Harvard Divinity Bulletin - Mark LaRocca-Pitts - Walking the Wards as a Spiritual Specialist

Among the members of the healthcare team, the chaplain's role and work are often the most enigmatic. Combining religious and spiritual motivations with clinical and medical ones, the professional health-care chaplain has emerged as a valued member of the health-care team. The chaplain's role and how it fits into that of the healthcare team are the subjects of this essay.

All members of the interdisciplinary health-care team know that religion and spirituality play a significant role in how patients cope with the effects of their illnesses. The question that keeps appearing in the medical literature, however, revolves around establishing and maintaining professional boundaries when treating spiritual needs. Relegating this responsibility to one profession only, as many hospitals tend to do with chaplains or volunteer pastoral teams, diminishes the overall impact spiritual care can have on the patient. From the physician who inquires about the psychosocial needs of the patient to the chaplain who helps a sick patient find hope to the housekeeper who listens to the patient talk about family concerns, meeting the spiritual needs of patients and their families is an interdisciplinary effort involving the entire staff. Yet, like any other specialty in the medical environment, effective, intentional, and patient-centered spiritual care still requires a specialist who is appropriately trained and who can coordinate and take responsibility for that care.

Spiritual care is designed to address spiritual distress. Spirituality is that which gives a person meaning and purpose and is found in relationships with self, others, ideas, nature, and, possibly, a higher power, or a wholly other. These many relationships are prioritized according to an organizing principle and form an intra-, inter-, and trans-relational web that houses a person's sense of meaning and purpose. Spiritual distress arises when one of these relationships that provide meaning is threatened or broken. The more significant a particular relationship or complex of relationships is, the greater the severity of spiritual distress if that relationship is threatened or broken. Spiritual wholeness is restored when that which threatens or breaks the patient's relational web of meaning is removed, transformed, integrated, or transcended.

Upon hospitalization, a person's relationships, and therefore his or her relational web of meaning, are potentially threatened. Access to family and friends is limited. Self images based on body or mental abilities are threatened. Sense of place, worth, and/or blame in light of one's God or organizing principle are subject to questioning. Spiritual care involves sorting through a patient's relational web of meaning and assessing how the patient's illness has negatively reverberated throughout that relational web such that spiritual distress occurs. This service takes time, active listening, a theologically developed acuity, and an ability to journey with patients as they tell their stories and mobilize their own spiritual resources for healing. The professional health-care chaplain provides this service.

A medical analogy may help shed light on how health-care professionals coordinate care. When a person is physically injured, several responses may occur, depending on the severity of the injury. If it is a slight or superficial injury, then it may only require first-aid medical treatment and, if that treatment is readily available, the person may be treated on site. If it is more severe, the person may come to the hospital or a clinic where a nurse or other health-care professional will triage the injury. At this point, various treatment options may be considered that range from non-emergent, which results in the patient waiting until the appropriate medical professional is available, to emergent, which results in the patient's immediate transfer to the appropriate treatment area and specialists.

Similarly, health-care professionals need to address the best way to coordinate care for spiritual injuries. As with a physical injury, a spiritual injury may call for various responses, depending on its severity; first impressions alone will not suffice to determine the degree of spiritual distress. However, the starting point for all spiritual care is a relationship. Thus, by entering into and developing a relationship with the patient, the physician, nurse, chaplain, social worker, housekeeper, or other members of the healthcare team provide first-aid spiritual treatment, and, in doing so, they demonstrate concern. Sometimes this sense of being cared for is enough.

At this level of first-aid spiritual treatment, role differentiation is unnecessary. And at the level of emergent spiritual care that deals with traumatic or debilitating spiritual distress, roles are generally clear: refer the patient to the hospital chaplain. It is at the intermediate level—triaging spiritual distress— that role boundaries become blurred.

On the one hand, this makes sense. If it is in the midst of forming relationships with patients that health-care professionals become aware of spiritual concerns, then all in health-care must take some responsibility for triaging. Beyond this rather accidental or incidental form of spiritual triaging, however, there are more intentional forms. They are, in order of complexity, spiritual screenings, spiritual histories, and spiritual assessments.

All patients should be spiritually screened in order to determine if a spiritual intervention is needed. At a minimum, spiritual screening should include the patient's faith tradition (if any), whether the patient has something or someone in place to address his or her spiritual needs while hospitalized, and whether the patient's faith tradition or spiritual pursuits dictate special requirements such as diet, prohibited medical treatments, or other cultural considerations. If in the course of spiritual screening something unusual surfaces, like an unfamiliar faith tradition or a unique request for ritual intervention, or if the patient exhibits spiritual distress through words, actions, or emotional expression, then a further spiritual intervention is indicated and a referral should be made to the chaplain. The chaplain will then conduct a spiritual assessment that includes the patient's spiritual history.

Due to chronic understaffing of chaplaincy departments, chaplains are unable to provide spiritual screenings for all patients. As a result, physicians and nurses must be trained on how to take spiritual screenings. If this training is not provided in their medical schools, then the chaplain should provide the necessary training specific for the population served. Spiritual assessment, which includes the spiritual history, should remain within the professional chaplain's domain. Professional chaplains not only have the clinical training to do such an assessment, they also have the necessary theological and spiritual training.

