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Healing the Soul: Pastoral Care
From: Columbia University
| By:
Raymond Lawrence |
EDITOR'S INTRODUCTION |
Pastors serve a unique role in the medical community. Dealing with souls in a realm devoted to biological medicine, they are the only members of the hospital staff who have the luxury of time and carte blanche to visit all patients. As the director of pastoral care at New York-Presbyterian Hospital, Columbia-Presbyterian Medical Center, Raymond Lawrence works directly with patients to address their needs and oversees the training of new pastoral counselors. |
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| New York-Presbyterian Hospital, Columbia-Presbyterian Medical Center. | |
 haplains hold a unique position in the medical community. We are the only members of the hospital's clinical staff who have carte blanche to visit all patients. Social workers and even physicians cannot just walk into any patient's room. Of course, we can get thrown out or be specifically requested not to visit, but that rarely happens. Since the chaplain's visit is not reimbursed by insurance, we're also the only people on the clinical staff who have the luxury of saying, "We have time." It does not matter whether we see six patients for 50 minutes or 30 patients for 10 minutes. We don't bill, so there is no loss of money. That distinct advantage allows us to take our time when assessing whether or not the patient wants to talk about matters that may be difficult. |
At Columbia-Presbyterian Medical Center (CPMC), the chaplaincy office has two foci: calling upon patients and providing training in pastoral counseling for clergy and select laypersons. In addition to responding to requests to visit specific patients, we try to make "courtesy calls" on every admitted patient. With only three full-time employees serving around 1,200 beds, it's a challenging task. The 30 to 50 trainees we teach every year greatly expand our reach. Some of these trainees are current seminarians attending a 10-week training course in basic pastoral counseling; others are members of the clergy or people who have chosen to undertake advanced study in pastoral counseling, which lasts between one and three years. |
Religious traditions
All hospital clergy work within a double agenda--alternatively acknowledging and ignoring specific religious traditions, depending on the context. CPMC's patient population is about 40 percent Catholic and 15 percent Jewish; the remaining 45 percent is a mixture. Some patients are self-consciously attached to their particular religious tradition. An observant Jew, for example, may want to see only a rabbi, or a Roman Catholic patient may want to see only a priest. But most patients are willing to work with an ecumenical, or generic, chaplain, often even being unaware of the chaplain's particular religious tradition. This is especially true of persons in the midst of a serious crisis. |
Our full-time staff includes a rabbi, a Catholic priest and myself, a Protestant minister. We can also call upon representatives of different religions who serve on our advisory committee--referring a patient to the Muslim representative, for example. |
For general courtesy calls and for patients without a stated religious affiliation, we serve as ecumenical chaplains without any predetermined agenda. We work with patients around basic human concerns regardless of whether they are Hindu, Presbyterian or atheist. At its core, religion boils down to basic values of justice, mercy and equity. These values are embedded, with some variations, in all religions. Most people are strangely ecumenical when lying in bed afraid of surgery and wondering if they are going to die or worried about some family or relationship problem. |
Pastoral counseling
The business of pastoral counseling brushes up strongly against psychology. We must have at least a basic understanding of psychology, psychoanalytic theory, personality theory, human relations and group theory. We're required to be polymaths in that sense. Clergy who are trained to do pastoral counseling almost invariably employ a psychoanalytic angle of vision that takes into account the unconscious--as opposed to a focus on behavior modification, which tends to diminish the unconscious. |
Pastoral counseling employs a consultative posture, open to a broad spectrum of topics. Patients bring up all types of issues. They talk about problems in their marriage and relationships. They talk about job problems. They talk about the meaning of life and their thoughts on death and dying. While we are interested in what an illness means to a patient, we cannot walk into a patient's room with any preconceived notion of what the illness means to them. An illness might mean anything from a minor inconvenience to a dramatic change in terms of relationships, or even the prospect of an end to the patient's life. |
In my experience, patients often do not even want to talk about their illness. They may want to talk about something else. A patient might come into the hospital for gall bladder surgery, but might want to talk about changing his vocation or some other topic that has nothing to do with the gall bladder. We might lead with a question about the patient's illness, but that may be only a small part of the larger picture of the patient we're meeting. On the other hand, the subject of concern may be ultimately related in some profound way to the cause of hospitalization. |
Countertransference
