Pastoral Care and Healthcare Chaplaincy

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Pastoral care normally refers to the help given by ordained ministers, priests, and other persons with designated religious roles (such as deacons and members of Roman Catholic religious orders) to suffering, troubled, or perplexed persons. In the simplest and most profound sense, pastoral care has been defined from a Christian perspective as "the attempt to help others, through words, acts, and relationships, to experience as fully as possible the reality of God's presence and love in their lives" (Holst, p. 46). The term is primarily Christian but it is sometimes used analogously in other faith traditions (e.g., the rabbi's care in Judaism). Recently the term spiritual care has been introduced into secular healthcare settings as a less specifically Christian alternative term. In any case, when pastoral or spiritual care is provided in healthcare facilities by pastors or rabbis sponsored by the institution, it is known as healthcare chaplaincy. This article largely focuses on healthcare chaplaincy because it is the primary way in which contemporary pastoral care becomes involved with the issues of bioethics.

Historically, pastors have extended their care to a wide range of personal needs and concerns, from struggles of faith, doubt, moral failure, and problems of conscience to marriage and family conflict and the suffering involved in illness, tragedy, and death. In Christian care, the historic, ritualized "means of grace"—sacrament, scripture, prayer— continue to be important resources of pastoral care, especially in situations of crisis (e.g., dying). But in many situations conversational methods predominate. Pastoral conversation emphasizes the caregiver's psychological understanding and ability to foster a therapeutic or healing mode of relationship and style of conversation with the person receiving care. This includes empathic listening, the ability to form emotionally honest, trusting relationships, and the care receiver's active participation with the pastor in the search for healing and wholeness. At the root of their care, pastoral caregivers help persons find the kind of faith and value commitments that can sustain, enrich, and give redemptive meaning to their lives, and "to experience as fully as possible the reality of God's presence and love in their lives" (Holst, p. 46).

Pastoral care and healthcare chaplaincy are often distinguished from another ministerial specialization—pastoral counseling. When this distinction is made, pastoral counseling is commonly defined as a specialized form of ministry characterized by an intentional contract between the pastoral caregiver and the person or family seeking help, usually involving a series of prearranged counseling sessions. This structured form of care contrasts with the more casual and varied forms of caring relationships that parish pastors and healthcare chaplains typically form. Though many ministers, priests, rabbis, and healthcare chaplains provide short-term counseling of the more formal kind, pastoral counseling as a specialized ministry is devoted entirely to this work. To a large extent it is a form of psychotherapy or family therapy (and is often called "pastoral psychotherapy"), and usually involves a number of sessions and the payment of a fee. Pastoral counselors, like healthcare chaplains, have specialized training requirements, professional organizations (principally, the American Association of Pastoral Counselors), and standards of certification. They serve on the staffs of larger churches, in pastoral counseling centers, and in other professional settings, and are often licensed by state governments as pastoral (or other) counselors, psychologists, or marriage and family therapists.

Pastoral Care in Healthcare Settings: The Healthcare Chaplain

FUNCTIONS AND ROLE. Much of what healthcare chaplains do involves helping persons and families (of all faiths) with the emotional and spiritual dimensions of the healing process, offering support and therapeutic care in situations of crisis and grief, helping to resolve conflicts and communication difficulties, and consulting in situations of bioethical and other decision making. Most chaplains also develop an extensive ministry with nurses, physicians, aides, administrators, and others in medical settings who carry significant emotional burdens and moral concerns. Chaplains promote communication between patients, families, and staff concerning religious and cultural traditions that may bear upon medical decisions (e.g., concerning blood transfusion, abortion, and the use of life-support technologies). They often become involved in discussions with all parties involved in healthcare decisions. In addition, healthcare chaplains form educational relationships with local clergy and congregations, function as liaisons between the healthcare institution and the community, and serve on the boards of related community organizations. As more and more medical care is provided on an outpatient basis, and as more congregations develop healthcare emphases and programs, these aspects of their work are expected to increase.

Chaplains often play a significant role in hospital ethics committees; in many instances, they helped to organize these committees in the late 1970s and 1980s. The chaplains' role in ethics committees, as in their consulting with patients and families on bioethical decisions, consists largely in promoting good communication and mutual understanding, interpreting religious and cultural traditions, resolving conflicts, clarifying moral issues, and facilitating free and responsible moral decision-making. It is a basic principle of the Association of Professional Chaplains, the National Association of Catholic Chaplains, and similar national certifying organizations that healthcare chaplains respect the belief and value systems of others and refrain from proselytizing or trying to impose their own convictions on them.

