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May 2011 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Spidell, S., Wallace, A., Carmack, C. L., Nogueras-Gonzalez, G. M., Parker, C. L. and Cantor, S. B. "Grief in healthcare chaplains: an investigation of the presence of disenfranchised grief." Journal of Health Care Chaplaincy 17, no. 1 (January 2011): 75-86.


SUMMARY and COMMENT: This study explores issues of grief in healthcare chaplains that may have implications for professional practice and the problem of burnout. The authors' objectives were to learn how chaplains "respond to grief" and experience "disenfranchised grief" [p. 77] --"grief that is not acknowledged by society, by the healthcare culture, or by individuals" [p.76]. Disenfranchised grief is a term coined by Kenneth J. Doka, MDiv, PhD, in 1985 (in a presentation by that title to a symposium of the Foundation of Thanatology in New York) and has been a core concept for a number of studies [--see p. 76, and also Related Items of Interest (§III, below)] but never with a focus on chaplains.

The present research sampled members of the Association of Professional Chaplains through an online questionnaire advertised through the APC e-News and PlainViews, yielding 577 respondents from the organization's 3,131 members (2009). The survey questions -- multiple choice and open-ended -- were [pp.78-79]:

  • "How are you affected when one of your patients dies?"
  • "Do you do anything special to mark a person's death?"
  • "How do you feel when the griefs at work begin to pile up?"
  • "What do you do to revive yourself?"
  • "Have you discovered certain aspects of grief or grieving that you as a chaplain are very uncomfortable hearing or talking about...?"
  • "Are there losses and griefs of your own that you would feel very uncomfortable talking about?"
  • "When you feel grief from the deaths of patients, do you feel that your grief is affirmed and supported in the workplace?"
  • "Do you feel appreciated in your ministry?"
  • [length of time served as a chaplain]
Analysis was both qualitative and quantitative. Included in the latter: "To look for the possible presence of disenfranchised grief and its relationship to mental well-being, we analyzed the relationship between negative religious coping [as indicated by 13 choices for answers to the question, 'How do you feel when the griefs at work begin to pile up?'] and whether the chaplains' grief was affirmed and supported in the workplace using a t-test" [p. 79].

Among the quantitative results: 31% reported five or more negative coping behaviors, 18% reported four such behaviors, and 21% reported three [--see p. 81 and Table 1 on p. 82].

...[W]e found that 79% of those chaplains whose grief was affirmed and supported in the workplace exhibited one fewer negative coping behavior (4 vs. 5) compared to the 21% of those chaplains who wrote that their grief was not affirmed and supported in the workplace (p<.0025). Thus the lack of affirmation of grief may lead to problematic or disenfranchised grief.
Further, we explored whether respondents who felt appreciated in their ministry were different than those who were not. Results indicated that higher levels of perceived appreciation were associated with fewer negative coping behaviors. Chaplains who were "always" appreciated for their ministry exhibited approximately one fewer negative coping behavior than those who were appreciated for their ministry "most of the time," and approximately two fewer negative coping behaviors than those who were appreciated for their ministry some of the time (p<.01 ...). [pp. 82-83]
The most prevalent responses to the question, "How do you feel when the griefs at work begin to pile up?" (suggesting negative religious coping) were: "...they would have low energy (79%), feel like they had no time for themselves (44%), go through the motions (41%), or distance themselves or withdraw from others (31%)" [pp. 80-81].

While a majority of respondents felt that their grief was affirmed and supported in the workplace, "20.9% felt that it was not"; and "15.5% reported feeling appreciated [in their ministry] only some of the time or almost never" [p. 81]. Also, 63% said there was at least one topic that they were uncomfortable hearing or talking about. "Some of the most frequently listed topics included the death of a child (36% of respondents), death by murder (9%), and suicide (10%)" [p. 83].

Qualitative results further fill out a picture of risk for disenfranchised grief. The article offers a number of illustrations in the text and in a table [--Table 1, p. 82]. "For example, individual chaplains wrote 'hospital culture encourages emotionless professional behavior including chaplain staff,' 'death is not talked about in the hospital setting,' and 'my colleagues assumed I am immune to grief'..." [p. 81].

Conclusions from this research are quite tentative, since the measurement tools used were not validated (e.g., the measure introduced for "negative religious coping" is quite different from the popular Brief RCOPE measure commonly associated with that concept), and the 577 respondents represent only an 18% response rate (though, interestingly, the sample did reflect the APC's statistic for length of time as a chaplain: 28% having less than 5 years of service, and 30% having at least 15 years of service). The authors point to a need for further research to precisely isolate factors and establish causal relationships. However, they hold that the results "indicate a possible relationship between disenfranchised grief and behaviors indicative of negative mood" [p. 85]. More basically, the authors advise: "A heightened awareness of grief on the job and how easily it becomes disenfranchised should be an important concern to those who train, manage, and work with chaplains" [p.84].


