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Chaplaincy Best Practices

for Care of Spiritual Not

Religious Persons
Judy Fleischman BCC M.S. M.Div. M.Phil.

APC Conference, PS5 Professional Development Intensive
June 22, 2014, Anaheim, CA
What is Spirituality?


open source, outside traditional religion

Network of Spiritual Progressives


(what) cannot be fit into scientistic or empiricist frame

love, kindness, generosity, awe

Consensus Conference 2009 (revisioned 2013)


aspect of humanity by which individuals

seek and express meaning and purpose
Seeing is Believing
What Makes Sensory Experience Spiritual?

Selfie snapshot

The Big Picture

Framing and Reframing

Nones (claiming no religion) in
the United States:

Year %
1972 5
1990 8
2000 14
2012 20 (> 46,000,000
*General Social Survey

largest percentage of nones:

young adults

more than earlier generations at

same age *Pew Forum 2010

among nones, many look to

develop their spirituality apart
from traditional structures

Spiritual Not Religious

Spiritual Not Religious
Spiritual (but?) Not Religious
Labeling vs. Being
Experiential: 1. What do I mean by (1:1, repeat)

Spiritual? Religious?

2. BEING Spiritual Not Religious

Role Play: (1:1)

Chaplain MONITOR: patients values/needs?

Refer to NVC
needs (core values) sheet


MONITOR: your feelings,

NVC = NonViolent (Compassionate) Communication
Who are Spiritual Not Religious?

Belief matters to a large percentage of SNR


IF Beliefs reflect Core Values, PROPOSE: Focus on Values (NVC)

Common Experiences (CPE translation: Meta-Story)
Life crisis, Often much experimentation, dissatisfied so move on
Common Views (CORE VALUES)
to believe what they chose (Freedom & Choice)
Non-Dogmatism & Questioning Attitude (Trust, Safety, Acceptance)
wanted a group that had same beliefs
(Belonging/Community, Shared Understanding)

Point to Ponder: Freedom + Choice + Belonging = ?
Independence vs. Interdependence
Linda Mercadente, Belief without Borders: Inside the Minds of the Spiritual but Not Religious (2014,
Oxford University Press)
Who are Spiritual Not Religious?
How do we categorize SNR?

Relationship with Religion

: Totally indifferent, Ambiguous, SBNR

Reasons, formative experiences, and goals

Dissenters, Casuals, Explorers, Seekers, Immigrants

DISCLAIMER: may not have been as pervasive in nonwhite, non-mainstream,

disadvantaged, and immigrant communities (by Linda Mercadente, protestant
theologian, formerly SBNR)
This chaplains experience: We might include:
children (depending on their environment, relationships, etc.)
religiously identified/non-practicing (lapsed Catholic, secular
Mix of Religious+SNR family systems (including staff)
Spirituality articulation as non-religion (humanist, ethical culture, etc.)
Stories, Needs, Reflections
Look Out the Window

Hand on the Other Side (of the fence)

Silent Scream
Spiritual Distress in SNR -

CAUTION: Defining SNR as a culture/demographic is tricky


Spiritual Distress can include many factors (multi-cultural,

race, gender, sexual orientation, class, socio-economic, etc.)

If not applying an assessment tool, misperceptions/

generalizations likely to arise

Among (predominantly white, middle class Americans, largely

non-veterans), says Mercandente, SBNR ethos is very far
from believing without belonging. Neither is it really a turn to
the East. Instead, it is a truly American blending of elements
resulting ina mixture (that) produces an internally
inconsistent schema
> spiritual distress
Shifting Paradigm: Transdisciplinary
(Patient-Centered) Care
Patient Centered Patient Experience

Bio-Psycho-Social-Spiritual Model

Focus on Patient Experience

Healing = Experience oneself as Whole

What is spiritual care in patient-centered care?

Spirituality is a vital sign. Spiritual Distress should be a diagnosis
- Puchalski, Christina M.D., founder, GWISH
Best Practice Guidelines for
Patient-Centered Care

Outcome Oriented
Identifies Spiritual Distress

Chaplain as spiritual specialist

3 Tiered-Protocol

Spiritual Screening (not chaplains role)

Spiritual History Taking (chaplain?)