Many healthcare institutions sponsor professional training programs in pastoral care called "clinical pastoral education" (C.P.E.). These programs train not only future chaplains in pastoral care, but also large numbers of theological students, pastors, and members of religious orders not seeking specialized ministry certification. C.P.E. students minister under the supervision of a highly trained and certified chaplain supervisor with whom they meet individually and as a group to analyze and reflect on their work. Such reflection involves intense examination of detailed case reports, personal reflection on the trainees' ways of caring for other persons, and consideration of the psychological, social, cultural, theological, and ethical questions involved in their experiences. Pastoral supervision evolved in the second half of the twentieth century into a distinct and important specialization within healthcare chaplaincy.

RELATION OF HEALTHCARE CHAPLAINCY TO OTHER HEALTHCARE PROFESSIONS. Most pastors who serve in healthcare settings hold a broad, liberal understanding of themselves and their ministries that enables them to cooperate easily with the medical profession and to work pastorally with a wide range of persons. They do not limit their ministries to persons with problems that are explicitly defined in religious or moral terms, but seek to become related to persons in supportive and therapeutic ways whatever the immediate, presenting needs or issues may be.

Thus their work often closely resembles, in certain respects, that of psychiatrists, psychologists, psychiatric nurses, social workers, and patient representatives. The chaplain functions as an integral member of the healthcare team. He or she is "cross trained" in a variety of institutionally valuable skills usefully integrated into a single profession: "psychosocial and spiritual counselor, clinical ethicist, patient representative and ombudsperson, cultural anthropologist and religious scholar, gatekeeper of community resources and public relations expert, and health promoter" (Burton, p. 2). But the chaplain's range of competencies also raises questions of vocational distinctiveness and identity for other professionals and sometimes for themselves. The situation is made more challenging by the fact that pastoral identity in healthcare facilities is usually not expressed solely or principally through the performance of religious rituals or conversation confined to overtly religious problems.

What then gives the chaplain's wide-ranging work comprehensive definition and focus? The answer to this question is much debated within the profession. In general, however, pastoral identity in healthcare settings has two intimately related poles of concern: healing and health, and religion (Burton). Chaplains are significantly identified with each. The distinctiveness of the profession lies in the way these two poles interrelate in an ambiguous but creative unity in the performance of the chaplain's professional function.

At one pole there is a concern for and participation in the processes of health and healing. While healthcare chaplains do not practice medicine or psychiatry, they believe that the meanings and values by which people live, and the quality of their personal relationships, play an important role in the organic processes of illness and health. They also believe that a comprehensive concern for human well-being, including health and healing, is integral to the faith traditions they represent. Thus chaplains believe that religion supports the fundamental aims of medicine and healthcare. And they see their ministries as essentially involved in the process of healing, which they understand in comprehensive terms as healing of the whole person—body, mind, and spirit. Consequently, they view themselves as significant members of the healthcare team, and increasingly they are being viewed in that way by the medical professions.

At the other pole, healthcare chaplains are committed to representing religious meanings and values that include but transcend the values of health and healing. They seek to enable people to find and experience, which ultimately can fulfill their lives and redeem them from the threats of meaningless shame, guilt, and death that pervade all of life, in illness as well as in health. And they set health and healing as values into an encompassing faith perspective that affirms the meaningfulness of life whether or not healing occurs. For the healthcare chaplain, this larger context is ultimately rooted in the reality and loving power of God, who makes health possible, but who also makes meaning, hope, and love possible in every circumstance of life, in illness and adversity as well as in health and wholeness.

Thus pastoral identity is bipolar, committed to both healing and religious faith and to their essential interrelationship. It is the ambiguous but disciplined interplay of these polar commitments that constitutes the distinctive orientation of healthcare chaplaincy.

EDUCATION, CERTIFICATION, AND LICENSURE. Nearly all specialized healthcare chaplains today hold college and seminary degrees or have other appropriate theological education, and have been ordained or otherwise endorsed by their religious denominations. Healthcare chaplains are not licensed by state governments, though some who also practice specialized pastoral counseling are licensed as pastoral counselors, psychologists, or marriage and family therapists.

