The Creative Tensions in Spiritual Care, circa 2018

May-June 2018


hp1805 Creative Tensions in Spiritual Care circa 2018_a
Illustration by: Curtis Parker

Every professional field that takes its own growth seriously will face ongoing tensions in confronting change, succeeding and learning, failing and learning, and grappling with what's essential versus what's negotiable.

What are the key tensions for spiritual care? The goal is not to pick sides or resolve the tensions, but rather to lift up these poles so that we may elicit creativity and clear thinking between (and within) them.

A different chaplain leader with a different experience, situated differently in terms of power structures, would come up with a different list. I hope this list spurs those lists and that our mutual discernment brings us into rich conversations. As is the hope we bring to each encounter with those we serve, may clarity beget clarity.

Supporting patients is in tension with supporting staff.

With only so many minutes in an hour, how do we know where to direct our care?

Care for those who are vulnerable is our core commitment, but does that mean just patients? Some systems dedicate certain chaplains exclusively to staff care. Most trust that staff care will happen "around the edges" of care for patients and their loved ones. Nearly all of us know the best referrals come from staff who have themselves benefitted from some form of spiritual care.

How do we as chaplains want our contributions measured? In terms of clinical service (that is, patient experience) or business function (employee retention and well-being)?

What risk do we take if we provide "whatever care is needed most" without referring to organizational goals?

When we do engage staff, is it better to address compassion fatigue or to build compassion satisfaction? And in both, what does it look like to prevent burnout in others without risking burnout in ourselves?

Using research to prove that we make a difference is in tension with using research to improve how we make a difference.

The thoughtful application of research is a new given for spiritual care. But where should those who undertake the creation of that research focus?

Can we find the resources to do investigations that both prove and improve our impact? Within that tension, is it wiser to study the generalized ways that spiritual care can help all patients, or the particular ways spiritual care can help specific populations with specific diagnoses or situations?

Finally, is our field better served by research focusing on spiritual distress, on spiritual health or just broadly on spirituality and human flourishing?

Impacting psychosocial health determinants is in tension with impacting physical health determinants is in tension with discovering and responding to spiritual health determinants.

How comprehensive is the focus of our ministries?

We know there are layers of impacts to healing; how broad is our attention?

Do we attend to how spirituality is embedded in psychosocial health through coping, resilience and connectedness? Or do we need to show that attending to the spiritual makes real differences in how people experience the physical? Finally, what are the big and small material, societal and cultural factors that determine someone's spiritual health?

Would the care we provide change if we could document all of the above?

Building resilience in individuals and teams is in tension with transforming the environments that threaten resilience in the first place.

What is the right balance between working individually to help people survive in difficult, unhealthy environments and working systemically to change those environments so they aren't difficult or unhealthy anymore?

This can apply for patients in communities just as well as for associates in work settings. In other contexts, this might be called the creative "both/and" tension between charity and justice. To what is spiritual care called?

Historical professional boundaries and "termination" at the end of an acute episode is in tension with new settings and methods for delivering care and the extended boundaries of pastoral care.

Another new given for spiritual care is how we are providing that care outside the acute-care setting – in outpatient clinics and doctors' offices, via phone or video, text or email. How does that opportunity to serve affect a ministry that traditionally ends at the close of the inpatient portion of an acute care episode?

We believe we can reduce readmissions as well as suffering, increase healthy days and patient activation as well as resilience and meaning-making. Can we still afford to focus on the sea of need within acute care, once we're aware of the sea of need outside acute-care settings?

Does the capacity that these new settings and technologies give us to prevent the spiritual distress that ordinarily would occur only when someone comes into an acute-care setting also open us to offering non-health-related ritual and spiritual care? What chaplain hasn't been asked to officiate at a funeral, then a wedding, then a child blessing?

All these strategic tensions pull at some core identity tensions, as well.

