The Place of Spirituality in Managed Care

January-February 1997


Attending to Spiritual Needs Can Help Managed Care Systems Achieve Their Goals

Dr. Hilsman is a clinical pastoral education supervisor at St. Joseph Medical Center, Tacoma, WA.


If managed care leaders are to achieve their goals of enhancing total well-being within a capitated system of care, they must attend to the broad new societal interest in spiritual perspectives and find ways to integrate them into their structures of care. Imaginative and sensitive members of many professions, particularly those who acknowledge the value of spirituality in their own lives and are convinced of its value in healing, will likely spearhead this integrative movement.

Promoting individuals' total well-being necessitates an acknowledgment that everyone has a unique personal spirituality that needs to be addressed at times of crisis, such as illness or hospitalization. Further, attention to the spiritual dimensions of problems that result in high healthcare costs, such as violence, alcoholism, and the fear of death, can help reduce those costs. The process of grief also needs to be addressed in healthcare settings, for professionals as well as patients, to enhance understanding, acceptance, and the quality of care.

People recover and retain health through a balanced integration of physical, spiritual, and community aspects of their lives. If professional chaplains who have emphasized crisis and acute care in their ministry styles are to contribute to this integrative healing and its adoption into managed care systems, they may need to explore broader frameworks, holistic concepts of healing processes, motivations for self-care, and a personal holistic balance.

Hospital administrators and chaplains generally have very different perspectives on healthcare. While administrators concern themselves with the material means to achieve efficient medical care, chaplains focus on the spiritual needs of hospitalized patients. Yet two current societal movements—the trend toward managed care and society's resurgent interest in spiritual expression—are challenging these professionals to understand the other's domain and work together for the good of the patient.

Administrators need to be interested in the spiritual renaissance because patients' spiritual experiences are likely to influence outcomes of treatment. To cost-conscious executives, spiritual care resources can easily appear peripheral to the basic work of the organization. But if wellness is valued for its financial benefit, the question of how spiritual perspectives relate to wellness becomes more central, and administrators may discover hidden gold mines in competent spiritual care providers who emphasize preventive care and total physical and spiritual well-being.

On the other hand, chaplains need to pay attention to the managed care movement because it challenges established patterns of organizational ministry, requiring it to contribute to holistic healthcare objectives. Just as physicians must adjust to the loss of a practice style that attracted them to medicine and has supported them reasonably well, and nurses must cope with more complex work and reduced staffs, clinical ministers must reexamine their practice, fashion imaginative approaches, and learn new skills that help achieve emerging healthcare objectives.1

Underpinnings of Collaboration
Managed care challenges administrators and spiritual practitioners to contribute to an integrated effort to promote the total well-being of individuals. The question is, Can they successfully collaborate? Several core beliefs may form the basis of a philosophy to underpin such cooperation.

People who enjoy a high degree of total well-being generally utilize fewer healthcare resources over their life spans than those who do not. This statement forms the basis of managed care objectives such as keeping people healthy and out of inpatient hospital units. It is reasonable to believe that people who are happy and fulfilled in important aspects of their lives will seek less medical attention. Many physicians acknowledge that a high percentage of their patients—perhaps as many as 80 percent—have nonmedical dimensions to the symptoms for which they seek medical treatment. Some physicians wonder whether less costly and more appropriate forms of care are available for personal problems that have medical manifestations.

The question of prevention naturally involves how to help people do what they can to influence their own well-being. But who decides what well-being is? Physicians? Nurses? Church leaders? Insurance companies? Researchers? Or should the definition be based on the personal and professional experiences of all these professionals? In both formal and informal ways this is already happening in various places. Commonly outside of or parallel to established structures of medical care, physicians, nurses, chaplains, and other professionals convinced of the need to attend to the personal aspects of healing processes are collaborating to find ways to integrate holistic perspectives into units of care.

Total well-being means a combination of relative vigor in bodily functioning, resilience in emotional self-care, satisfaction in social contexts, and fulfillment in the spiritual arenas of life. This is one way of stating a holistic view of people. Holistic practitioners believe that people feel better when their relationships and the major factors in their lives are going well. A physical problem generally throws an individual's feelings of well-being out of balance. But problems in other significant arenas of life may manifest themselves in the body, and thus mislead medical practitioners who focus on biological symptoms and treatment.