Most full-time, professional healthcare chaplains have trained for their ministries through clinical pastoral education as described above. The C.P.E. certification is sponsored mainly by the Association for Clinical Pastoral Education, the National Association of Catholic Chaplains, the Canadian Association for Pastoral Education, and similar bodies in other countries. In 2002 the Association for Clinical Pastoral Education listed 350 accredited C.P.E. training centers and 600 certified C.P.E. supervisors. Similar organizations and C.P.E. programs exist in Canada and a number of other countries. An international organization closely related to the movement, the International Council for Pastoral Care and Counselling, meets quadrennially.

Various national professional associations also exist for specialized healthcare chaplains, principally the Association of Professional Chaplains, the National Association of Catholic Chaplains, and the National Association of Jewish Chaplains. These organizations set high standards for professional practice that are enforced through rigorous certification and review procedures. A consortium of these and related organizations publishes the Journal of Pastoral Care. There is also a large umbrella organization in the United States and Canada, the Congress on Ministry in Specialized Settings (COMISS), that sponsors joint meetings of pastoral-care organizations.

HISTORY OF HEALTHCARE CHAPLAINCY IN THE UNITED STATES. Hospital chaplaincy, like the hospital itself, had its origin in the ancient and medieval Christian church. The rise of the modern secular hospital in the late nineteenth century, however, was not immediately accompanied by the presence of chaplains as members of hospital staffs. Such pastoral ministry as occurred in secular hospitals was usually provided by retired clergy with no special training for the work beyond general parish experience, often on a voluntary and/or part-time basis. This pattern has continued in some smaller institutions, but today healthcare chaplaincy is fully established as a specialized ministerial profession, and chaplains are employed as regular staff members by most large healthcare institutions.

The turn toward specialized, highly trained, professional healthcare chaplaincy had its roots in the "religion and health" movement early in the twentieth century, in which a positive relation between religion and modern medicine was first seriously explored (Holifield). In the 1920s, this led to the first attempts to train theological students in clinical settings (Thornton). Notable was the groundbreaking work of a physician, William S. Keller, who placed theological students in a general hospital in Cincinnati in 1923, and Anton T. Boisen, a Congregational minister who began what became the "clinical pastoral training movement" with his pioneering program relating religion to mental disorders at Worcester State Hospital in Massachusetts in 1925. Boisen had the key support of two physicians, the distinguished Boston medical educator, Richard C. Cabot, and the progressive superintendent of Worcester State Hospital, William A. Bryan. Soon thereafter another physician, Flanders Dunbar, noted for her research in psychosomatic medicine, became a major leader of the movement. These and other early innovators were convinced that not books but intensive clinical experience—learning to interpret the experience of real human beings, to read the "living human documents" through clinical encounters—held the key to developing a realistic and profound theological understanding of human nature and the art of effective pastoral care (Boisen). The movement developed rapidly in the postwar period, when many training centers were organized, chaplain supervisors certified, and staff chaplaincy positions created in mental and general hospitals.

Clinical pastoral education was seldom undertaken in congregational settings, partly for pedagogical and practical reasons related to the abundance of pastoral opportunities in hospitals, and partly for financial reasons—hospitals were better able to pay for these programs than churches or seminaries. Most programs were sponsored by hospitals, and C.P.E. programs remained largely unrelated to the formal curricula of the theological seminaries until the late 1950s and 1960s. C.P.E. thus acquired a somewhat nonecclesiastical, "secular" style and appearance, and there has always been a concern that C.P.E. students would develop a confused professional identity as a result of C.P.E.'s close ties to the medical establishment.

Medical institutions still comprise the vast majority of C.P.E. training centers. Today, however, C.P.E. is widely embraced by the "mainline" Protestant and Catholic churches, and C.P.E. programs are a common, and often required, component of Protestant, Catholic, and some Jewish theological education. Healthcare chaplaincy itself is similarly established as a highly specialized, professionally trained and certified form of ministerial practice. Most hospital administrations require staff chaplains to have completed a year or more of C.P.E. or its equivalent. The Association of Professional Chaplains, the National Association of Catholic Chaplains, and similar organizations require C.P.E. in their certification standards.