Art Lucas, a board-certified chaplain and supervisor in Clinical Pastoral Education at Barnes-Jewish Hospital in St. Louis, has developed an outcome-focused process of spiritual assessment and documentation," which he and Larry VandeCreek have published in their Discipline for Pastoral Care Giving: Foundations for Outcome Oriented Chaplaincy. Beginning with the patient's spiritual history, which includes the patient's needs, hopes, and resources, the chaplain constructs a spiritual profile that indicates how the patient's faith functions in terms of certain categories, such as Holy, Meaning, Hope, and Community. Based on this assessment, the chaplain will determine the desired contributing outcomes for the patient during that encounter. The chaplain and the patient together will then identify an appropriate plan of care with specific spiritual care interventions and a way to measure actual outcomes.

In their landmark paper "Professional Chaplaincy: Its Role and Importance in Healthcare," Larry VandeCreek and Laurel Burton state that "[t]he professional chaplain does not displace local religious leaders, but fills the special requirements involved in intense medical environments" (Journal of Pastoral Care 55, 1 [spring 2001], 6). To meet these "special requirements," the professional health-care chaplain needs extensive training and education. The minimum educational requirement is a graduate-level theological degree or its equivalent. For many chaplains, this is a three-year Masters of Divinity degree, although some also pursue doctoral work. As in the medical professions, chaplains must also undergo intensive clinical training in an accredited program. The minimum requirement is 1,600 hours of supervised clinical training that includes weekly didactics, verbatim consultations, interactive peer group development, rotation in 24-hour on-calls, and one-on-one supervision. In addition to this theological education and clinical training, a faith group must endorse the chaplain. Depending on one's faith tradition, acquiring endorsement may call for additional years of ecclesial supervision, ordination, and possibly parish or congregational work. Finally, a chaplain must demonstrate in writing and through interviews a variety of personal, pastoral, and professional competencies in order to achieve board certification and must continue professional development throughout his or her career to maintain certification.

Most local faith leaders do not have the layers of clinical training on top of their theological training, and there is no reason they should. Central to the identity of most religious professionals is some sort of "call." For chaplains, an important part of their call includes being called to a specific, and often secular, setting, such as the military, prisons, industry, colleges, or hospitals. Within the respective setting, the chaplain ensures that the religious and spiritual needs of those in that specific institution are duly recognized and actualized. To respond appropriately to such a call, chaplains must receive training that is specifically suited for that particular setting.

Hospitals are places where life-altering crises can occur daily, sometimes hourly. When these crises involve physical needs alone, the health-care team responds like a well-oiled machine. For many patients, however, the experience of hospitalization goes beyond their physical needs and involves their spiritual needs. As such, hospitalization becomes a profoundly liminal experience in which patients are confronted by their own weaknesses and limitations.

This is where the professional healthcare chaplain fits into the health-care team. In the midst of this kaleidoscope of uncertainty and ambiguity, the chaplain represents, if not the very presence of God, at least the presence of a spiritual strength and abiding hope. The chaplain stands with patients and their families in their pain and distress as they seek meaning and purpose in their health-related crisis. The patient's faith and/or spiritual resources play a significant and, often, determinative role in that search.

The chaplain's tool kit still contains many of the traditional spiritual care tools like prayer, scripture reading, religious rituals, presence, active listening, sustaining, and comforting. But the "special requirements" of the hospital setting also necessitate some less traditional tools:

Due to the often unpredictable influences that spiritual interventions can have on medical outcomes, and due to the chaplain's own connections with his or her source of spiritual strength, the role and the work of the professional health-care chaplain will always remain somewhat enigmatic. In today's holistic, interdisciplinary approach to health care, all members contribute from the perspective of their specialization to the care and healing of the patient's mind, body, and spirit. This is also true for the chaplain. The professional health-care chaplain's role is that of the spiritual care specialist in the context of modern health care. The work of the professional health-care chaplain is to help patients mobilize and actualize their spiritual resources in such a way that they contribute to their own healing process.

Mark A. LaRocca-Pitts, MDiv '91, completed a PhD in Near Eastern Languages and Civilizations at Harvard in 2000. He works as a staff chaplain at Athens Regional Medical Center in Athens, Georgia.

Recommended Reading
Clark, P., M. Drain, and M. Malone. "Patient Centeredness: Addressing Patients' Emotional and Spiritual Needs." Joint Commission Journal on Quality and Safety 29, 12 (December 2003): 659-70.

Koenig, H., M. McCullough, and D. Larson, Handbook of Religion and Health. Oxford: Oxford University Press, 2001.

LaRocca-Pitts, M. "Higher Power: Addressing Spiritual Care Needs Is a Team Effort." ADVANCE for Nurses, Southeastern States 5, 26 (December 8, 2003): 27-28.

Post, S., C. Puchalski, and D. Larson. "Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics." Annuals of Internal Medicine 132, 7 (April 2000): 578-83.

Sloan R., E. Bagiella, L. VandeCreek et. al. "Should Physicians Prescribe Religious Activity?" New England Journal of Medicine 342, 25 (June 22, 2000): 1913-16.

VandeCreek, L., and L. Burton, eds. "A White Paper—Professional Chaplaincy: Its Role and Importance in Healthcare." Journal of Pastoral Care 55, 1 (spring 2001): 81-97.

Harvard Divinity School