Jungian analyst Thomas Moore argues convincingly that, although we have known of a mind-body relationship for a long time, we cannot successfully integrate the two until we focus more vigorously on the soul.2 Competent spiritual caregivers believe that attending to the concerns of a person's inner life, when combined with the established regimens of medical diagnosis and treatment, is likely to increase patient satisfaction and motivation for self-care, as well as unlock personal energy to enhance healing from the medical complaint. There is a growing body of research to support this idea, appreciated by professional chaplains and also by an increasing number of other professionals.3

Our current healthcare system has been fashioned from a body-oriented perspective. Psychological problems are dealt with separately, and social and spiritual practitioners are seen as marginal to the main focus of care. Entire professions have developed from the different perspectives of social systems, spiritual dynamics, psychological theories, and specialized medical practices.

Will managed care succeed in encouraging greater collaboration centered on the person rather than the practices of specialized professionals? Is there an integrative perspective that could help keep the focus on an individual's needs and concerns rather than on the diagnostic and treatment habits and structures of a burgeoning healthcare system? If so, qualified spiritual caregivers, from any profession, will be at the heart of that new perspective.

The spiritual component of total well-being refers to a developed capacity to negotiate the limitations of life and find richness and meaning in those aspects of life we cannot control. This definition of spirituality is offered for its applicability to managed care. It emphasizes the fact that our control of our lives is limited, and that there are clearly powers greater than the human. A perennial theme of human history consists of the myriad words, practices, symbols, and beliefs people have adopted throughout the centuries to help them deal with the fact that life is inherently mysterious and can only be influenced rather than controlled by our considerable power. Everyone develops a set of responses to the unpredictable and uncontrollable aspects of reality, or, in other words, a unique personal spirituality.

The profession of hospital chaplaincy has evolved in this country during the twentieth century as clergy have attended to the spiritual needs of people while they are in the midst of major life crises and facing their own personal limits. As a profession, however, chaplaincy remains little understood by most other clinical practitioners. It lacks the highly religious orientation of some parish clergy, which can be either a support to healing processes or a moralistic, discouraging influence. Using broad perspectives of spiritual care, professional (as distinct from denominational) chaplains are clinicians in their own right, although, as in any profession, their skills vary considerably. The clinical pastoral education movement, which is about 70 years old, trains professional clergy who are highly skilled in integrating the behavioral sciences with theological perspectives and accustomed to exploring their own religious and spiritual convictions. Theologically educated in many different religious denominations, all are clinically skilled at addressing the personal and spiritual concerns of diverse groups of patients, and in teaching others similar skills.

People seek medical attention when they are confronted with the limitations of life and their own self-care, thus making outpatient care or hospitalization a spiritual challenge. This does not mean that all patients need professional spiritual assistance, but it does suggest that a spiritual perspective on any patient's care is likely to be useful. Any problem significant enough to warrant healthcare will test a person's established methods of coping with the spiritual aspects of life. But a spiritual perspective is seldom taken seriously in considering treatment decisions. Openly dealing with the diversity of deeply held values among staff members themselves is too intimate for the professional setting, and thus the spiritual perspective is shunted off to a few nurses or doctors, the chaplaincy staff, or even parish clergy, who may be disconnected from the healthcare system.

Many people seek control over uncontrollable—that is, spiritually linked—aspects of life through chemical addiction, violence, or by prolonging medical efforts when it is futile to do so. A significant portion of healthcare costs in our society is spent dealing with the consequences of addiction, violence, and the fear of death. If managed care programs do not address the spiritual dimensions of these underlying causes of high healthcare costs, we will continue to treat medically symptoms of illnesses and conditions that require completely different forms of care. Alcoholism treatment centers emerged from a failure of healthcare systems to deal with the inscrutable character of addiction.4 Those involved in battered-women and child-abuse cases know how unsuited hospitals and doctors' clinics are to address domestic violence. And the entire hospice movement emerged as a consequence of the difficulty highly technical healthcare institutions had dealing sensitively with the natural phenomenon of dying.5

Integrating spiritual perspectives into all levels of care, although it is difficult and may threaten control-oriented medical professions, may be the only way to meet the complex treatment challenges posed by spiritually rooted behaviors that have costly medical consequences.

Effective self-care and shorter recovery times are directly linked to positive self-esteem, strong connections with friends and family, a satisfying social and community life, and a positive regard for transcendent forces. These are not factors on which traditional, science-based medical treatment can have much effect. Some may be addressed by psychological therapies, but the spiritual component cannot be ignored. Preventive care and shorter recovery times are goals of managed care; spiritual care can help achieve these goals.