Philosophical and Cultural Orientations

RELATION OF RELIGION AND HEALTH. The high degree of professional cooperation existing today between pastoral caregivers and medical professionals represents a remarkable and relatively recent development in both medicine and religion. In ancient and medieval times medicine and religion often enjoyed a close relationship; healing rites, exorcisms, pilgrimages, and health cults flourished. But with the Protestant Reformation and the later rise of modern science and scientific medicine, Christian ministry began a long retreat from its tradition of involvement in healing, and theology grew increasingly wary of making scientific, empirical claims about the natural world. An intellectual and professional schism between religion and medicine resulted. As medicine became scientific and ministry became con-fined to matters of God and the soul, corresponding spheres of professional influence were delineated: physicians cared (scientifically) for the body; clergy cared (spiritually) for the soul. Medical science assigned mental and emotional disorders, traditionally considered problems of the soul, to the body as organically caused, and regarded them as at least potentially treatable by physical (i.e., medical) means.

With the development of dynamic psychiatry and the religion and health movement in the early twentieth century, such distinctions began to blur. Psychoanalysis and related developments in psychiatry revealed psychogenic factors in many psychiatric disorders, while empirical studies in psychosomatic medicine demonstrated the profound effects of emotional and spiritual attitudes on physical health and healing. At the same time, theology began to recover biblical, holistic conceptions of human personhood, salvation, and the healing potential of religious ministry. In this theology the welfare of the whole person, physical, mental, and spiritual, was regarded as a profound unity. The result was a gradual closing of the theoretical gap between medicine and religion and the emergence of a more collaborative style of work between physicians and pastoral caregivers.

INFLUENCE OF THERAPEUTIC PSYCHOLOGY. Prior to the twentieth century, pastoral care was dominantly concerned with problems that could be clearly or outwardly identified as religious and moral in nature or as having religious significance, such as faith, doubt, sin, repentance, and the mysteries of suffering, illness, death, and dying. Contemporary pastoral care, however, at least as practiced in the larger Christian denominations (sectarian churches being the usual exception), holds to broader conceptions of Christian ministry, human welfare, and the meaning of salvation. In these traditions, physical welfare and emotional health play prominent parts in the overall meaning of salvation; ministry's sphere of concern includes the total health and welfare of persons and families in this world. Often this understanding gives prominence to psychology as an adjunctive discipline, and ministry acquires a distinctly psychotherapeutic style and orientation. This has been especially evident in the mainline Protestant denominations, but it is increasingly true of Roman Catholic and some conservative Protestant traditions. Judaism has historically emphasized the values of human health and welfare.

This therapeutic style of ministry has important ethical and professional consequences. Typically, it seeks to broaden moral discussion in healthcare settings from a focus on the content of moral decisions—what to do—to a focus on the process and quality of the decision making itself. Healthcare chaplains try to foster the psychological conditions that will facilitate free and responsible moral judgment and decision. These conditions include relationships of trust that permit open, honest communication among all parties concerning feelings as well as ideas and opinions. Though facilitating such conditions is not usually thought of as a form of moral guidance, it obviously has important moral value. Some pastoral authorities, however, while affirming this approach, have also urged pastoral caregivers to engage the substantive questions of ethics more directly in their caring ministries (Browning, 1976, 1983; Carnes).

AFFINITIES WITH SITUATION ETHICS AND CHARACTER ETHICS. Pastoral care, including healthcare chaplaincy, has not been highly articulate concerning the traditions of philosophical and theological ethics out of which it has operated (Carnes). Most pastoral theologians have concentrated instead on theological questions of human nature and the relation of religion to health (Browning, 1983; Holifield). However, much of the informal ethical reflection in the field has probably been influenced chiefly by some form of situation ethics. Situation ethics holds that fixed laws and rules are inadequate for moral decision making; decisions must be reached through a careful assessment of the particulars of each situation, guided by very general principles such as love, justice, and responsibility. Pastors with therapeutic training often exemplify this orientation since they tend to be concerned more about the specifics of situations than the application of abstract moral rules and principles (Poling, 1984b). Their typical ethical question is likely to be: "What is the appropriate, responsible, loving, or just thing to do in this situation, given its many complexities and dynamics?"