Spiritual Assessment (by BCC Chaplain)

Transdisciplinary Care Planning

Standardization of charting summary notes,

e.g., SBAR (Situation, Background, Assessment, Recommendation)
Spiritual Assessment -
A Functional Approach
In a spiritually pluralistic context such as a hospital, the functional
approach to spiritual assessment is preferable. It offers a greater
possibility that a person can share their spiritual story in their own terms
versus having to organize their story around the ideas of one particular
substantive religious-spiritual world view or another. - George Fitchett

Patient-Centered Holistic Assessment

Dimensions of a Persons Life
Medical, Psychological, Family Systems, Psycho-
Social, Ethnic, Racial, Cultural, Social Issues,
Spiritual (Fitchett)
Qualitative (narrative-based) Spiritual Assessment
Stories, Needs, Reflections
What Keeps You Going?

Whats Important Now?
Spiritual Assessment
How do you assess?

How do you assess? Frameworks?

Experiential (role play):


Monitor: how you feel during visit? Needs met?


Assessment Framework(s)?

CPE tools? Other tools?

Which other disciplines/specialists might be involved in care

SNR Spiritual Care Toolkit

Non-Violent Communication (NVC)

Contemplative Approaches

Attuned Breath Centering

(ABC) (integrates with CBT)

guided imagery to rate spiritual pain on numeric scale (self


Cognitive Behavioral Therapy


Expressive Arts Therapies Methods

Assess non-verbal indicators/symptoms (e.g., pain, anxiety)

through response to art and music/sound

What is in your assessment toolkit?
Spiritual Assessment
Frameworks (selected)

Structured, Qualitative


Faith (&Belief), Importance, Community, Address in Care


Hope, Organized Religion, Personal Spirituality, Effects on Care

The Integrative Assessment Tool


How (Informational) + What (Substantive)

The questions offer a framework eliciting thoughts, memories and
experiences that give coherence to a persons life, and help locate
their source of strength or distress be it intrapersonal,
interpersonal or transpersonal. - Chung, C.H.
Spiritual Assessment
Frameworks (selected)

Unstructured, Qualitative


Beliefs&Meaning, Vocation&Obligations,
Experience&Emotions, Courage&Growth, Rituals&Practice,
Community, Authority&Guidance

Spiritual Pain

4 Realms: Meaning, Forgiveness, Relatedness, Hope

Emotional & Spiritual Equilibrium (Donovan, D.W.)

Relationships & Connectivity, Meaning Making, Congruence

with Purpose
Spiritual Distress

The disruption of ones beliefs, assumptions, or values that occurs

when ones valued relationship with ones self, others, ideas, nature,
higher power, art, or music is threatened or broken.

Distinct from Social Distress

Types: (include)

Existential Distress

Moral Distress & Moral Injury


Civic Injury, Institutional Distress

Underlying Religious Distress

Moral Distress & Moral Injury

The effects of not following through with a moral decision

in the context of unsettling and unresolved conflict

The painful psychological disequilibrium that results from

recognizing the ethically appropriate action, yet not taking it,
because of such obstacles as time, supervisory reluctance,
an inhibiting power structure, institution policy, or chain of
command considerations
(Corley et al., 2001)

Moral Injury is common among U.S. combat Veterans and

many healthcare workers.
What Do People in Spiritual
Distress Say?

Im lost. Nothing makes sense anymore

Fine, Im fine... but at night I feel alone, terribly


What I (we) DID ... is not consistent with who I

AM.... (in war, to my children, for a living.)
Assess for Spiritual Distress

Patient (same situation and basic setup as earlier):

Include (more) non-verbal expression, as able

Monitor: Feelings and Core Values (Needs met)?

Chaplain (in same context of care as earlier):

Keep same Spiritual Assessment framework as earlier

Bring in new tools (e.g., NVC, contemplative, CBT, expressive art)

What are core values (NVC needs)?

What might be the spiritual distress?

Which other disciplines/specialists might be involved in care

Chaplaincy Interventions


Children (Memorial Sloan Kettering Cancer Center)

HIV Trauma Center

(Housing Works)

Triple Diagnosed Clients

Palliative Care

Memorial Sloan Kettering Cancer Center

NYU Langone Medical Center

Home Hospice

Sutter Care At Home (VNA&Hospice)

Intervention Tools

Intervention Tools can bring together multiple approaches:


Cognitive Behavioral Therapy

Expressive Arts Therapies


Attuned Breath Centering (ABC)


guided imagery to treat spiritual pain

music therapy - composing together (children, clients, patients; 1:1,


art therapy (1:1 & groups)

What about Prayer?