To join the chaplaincy you have to learn some things in the arena of psychology, group dynamics and human relations. But the most important thing to learn is how to deal with your own agenda, otherwise known as countertransference. Chaplains need to understand how to manage the unconscious psychological material that tends to skew and interfere with all human relationships. Persons working with other people bring their own agenda into the mix; that agenda sometimes intrudes in ways that are not helpful. The only cure is to become increasingly self-aware and to learn how one's own agenda can impact the pastoral relationship. |
Case presentations comprise a major component of pastoral training. Trainees present a three- or four-page document that details their interaction with a patient, including a verbatim section. As these case presentations build, patterns of interaction emerge. For example, a woman who always seems to have trouble with male patients might need to explore and reflect on her own personal issues with men. |
The pastor-physician relationship
The relationship between pastors and physicians is quite variable; it all depends on the individuals involved. Many physicians view us as complementary to the health care process. They believe that their patients will benefit from having somebody like a chaplain to talk to and are very eager to suggest that we "go see Ms. Brown." They assume that if we pick up matters that impinge upon the health of the patient, we will let them know. No one else has very much time to listen. The nurses are stretched very thin and have a great deal of work to do. Some of the housekeeping staff have been known at times to have innate listening skills, but they can only stay for so long. Assuming the chaplain is competent, he or she can sit with the patient and assist them in reflecting on their concerns. |
But not all physicians understand what we're doing. Some are even hostile and others are ambivalent. We have all kinds. Some physicians think that religion itself is a distraction and have no interest in it. They think the chaplain's office just drains money off the hospital budget. |
Supporting patient autonomy
We do come into direct conflict with physicians on occasion. An authoritarian doctor might override a patient's wishes, subtly or otherwise. That patient may then tell us, "The doctor's telling me to have surgery, but something's telling me I don't want the operation." We would want to explore with the patient the reluctance and ultimately support the autonomy of the patient's decision. |
Some doctors maintain goals for patients that the patients themselves don't have. Several years ago, my mother was in terrible pain from cancer, which had metastasized in her lung, skull and spine. She told her doctor, "I want you to help me have a comfortable, easy death so I don't suffer. I don't want to linger or to suffer in pain." Her doctor said that he couldn't believe what she was saying. She eventually experienced weeks of terrible pain. I went to meet with him to complain that he was prescribing relatively mild analgesics, and he began speaking about his concern that my mother might become drug addicted. This was 12 weeks prior to her death. Such conflicts over treatment goals do arise and will continue to arise wherever people have differing values. I don't think that will ever change. |
Of course, in that situation I was not her chaplain; I was her son. Had I been the chaplain, I would have been in a position to engage the doctor and hopefully to change his mind on the matter. The patient knew she was dying and didn't see any hope, but the doctor was still trying to cure her and was inappropriately concerned about addiction. The doctor was not listening to the patient and was not giving her what she wanted and needed. Sometimes we can help physicians hear things that they would not typically hear. |
Confronting the end of life
The dying process is a universally difficult one. Anyone is capable of bizarre decisions when it comes time to choose what to do about dying. One of the most difficult decisions is when to let go and give in to the dying process. This is never easy. Physicians who spend their professional lives promoting life have a special difficulty with this. Dying is an insult to them. Often we encounter the awful question of unplugging the patient's respirator, for example. Family members or physicians may come down on either side of the question--attempting to speed up or slow down the dying process--for a lot of different reasons. |
Some people have no qualms about a prolonged stay on a respirator; patients have been kept in a vegetative state for years. A decision to maintain life support in these instances is often based on deeply held values. It seldom occurs to anyone, as I see it, that a prolonged vegetative state would be a horrible form of torture if the patient retains even the slightest level of consciousness. A competent chaplain, one who is clinically astute, may be able to help clarify what is at stake in the dying process. It is a delicate and difficult time for most people, and it is a time that professionals spend too little time reflecting upon. |
When we enter into these situations, our role is to represent the best values that we can. Sometimes the physician may seem myopic, and sometimes the patient or family members seem so. We listen, attempt to assess and evaluate the situation, and give the best input we can. Sometimes we're effective. Sometimes we're not. |
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