This is the 2nd and final part of a two part series on chaplaincy.
Last week I began to look at chaplaincy in the UK’s publicly funded National Health Service (NHS) as a profession that brings religion and science together in particularly interesting and challenging ways. The NHS requires the treatments it offers to be based on evidence of efficacy, a requirement that presses in on chaplaincy.
It is clear that chaplaincy has moved far from the stereotype of a male priest administering blessings to church members in hospital. In our postmodern and relativistic times, chaplaincy can no longer be assumed to be a good in itself. Increasingly people focus on spirituality but do not necessarily have any particular or strong religious affiliation. Chaplains have to find ways of making space for different narratives and of offering something for those who have no particular belief or do not belong to a faith community.
Chapter 5 of Paul Lample’s Revelation and Social Reality (2009, Palabra Publications) is strikingly useful in helping to clarify some of the issues in the philosophy of knowledge that postmodernism raises for chaplains as they cope with the relativistic world of the 21st century. Lample uses the terminology of “foundational” and “nonfoundational” approaches to knowledge as the basis on which to develop a Bahá’í approach to the problem of knowledge that may point towards ways of transcending the “religion vs science” dichotomy – a dichotomy which may turn out to be false.
So what does this mean in practice?
Two stories may help to illustrate some of the practicalities of healthcare chaplaincy. Careful reading of the stories will highlight all the elements highlighted by Paul Lample – language, justification, intersubjective agreement and relations of power.
A chaplaincy team leader regaled one of our groups of Bahá’ís training for NHS chaplaincy with a story from one of her hospitals. An elderly female patient had become deeply distressed, crying inconsolably. None of the nurses on the ward could figure out why the tears and distress, so they sent for the chaplain. The chaplain arrived on the ward and went to the patient’s bed.
The chaplain (also a woman) talked quietly with the distressed old lady, calmed her down and asked what was the matter.
It seems that a senior doctor (known in the UK as a “consultant”) on his ward round had discussed the old lady’s case across her bed with a more junior physician. The doctors had made no attempt to bring the patient into the consultation. The old lady had not been able to make sense of what they were saying, but had picked up some words that led her to believe that the doctors considered she was not long for this world.
She panicked and threw the ward staff, who were unaware of the content of the conversation between the two doctors, into confusion.
It took the chaplain, with her knowledge of people’s spiritual needs and her training in communicating with people at times of difficulty, to find out what was really troubling the patient, to check with the doctors what they had actually said, and to reassure the patient that death was not actually waiting at the bedside.
Another chaplain, the Head of Chaplaincy at a large city hospital in the north of England, told some of our trainees about the time he had been called to Accident and Emergency. One of the nurses pointed towards a cubicle.
“The patient in there has asked to see the chaplain,” she said.
The chaplain went over to the cubicle and peered in through the window in the cubicle door. Inside, sitting on the treatment couch was a large, tough-looking man, shaven-headed, tattooed, looking ready for a punch-up.
The chaplain thought about all the other places he’d rather be at that particular moment, but he screwed up his courage and, expecting the worst , went in through the door. “Hello,” he said, “I’m the chaplain. Do you want to talk?”
The patient looked at him, grabbed his hand and burst into tears.
Not knowing how to respond, the chaplain sat while the man cried, calmed and began to talk. He was, as he looked, the tough guy, always in control, never at anyone’s mercy. But injured and in the strange environment of a hospital’s emergency room he was no longer in control. His life was in other people’s hands and this was an unsettling, even frightening experience for him.
In these two instances the medical staff had neither time nor training to deal with what were not medical problems. The patients, as are so many who find themselves in hospital, were suddenly faced with existential questions, questions about who they were, what was the purpose of their life, where were they going to?
In both situations, the chaplains acted to achieve intersubjective agreement with the patient about what the objective situation was and what their existential fears were. In both cases, the chaplains’ relative powerlessness and, in the latter case, vulnerability allowed them to come alongside the patients and to mediate between the patients and the complexities and power structure of the hospital.
How is the impact of these kinds of chaplaincy intervention to be measured? No X-Ray is able to show a broken heart and no fMRI scan can show what it is like to be searching for the meaning of suffering. It may seem that to demand that chaplains produce evidence of the efficacy of their work is to demand the impossible.
Definitions of spirituality
To begin to see how to measure the efficacy of spiritual care (if that’s what chaplains are understood to offer), it may be important to try to define spirituality. But this is not a simple matter. Mowat (2008) cites the thinking of sociologist Dr Tony Walter (Walter, T, “Spirituality in palliative care: opportunity or burden?” Palliative Medicine 16, 2, 2002, pp. 133-139):
He wonders, as a sociologist, why there is such a focus on defining spirituality. He offers three explanations. Firstly spirituality and the work of defining it represents a critique of scientific reductionism and church establishment. Spirituality is a concept that cannot be reduced to that which is easily measurable. Whilst this is a problem, as we have discussed, for evidence based practice, it is also a statement that some aspects of human suffering and experience are immeasurable. As a society, he suggests, we have to decide whether the immeasurable is also the unimportant. Secondly he advances the view that the attempt to separate religion from spirituality is an attempt to challenge religion and established church institutions. This reflects a societal mistrust of institutions. (Mowat 2008:34)
In her review of the research literature about chaplaincy, Mowat came across a small-scale phenomenological study undertaken by a UK chaplain, Michael Wright, on the essence of spiritual care. Amongst other things, each of the 16 respondents in the study was asked what they understood by the word “spirituality”. Wright tabulated the responses and identified his respondents’ transcendent understanding or spirituality, “reaching beyond and within the self and the capacity to search for meaning by addressing the big questions of life and death.” (Mowat 2008:34).
