. T., Koper, I., Schweitzer, B. P. M., Jongen, E. and Onwuteaka-Philipsen, B. D. "Strengthening the spiritual domain in palliative care through a listening consultation service by spiritual caregivers in Dutch PaTz-groups: an evaluation study." BMC Palliative Care 19, no. 1 (June 29, 2020): 92 [electronic journal article designation]. [(Abstract:) BACKGROUND: Palliative care should be holistic, but spiritual issues are often overlooked. General practitioners and nurses working together in PaTz-groups (palliative home care groups) consider spiritual issues in palliative care to be relevant, but experience barriers in addressing spiritual issues and finding spiritual caregivers. This study evaluates the feasibility and perceived added value of a listening consultation service by spiritual caregivers in primary palliative care. METHODS: From December 2018 until September 2019, we piloted a listening consultation service in which spiritual caregivers joined 3 PaTz-groups whose members referred patients or their relatives with spiritual care needs to them. Evaluation occurred through (i) monitoring of the implementation, (ii) in-depth interviews with patients (n = 5) and involved spiritual caregivers (n = 5), (iii) short group interviews in 3 PaTz-groups (17 GPs, 10 nurses and 3 palliative consultants), and (iv) questionnaires filled out by the GP after each referral, and by the spiritual caregiver after each consultation. Data was analysed thematically and descriptively. RESULTS: Consultations mostly took place on appointment at the patients home instead of originally intended walk-in consultation hours. Consultations were most often with relatives (72%), followed by patients and relatives together (17%) and patients (11%). Relatives also had more consecutive consultations (mean 4.1 compared to 2.2 for patients). Consultations were on existential and relational issues, loss, grief and identity were main themes. Start-up of the referrals took more time and effort than expected. In time, several GPs of each PaTz-group referred patients to the spiritual caregiver. In general, consultations and joint PaTz-meetings were experienced as of added value. All patients and relatives as well as several GPs and nurses experienced more attention for and awareness of the spiritual domain. Patients and relatives particularly valued professional support of spiritual caregivers, as well as recognition of grief as an normal aspect of life. CONCLUSIONS: If sufficient effort is given to implementation, listening consultation services can be a good method for PaTz-groups to find and cooperate with spiritual caregivers, as well as for integrating spiritual care in primary palliative care. This may strengthen care in the spiritual domain, especially for relatives who are mourning.]

Soroka, J. T., Collins, L. A., Creech, G., Kutcher, G. R., Menne, K. R. and Petzel, B. L. "Spiritual care at the end of life: Does educational intervention focused on a broad definition of spirituality increase utilization of chaplain spiritual support in hospice?" Journal of Palliative Medicine 22, no. 8 (August 2019): 939-944. [(Abstract:) Background: Research shows that religion and spirituality are important when persons cope with serious and life-threatening illness. Patients who receive good spiritual care report greater quality of life and better coping, and such support is strongly associated with greater well-being, hope, optimism, and reduction of despair at end of life. Despite these benefits, evidence shows that many patients and caregivers (P/C) refuse spiritual care when a hospice team offers it, possibly resulting in unnecessary suffering. Objective: To better understand what contributes to spiritual support acceptance in hospice care. Design: Quasi-experimental quantitative study. Setting/Subjects: 200 patients admitted to hospice. Measurements: Participants were divided equally into intervention and control arms. Control participants received standard information about the availability of chaplain support and an offer for referral to chaplain services. Intervention participants received educational intervention that explained hospice chaplain services and the evidence-based benefits of spiritual support. The association of chaplain acceptance was measured with treatment group, patient age, disease, church affiliation and support, sex, bereavement risk, and place of residence. Results: Among intervention participants, 64 (64%) accepted spiritual support versus 52 (52%) of control participants. The intervention arm's acceptance rate was higher than the control arm after adjustment for other variables. The variables associated with acceptance were age, primary diagnosis, and place of residence. Conclusions: This research suggests that educational intervention that explains spiritual care in hospice and its benefits contributes importantly to greater acceptance and allows P/C to gain the benefits of spiritual support during end-of-life care.] [This was our May 2019 Article-of-the-Month.]



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