October 2003 Article of the Month
Simon J. Craddock Lee. "In a Secular Spirit: Strategies of Clinical Pastoral Education." Health Care Analysis 10, no. 4 (December 2002): 339-356. [Note: The author's name is indexed as Lee, S. J. in the PubMed data base through the National Center for Biotechnology Information. Click here for the entry.]
COMMENT, SUMMARY, AND THOUGHTS FOR DISCUSSION: Lincoln once said, "If we could first know where we are and whether we are tending, we could then better judge what to do and how to do it." One way to know "where we are and whether we are tending" is to receive feedback from interdisciplinary professionals who observe our process and practice. Such feedback is the essence of Clinical Pastoral Education.
The article summarized here provides feedback from an anthropologist who reports observations from a year-long "ethnographic engagement" of a large medical care system. The author spent some time with chaplains and the CPE program (although the actual amount is not disclosed), and this article reports the results.
First, a word about this "ethnographic engagement": What is it? Ethnography is one of the qualitative research methods that historically arose in the field of cultural anthropology. One thinks of anthropologists going off to the South Seas and studying tribal peoples. The essence of this methodology consists of the researcher getting inside the culture, organization, or group under study, all the while maintaining an objective, scientific stance. The research purpose is to figure out how the culture, organization, or group works and why. The result of the "ethnographic engagement" reported here, therefore, sought to understand how a specific medical system worked and why. As pertains to this article, the author reflects on his experience with the chaplains in the system.
The anthropologist spent time at two hospitals in a California health care system, although their identities are not revealed. He notes that in 1994 a "secular community-based non-profit facility" suffered economic pressures and as a result became part of a "large, religiously sponsored hospital management system." This larger system is Catholic. Each hospital contains a department that provides pastoral services. In the "traditional Catholic hospital," CPE is provided through the Chaplaincy Department; in the secular hospital now merged into the Catholic system, CPE is based in the Department of Spiritual Care Services. The anthropologist found this difference in name very significant, and his observations are best summarized by the abstract at the beginning of the article.
The CPE model for the provision of spiritual care represents the emergence of secularized professional practice from a religiously based theological practice of chaplaincy. The transformation of hospital chaplaincy into "spiritual care services" is one means by which religious healthcare ministry negotiates modernity, in the particular forms of the secular realm of biomedicine and the pluralism of the contemporary US healthcare marketplace. Spiritual is a label strategically deployed to extend the realm of relevance to any patient's "belief system," regardless of his or her religious affiliation. "Theological" language is recast as a tool for conceptualizing the "spiritual lens." Such moves transform chaplaincy from a peripheral service, applicable only to the few "religious" patients, into an integral element of patient care for all. Such a secularized professional practice is necessary to demonstrate the relevance and utility of spiritual care for all hospital patients in an era of cost-containment priorities and managed care economics. (p. 339)
Here are some additional observations by the author:
The distinctions between chaplaincy and spiritual care services revolve around the difference between "religion" as a social organization of belief and practice with a particular faith community (e.g., Roman Catholic, Methodist) and "spirituality" understood here as the "experiential integration of one's life in terms of one's ultimate values and meanings," without the institutional element connoted by "religion." (p. 343)
I will lay out the strategies of CPE to demonstrate that pastoral concepts are applied both to patient care and to the development of the chaplain's professional identity. At these two hospitals sites, the central element of chaplaincy technology is the spiritual assessment model which defines the chaplain's task through a summary of the whole person that is the patient. ...The assessment model used here is oriented toward ascertaining a person's core spiritual needs, which are broken down into three typologies: 1) self-worth, 2) reconciliation, and 3) meaning and direction. (p. 344)
CPE is challenged, on the one hand, to reduce denominational markers but also to rely on theological concepts and language to distinguish spiritual care from social work and psychology, two other fields represented on the interdisciplinary patient care team. (p. 344)
And then this:
Claiming expertise in matters spiritual is a marker of professionalization for chaplains and is a regular concern in the professional literature. (p. 348)
Here is another quote:
The comments of senior CPE administrators during interviews constitutes, at some level, a form of "impression management," a clear effort to mobilize a convincing narrative asserting CPE as a professional patient care strategy and the situations recounted to me reflect that selectivity. In this case, the senior CPE administrators are participants in an institutional discourse seeking to legitimize spiritual care as an effective and worthwhile patient care strategy for this era. (p. 349)
Popular misperceptions of the Catholic tradition, for example, are rife with the idea that the appearance of clergy in a hospital ward signifies impending patient demise and the narrative restricts the role of the priest to conducting "last rites." In actuality, the situation is considerably more nuanced. Physicians and other providers are often not comfortable accepting the limits of their science and are rarely trained to counsel patients when physicians themselves often perceive the limits of their intervention as "medical failure." Chaplains on the other hand, as people trained in religion and spirituality, are much more grounded in the inevitability of death as a universal human experience, and many faith traditions have specific rituals that are mobilized to address the uncertainties of the illness experience, as well as the last stages of life. (p. 351)
Then this brief quote:
The reluctance of other provider disciplines to manage adverse outcomes seems to work in the favor of spiritual care services. (p. 352)
And finally one last quote:
[The] interdisciplinary context demands that CPE graduates demonstrate applied expertise, defined by both language and method that warrants their professional authority as a legitimate component of the patient care team. In meeting that demand, the professionalization of CPE connotes a necessary secularization driven by the closer collaboration with biomedical rationales. (p. 353)
What is the CPE community and the CPE student to make of all this? Is there anything really important here for discussion? I limit myself to one observation that may stimulate thought.
Should chaplains describe themselves as offering "pastoral care" (which carries with it the historic sense of providing traditional ministry although in an institutional setting) or as providing "spiritual care" with its more generic connotation? Should chaplains be part of a "Pastoral Care Department" or a "Department of Spiritual Services"? Such questions are no small matter because, as this author points out, a discussion soon reveals a tangled web of dynamics. For example, if a chaplain or a CPE student says, "I offer pastoral care" (again, with the traditional meaning), the cost conscious administrator may well say, "Well, then the church, synagogue, or mosque should pay for that because there are a limited number of persons who need your services--only those who are traditionally religious." If a chaplain or CPE student says, "I offer spiritual care to all persons no matter what their faith stance," then faith group judicatories are likely to ask why chaplains need ordination--particularly when chaplains cannot engage in proselytizing?
As I mean to point out, this distinction between "pastoral care" and "spiritual care" goes to the heart of the professional identity question and how we relate inter-professionally. And further, if it is "pastoral care" that is offered, then the demonstration of effectiveness for administration is considerably less pressing. Many administrators may readily admit that they really do not understand what chaplains do and may be quite content to let them do it within prescribed administrative limits because such chaplains are on the margin of the organization. If, however, chaplains provide spiritual care with the intention that it be relevant to every patient and family member, then the administrator wants considerably more control of and accountability from the chaplain. And the chaplain will need to become a professional peer to the other health care professionals. And then the religious endorsing body representatives will want to know just why chaplains merit ordination. These are not easy questions and are worth considerable discussion. And the entire discussion involves theological assumptions and administrative strategies as to how best to provide ministry.
If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at firstname.lastname@example.org