Pastoral care also has a close affinity with what is called the "ethics of character and virtue," though this connection is seldom recognized (Poling, 1984a). Conceptions of personality implicit in therapeutic psychology often function as secular character ideals within pastoral care. For example, healthcare chaplains commonly assume that psychological self-knowledge and the ability to experience oneself and others fully, without the distorting effects of emotional defensiveness, is desirable not only as an aspect of mental health but as a moral good—as a basis for free and responsible moral action. In many situations, as a matter of principle, healthcare chaplains are therefore likely to be as concerned about the emotional health and maturity of the persons exercising moral judgment as about the decisions they reach. This commitment to an ethic of character and virtue thus easily complements the field's general tendency to support situational or contextual forms of ethical reasoning.

RELATION OF THEORY AND PRACTICE. Many of the ways pastors have ministered to troubled and suffering persons over the centuries may be regarded as a practical implementation of the ethical principles of the pastors' religious communities and traditions. Practice has tended to follow theory, "applying" it.

But human needs and problems do not always fit neatly into prescribed categories and practices, and social and cultural forces change over time; contemporary problems of bioethics provide many cases in point. In such situations, pastoral care cannot operate as a straightforward application of established moral theories and principles. Conscientious improvising becomes necessary, especially in times of rapid social, cultural, and technological change.

Thus moral theory does not always easily or clearly guide practice; in fact, to some degree it reflects practice and is changed by practice. To this extent pastoral care, over time and in concert with other social and cultural factors, gradually helps moral theory to evolve. The Jewish responsa literature, representing the accumulated moral debates and evolving traditions of Judaism's encounter with novel problems over many centuries, provides massive evidence of this process in one tradition (Meier). A similar process, though often less explicit and legally constructed, has occurred in Christian pastoral care (Browning, 1976). This can be seen in changing contemporary pastoral attitudes in the mainstream Protestant churches on issues like divorce, remarriage, abortion, and artificial life support. Pastoral caregiving is thus culturally innovative as well as conservative, and represents (as Browning argues) a practical form of "moral inquiry."

Issues in Healthcare Chaplaincy

Like other health-oriented professions, healthcare chaplaincy faces a number of challenges as the technology and institutional forms of healthcare undergo rapid and extensive developments. Four major contemporary challenges may be noted:

  1. Multiculturalism and minority concerns constitute an increasingly visible and important feature of the social landscape in which healthcare chaplaincy functions. This fact presents novel professional issues for healthcare chaplaincy. Today's hospital chaplains must understand a growing range of religious and ethnic cultures and find ways of relating their ministries with appropriateness and integrity to persons with religious faiths and social customs different from their own. They must also be able to help persons of non-Western cultural and religious traditions relate to the social values and practices of advanced Western healthcare facilities.
  2. The overlap of professional roles in contemporary healthcare settings intensifies the problem of defining the healthcare chaplain's pastoral identity. This question is becoming urgent. As institutional budget pressures increase, many healthcare chaplains and pastoral departments have been forced to define their identities and defend the value of their ministries to healthcare administrators, often in quantifiable, cost-benefit terms alien to the traditional meanings and purposes of ministry.
  3. How (in theory or practice) can chaplains maintain an institutionally appropriate neutrality yet remain significantly committed to their traditions of faith? Focusing on process rather than content in moral decision making, and maintaining an institutionally proper value-neutral stance on specific questions, are clearly helpful in this regard. But such public neutrality may beg important questions. Is there any way for ethical commitments and insights of particular religious traditions to contribute to contemporary moral reflection in institutional decision-making and policy formation? How can healthcare chaplains represent their traditions without imposing themselves inappropriately on others or abusing their institutional positions?
  4. Healthcare chaplains are being drawn into discussions of healthcare policy in their institutions and in the larger society. This expanded arena offers new opportunities to witness to their moral and spiritual commitments, by questioning unjust policies and practices and advocating the rights of the poor, for example. But it also raises difficult questions. How far and in what way—if at all—should healthcare chaplains develop this expression of their ethical integrity in place of, or in addition to, their work of holistic healing, care and compassion?

rodney j. hunter (1995)

revised by author

SEE ALSO: Beneficence; Care; Compassionate Love; Death: Western Religious Thought; Grief and Bereavement; Mental Health: Meaning of Mental Health; Teams, Healthcare; Trust; Value and Valuation


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