Self-esteem, relationships, community values, and positive impressions of transcendence can be influenced by affective, experiential education. The "values-free" tradition in psychology, research, and public education that began in the 1940s,6 and some church leaders' manipulation of people when spiritually vulnerable, have made it difficult, if not nearly taboo, to publicly address the personal and spiritual aspects of well-being. In a capitated system, however, adults can benefit from involvement in the discussion, support, and education that facilitated group interaction can foster. Skilled, knowledgeable, and empathic educators, sensitive to the unpredictable and incomprehensible nature of everyday life, can foster insight and growth in groups of people exploring their own health and living issues.

One hospital department in Tacoma, WA, for example, held five one-hour small-group sessions for participants to discuss their physical, emotional, and educational well-being and their history of relating to a religion and to transcendent forces. They later reported expanded understanding of one another and greater energy for collaborative efforts.

Managed care structures should include incentives for individuals to avail themselves of similar educational opportunities. Spiritual caregivers, who are appropriate leaders in this work, must be capable of facilitating such group sharing and individual self-exploration.

Healthcare costs could be reduced by attending to individuals' unresolved grief and degree of acceptance of their own mortality. Experienced helpers in many disciplines know that the art of teasing out the specific feelings, memories, and meanings associated with a major life loss—that is, facilitating the grieving process—frees energy in a person. Healthcare clinicians in general, however, may not attend as carefully to the process of grief. A nurse educator once told me that she had taught about the grieving process for years, but only when her own baby died did she begin to understand grief on any useful level. Loss and grief are universal experiences that give us the opportunity to emerge with enhanced wisdom, but the process of grief requires time and active sharing with empathic and patient people.7

Most healthcare structures, policies, procedures, and workloads are not set up to foster such care or even tolerate it to any great degree. Professional staff members share their own losses among themselves only briefly, if at all. As managed care structures come to value total well-being more, their convictions must be strong enough to invest in structures that will help patients and staff deal healthfully with their losses.

Our acceptance of our own mortality comes from how we deal with personal experiences of loss, and from open conversations about what has meaning for us in life. Managed care systems would benefit by fostering the spiritual health of all their workers. Clinical practitioners dealing with patients who are terminally ill are often upset or burdened by instructions from the family to "do everything possible." Yet in-house ethics committees generally focus on decisions regarding treatment, not on allowing staff members to express their own feelings. The opportunity to speak with neutral counselors is all too rare. The space and time to talk about their own feelings of loss would help healthcare professionals care more compassionately and effectively for the dying and their families.

Healing is a communal, as well as a personal, phenomenon. Optimum healing requires a collaboration of professions, systems, agencies, and congregations. The reason helping professions are needed at all is that a combination of efforts can achieve more healing than individual attempts. The success of communal healing phenomena such as Alcoholics Anonymous and its dozens of clones demonstrates that healing happens when people overcome the barriers to addressing personal issues with others. Both administrative and spiritual care professionals need to conceive of healing as community wide and deeply personal at the same time.


  1. Gordon J. Hilsman, "Competencies of the New (and Some Old) Spiritual Care Work," Caregiver Journal, Summer 1996.
  2. Thomas Moore, Care of the Soul: A Guide to Cultivating Depth and Sacredness in Everyday Life, Harper Collins, San Francisco, 1992, p. xiii.
  3. Larry Dossey, Healing Words: The Power of Prayer and the Practice of Medicine, Harper San Francisco, San Francisco, 1993; Larry Dossey, Recovering the Soul: A Scientific and Spiritual Search, Bantam New Age Books, New York City, 1989.
  4. Damian McElrath, Hazelden: A Spiritual Odyssey, Hazelden, Center City, MN, 1987; Ernest Kurtz, Not God: A History of Alcoholics Anonymous, Hazelden, Center City, MN, 1976.
  5. Sandol Stoddard, The Hospice Movement: A Better Way of Caring for the Dying, Vantage Books, New York City, 1992.
  6. Mary Vander Goot, Narrating Psychology: Or How Psychology Gets Made, Wyndham Hall Press, Bristol, IN, 1987.
  7. C. Margaret Hall, "Crisis as Opportunity for Growth," Journal of Religion and Health, Spring 1986, pp. 8-17.


Copyright © 1997 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

The Place of Spirituality in Managed Care

Copyright © 1997 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.