Filling a gap for people who identify with a religious affiliation (addressing the short-term spiritual dimensions of illness) is in tension with filling in a perceived gap for the "none of the aboves" (meeting the ritual and meaning-making needs of those with no other institution they bring those needs to) is in tension with interacting with people as if their affiliations don't affect what we do.

Some say chaplains are de facto pastors for the "unchurched." Others say we are a supplement to what people can get in their own faith institutions. Are we "spiritual paramedics" that scoop and stabilize and deliver to care?

Are we a way station until people connect to resources outside of us?

Are we a well that anyone can come to when he or she is spiritually thirsty?

For those we serve who do have a religious affiliation, what happens when a person has a more meaningful connection with a chaplain than with her or his clergyperson? Do we fulfill these persons' requests at the risk of distancing them from their local religious leader?

Does denying those requests point them to spiritual isolation or distress?

Serving as a subspecialty of medical personnel with spiritual training is in tension with serving as a subspecialty of religious personnel with medical familiarity.

Where is the center of gravity for our identity?

Is there just one?

Can it shift in a way that doesn't feel like either displacement or abandonment?

If it does shift, does that mean loss, gain or both?

Perhaps more than any other, this tension has corollary tensions: Becoming an evidence-based profession is in tension with doubling down on being story catchers because "God is not a number."

Being a unified field with shared standards and processes is in tension with being a diversified field best served by different professional organizations and procedures.

Prioritizing the professionalization of our field as "spiritual specialists" is in tension with prioritizing the training of our interdisciplinary colleagues as "spiritual generalists" is in tension with committing to both of those.

Being a cost center is in tension with being a revenue generator is in tension with being a revenue multiplier is in tension with being a cost reducer or value enhancer.

Health care is a mission. Health care is a business. The truth of each statement does not negate the truth of the other. Does the call for spiritual care look different in health care as mission than it does in health care as business? Does our response as a field?

Amid increasing financial scrutiny, how might we best position ourselves?

Are we simply a cost center, but one that is essential to the mission and therefore should be funded — and if so, funded to what level?

Are we a potential revenue generator by providing resources to our organizations outside of the acute space or by contracting to sell our services to outside partners?

Are we a revenue multiplier by supporting activities like staff support or advance care planning for which we get paid (or could get paid), but offering them more efficiently?

Or in the current environment of risk contracts, do we lower the overall cost of care by helping people heal more completely, in less resource-intensive settings, or in ways that enhance overall wellness?

The answers involve us continuing, of course, to serve face to face but also through technology (phone, video, email, text). How do we train current and future chaplains to unleash their timeless skills, no matter what cutting-edge tech it is through?

Finally how does the space we occupy in this multipart creative tension enable or inhibit our advocacy for more chaplains to join our number in service of our mission?

What clarity does this brief offering beget for you?

There are numerous other concerns that mirror tensions already existing in our culture (such as racism, sexism, classism, ableism, heterosexism, thanatophobia, etc.) that are not named here precisely because they are not unique to spiritual care. But one demands mention because of its capacity to make or break our ability to serve all God's people. Put broadly: How do we approach diversity and unity across culture, gender, social class, religious tradition and all the other differences we hold in tension with our unity?

As just one significant implication of that challenge, what is our response to the fact that current forms of chaplain training privilege those whose circumstances or traditions make it possible to get a master's degree?

It takes major risks of both time and money to get educated, trained and certified. Is our field willing to take risks to enable the fullness of those who hear the Divine's call to this work, or are we content to look like we've always looked?

As chaplains, we're called to name the dynamic, speak the truth in love and open all eyes to look for opportunities for healing — in all its forms. What does that rich conversation need to sound like where you are?

ZAC M. WILLETTE is a board-certified chaplain and system director for spiritual care and mission integration, Ascension Healthcare, St. Louis.


Copyright © 2018 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

The Creative Tensions in Spiritual Care circa 2018

Copyright © 2018 by the Catholic Health Association of the United States

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