Spontaneous Prayer

Adapting Religious Prayers

Non-Religious, written and Spoken Words

Prayer through Music, Art, Drama


Gatherings, Services with mixed religious,SNR

Stories, Needs, Reflections
Caring Community
Turn Our Hearts Around
Moving On: circle of HealingCommunity

Reflection Board/Reflection Room
Chaplaincy Interventions

Patient (same situation and basic setup as earlier):

Include (more) non-verbal expression, as able

How would you ask for prayer?

Monitor: Feelings and Core Values (Needs met)?

Chaplain (in same context of care as earlier):

What are possible interventions?

Experiment with including new tools

How might you offer spontaneous prayer?

Which other disciplines/specialists might be involved in care and

care planning?
Next Steps?

Expanding how we care?

What Difference Can We Make?

Who Benefits?





growing Beloved (aka Caring) Community

Celebrating creativity, connection,and community
We are the Potluck!
1. Linda Mercadente, Belief without Borders: Inside the Minds of the Spiritual but Not Religious , Oxford University Press, 2014.
2. Puchalski, C. et al., Improving the Quality of Spiritual Care as a Dimension of Palliative Care: The Report of the Consensus Conference,
Journal of Palliative Medicine Vol. 12, No. 10, 2009
3. Center for Non-Violent Communication, cnvc.org
4. Robert Fuller, SBNR: Understanding Unchurched America , 2001.
5. GWISH (George Washington Institute for Spirituality & Health, http://smhs.gwu.edu/gwish
6. VandeCreek, L. and Lucas, A.M. Editors, The Discipline for Pastoral Care Giving - Foundations for Outcome Oriented Chaplaincy, Routledge,
7. Handzo, G., Best Practices in Professional Pastoral Care, Southern Medical Journal, Vol. 99, No. 6, 2006
8. Wintz, Sue, Cooper, Earl, and Pastoral Leadership and Practice Group, The Healthcare Chaplaincy, Cultural and Spiritual Sensitivity - A
Learning Module for Healthcare Professionals, 2009.
9. Fitchett, G. Assessing Spiritual Needs: A Guide for Caregivers, Academic Renewal Press, 2002.
10. Fleischman, J., Attuned Breath Centering: A Contemplative Practice Integrating Psychology and Spirituality to Activate Well-Being,
Association of Professional Chaplains Conference Presentation, 2010.
11. Chung, C.H., Paradigm Shifts in Chaplaincy & The Implementation of Spiritual Assessment Tools, http://www.upaya.org/uploads/pdfs/
12. Groves & Klauser, The American Book of Living & Dying. (spiritual pain assessment tool)
References (cont.)
13. Rosmarin, D.H. et. al., Integrating Spirituality Into Cognitive Behavioral Therapy in an Acute Psychiatric
Setting: A Pilot Study , Journal of Cognitive Psychotherapy, Volume 25, Number 4 2011 . http://www.upaya.org/
14. http://www.centerforanxiety.org/readings/2011_JCP_Proof.pdf
15. Hughes, B. and Handzo, G., Spiritual Care Handbook on PTSD/TBI: The Handbook on Best Practices for the
Provision of Spiritual Care to Persons with Post-Traumatic Stress Disorder and Traumatic Brain Injury, 2009.
16. Maxwell, Susan, PTSD and Aging in the Veteran Population,http://www.ptsd.va.gov, 2013
17. Kalvemark, Living with Conflicts: Ethical Dilemmas in the Healthcare System, Social Science & Medicine
58, 19765-1084, 2004
18. Johnstone, C. and Granovetter, D., Lives At Risk: Spiritual & Ethical Dimensions of Healthcare Fatigue,
Kaiser Permanente Regional Bioethics Presentation, 2013
19. Fleischman, J., Chaplaincy Best Practices in Caring for Persons who Identify as Spiritual Not Religious,
Association of Professional Chaplains Conference Presentation, 2013.
20. Fleischman, J., Healing Community: Transforming Trauma in Relationship, Compassionate care in an
integrative health center for people living with HIV/AIDS, Plainviews, July 2008.