Mowat considers that Wright’s conclusions are relevant for chaplains.
He notes that spirituality incorporates intangible and immeasurable features that contrast with the “high-tech” physical care which dominates hospital life.…
He concludes by noting that the lived experience of those interviewed is founded on the belief that all humans are spiritual beings. He expresses the hope that more research can be carried out perhaps using the opportunity of the investment in new information systems on patient spirituality and religious affiliation. (Mowat 2008:35, emphasis added)
How to measure chaplaincy?
It looks as if the efficacy of what might be considered the real work of chaplains could be impossible to measure.
However, chaplaincy is being increasingly professionalised and is having to compete for funding and recognition in an NHS that is under political pressure to reduce public expenditure. In these circumstances chaplains have to find finding ways of demonstrating that their work is efficacious – for example, by helping reduce the length of hospital stays or the need for pain-relieving medication, or by improving the experience that patients have during their hospital stay – and explaining this to those who hold the purse strings. As Mowat says:
Healthcare chaplains are being asked to show that what they do results in desired outcomes for those they work for i.e. patients, families, staff, organisation, community. This requirement is linked to resource allocation. The question is how does healthcare chaplaincy expedite the healthcare journey for those who are recipients and providers of health care.
Healthcare chaplains are currently unlikely to be able to provide evidence based on the typical gold standard approach. Research that intends to show that an intervention or practice “works” has to produce some outcomes against which to measure the intervention or practice. If the work of the chaplain or spiritual care giver is to be shown to be useful it must show that some agreed and valued outcome is achieved. The problem for healthcare chaplaincy and spiritual care is that outcomes may not
a) be visible
b) be measurable
c) be available in the timescale of the “typical” research project
d) be agreed by all parties
e) be static over time
This does not mean that healthcare chaplaincy practice is not valued or valuable but it does mean that it may be difficult to demonstrate immediate outcomes. A good outcome in a health service is, arguably, to either resolve the health problem which has presented or provide care for those whose health problem cannot be resolved. A good outcome contributes to wellbeing. At times the good outcome causes some distress and anxiety before it is achieved, for instance cessation of smoking or changes in diet and exercise.
The healthcare chaplains or spiritual carers understanding of a “good” outcome will be just as complex given the theological understanding of suffering and ill health. A good outcome for spiritual growth and comfort might be an act of forgiveness which in its process causes great distress and anxiety. In common with other healthcare professions, the outcomes for chaplaincy may not be immediately measurable and have a more long term ripple effect.
There is a complexity in establishing outcome measures for healthcare chaplaincy. This is reflected in corresponding lack of intervention research currently carried out. Currently studies tend to focus on the process of chaplaincy rather than the outcome. (Mowat 2008:21–220
It is not my purpose here to give definitive answers to the questions raised by the need to justify the practice of chaplaincy and its funding from the public purse. The issues raised are too complex to be satisfactorily addressed in a relatively short space such as this post. But I do want to indicate that this is an area in which there is a nexus between religion and science. And the nexus is not a simple one.
Religion & science – dichotomous or coherent?
There would seem, on the face of it, to be a conflict between the understanding that chaplains have of their work being about spirituality and wholeness – a concept closely related linguistically to health – and reductionist demands for demonstrable efficacy (of the kind obtainable from double-blind trials of pharmacological products).
What One Common Faith (Haifa: Bahá’í World Centre, 2002) describes as “the iron dogma of scientific materialism” just will not do when it comes to studying the essentially human and spiritual service offered by chaplains.
This brings us back to the question of what can count as evidence of the efficacy of the work of chaplains. Are double-blind trials the only way to do science, or are there other more qualitative modalities that might be more appropriate when it comes to the studying the intangibles of chaplaincy interactions?
Chaplains can and do gather evidence from their own and colleague’s work. If the scientific method is understood as a systematic knowledge-generation cycle of observation, theorising, experimenting, refining, practising, then most chaplains learn to do this when they are training. What is known as reflective practice is now a central part of chaplaincy. And established chaplains increasingly engage in action research, which is also a form of reflective practice. Such modalities could well be practical examples of “nonfoundational” approaches (see above, Lample 2009) to the generation of knowledge about chaplaincy and its efficacy.
Such processes are familiar to Bahá’ís, for whom processes of consultation, action, reflection, and further action are becoming very much part of their life. Bahá’í understandings of the nature of knowledge and praxis are becoming more sophisticated, as a study of Paul Lample’s book will show, and as the experience of Bahá’ís as they gain experience of how to learn as a community and how to put their learning to work.
Much more research remains to be done. Mowat’s (2008:70) map of the categories that emerge from the literature may be seen as a starting point for this research.
This is second part of the 9th in a series of blogs on the unity of science and religion and its applications by Barney Leith, a member of the UK Bahá’í community and its National Spiritual Assembly. For more of his blogs, see http://barneyleith.com on Posterous.