Suggestions for the Use of the Article for Discussion in CPE: 

Students are often concerned with burnout, often in light of their fatigue from a CPE program itself, and this month's article may help them engage that topic broadly and help them focus specifically on the role of grief in chaplaincy. The introductory section [pp. 76-77] presents a concise explanation of disenfranchised grief, but the narrative of the results [pp. 80-83] and especially the table of Examples of Disenfranchised Grief as Demonstrated in Survey Responses [Table 1, p. 82] may give a more practical sense of the phenomenon that would benefit discussion. Students might relate their own experiences to the results here, and the survey questions could themselves serve as a structure for conversation. The article may be especially well suited for the latter half of a residency program, when students might best be able to relate to "when the griefs at work begin to pile up." Verbatim work might be brought into play here, especially in revealing subjects that students have difficulty hearing or talking about. Also, a CPE group might compile a list of commonly disenfranchised griefs that they find in patients as well as themselves in the course of their program (e.g., fetal deaths, loss of property, loss of specific hopes/dreams, the death of a pet, losses experienced by children, etc.) in order to realize the range of grief. Finally, students might be challenged to become more intentional about self-care and coping. The question, "What do you do to revive yourself?" can be critical for professional resilience. The data from this research suggest that common revitalizing activities may be "prayer (61%), talking with colleagues (57%), and reading (42%)," though respondents also wrote that "they would sleep more, see a movie, go to a beach or park, go dancing, or be with their family" [p. 81].


Related Items of Interest:

I. For more on disenfranchised grief as a concept, see:

Attig, T. "Disenfranchised grief revisited: discounting hope and love." Omega: Journal of Death and Dying 49, no. 3 (2004): 197-215. [(Abstract:) Kenneth Doka's two anthologies on disenfranchised grief (Doka, 1989, 2002) are filled with discussions of the effects of disenfranchisement and its scope. The present article furthers reflection on both topics. It first explores the nature of disenfranchisement as a denial of a mourner's "right to grieve" and analyzes the empathic, political, and ethical failures involved in this denial. It then notes that the literature on the subject is dominated by treatments of the disenfranchisement of suffering. And it urges that the scope of disenfranchisement extends to efforts to overcome suffering, the constructive labors of hope and love at the heart of grieving response to bereavement.]

Doka, K. J. "Disenfranchised Grief in Historical and Cultural Perspective." Chapter 11 (pp. 223-240) in Strobe, M. S., Hansson, R. O., Schut, H. and Strobe, W., eds., Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC: The American Psychological Association, 2008.

Doka, K. J. Disenfranchised Grief: New Directions, Challenges and Strategies for Practice. Champaign, IL. Research Press, 2002. [This book updates Doka's work originally published in his 1989 book, Disenfranchised Grief.]


II. Though not a report of research, see the following article for more on disenfranchised grief in relation to chaplains:

Helsel, P. B. "In memoriam: the disenfranchised grief of chaplains and the recovery of memory." Journal of Pastoral Care and Counseling 62, no. 4 (2008): 337-342. [(Abstract:) The article explores the disenfranchised grief of the chaplain from the perspective of the author's own experience in hospice chaplaincy. Borrowing from the works of Kenneth J. Doka on disenfranchised grief, Robert C. Dykstra on crisis ministry, and James Dittes on grief work in ministry, this article focuses on the grief work of chaplains. In doing so, it analyzes the theological perspective of remembrance, explaining how personal remembrances connect the chaplain with his or her own repressed grief in a way that communal events can not accomplish because of the chaplain's responsibility for the grief of the community in these settings. From the perspective of the Christian faith in its sacramental connections with the Lord's Supper, the spiritual practice of honoring the deceased and praying for their guidance is posed as a possible model of healing remembrance.]


III. On the subject of burnout, see the following for the latest research about chaplains.

Galek, K., Flannelly, K. J., Greene, P. B., and Kudler, T. [HealthCare Chaplaincy, 307 E. 60th St., New York, NY;]. "Burnout, secondary traumatic stress, and social support." Pastoral Psychology 60, no. 5 (October 2011): 633-649. [The authors mention grief only generally and in passing, but the study's insights about social support may in some ways connect with our featured article's findings about chaplains finding affirmation and support in the workplace, though the data from Galek, et al. places emphasis on the value of support from family and friends rather than on workplace sources. (Abstract:) The current study examines the extent to which selected work-related variables differentially predict burnout and secondary traumatic stress (STS) and the degree to which social support mitigates both of these occupational stress syndromes. Multiple regression performed on responses from 331 professional chaplains found that: (1) the number of years worked in the same employment position was positively associated with burnout but not STS; (2) STS, but not burnout, was positively associated with the number of hours spent per week counseling patients who had had a traumatic experience; and (3) social support was negatively related to burnout and STS. Only specific sources of social support (supervisory support and family support), however, were negatively associated with burnout. Results highlight the need for counselors to be attuned to not only their clients but also to their own inner dynamics in order to mitigate the possible deleterious effects of their work. (Note: This article is featured as our October 2011 Article-of-the-Month.)]



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