Chaplaincy Best Practices for Care of ‘Spiritual Not

Religious’ PersonsPresenter:

Judy Fleischman BCC M.S. M.Div. M.Phil. !

judy@opensourcechaplaincy.com

APC Conference, PS5 Professional Development Intensive June 22, 2014, Anaheim, CA

What is Spirituality?

• SBNR.org1

• “open source”, outside traditional religion”

• Network of Spiritual Progressives1

• (what) “cannot be fit into scientistic or empiricist frame…love, kindness, generosity, awe…”

• Consensus Conference 2009 (revisioned 2013)2

• “…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 persons) *General Social Survey1

• largest percentage of “nones”: young adults • more than earlier generations at same age *Pew Forum 20101

!• among “nones,” many look to “develop their spirituality apart from traditional structures” !

• Spiritual Not Religious

“Spiritual Not Religious” growing…

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: patient’s values/needs? • Refer to NVC

3 needs (core values) sheet

!• Patient

• MONITOR: your feelings, … !

NVC = NonViolent (Compassionate) Communication1

Who are Spiritual Not Religious?• “Belief matters to a large percentage of SNR”1

• 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

4: Totally indifferent, Ambiguous, SBNR

•Reasons, formative experiences, and goals1:

•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 chaplain’s experience: We might include:

•children (depending on their environment, relationships, etc.)

•religiously identified/non-practicing (“lapsed Catholic,” “secular Jewish”)

•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 - Considerations

• CAUTION: Defining “SNR” as a culture/demographic is tricky business !

• 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 in…a mixture (that) produces an internally inconsistent schema”1 —> 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, GWISH5

Foundation

Best Practice Guidelines for Patient-Centered Care

• Outcome Oriented6,7,8 Identifies Spiritual Distress

• Chaplain as spiritual “specialist”

• 3 Tiered-Protocol

• Spiritual Screening (not chaplain’s 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 Fitchett8

• “Patient-Centered” Holistic Assessment8: Dimensions of a Person’s 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? !

!

What’s Important Now?

Spiritual Assessment How do you assess?

• How do you assess? Frameworks?!

• Experiential (“role play”): !

• Patient: !

• Monitor: how you feel during visit? Needs met?!

• Chaplain: !

• Assessment Framework(s)?!

• CPE tools? Other tools?!

• Which other disciplines/specialists might be involved in care planning?

SNR Spiritual Care Toolkit• Non-Violent Communication (NVC)

• Contemplative Approaches

• Attuned Breath Centering10

(ABC) (integrates with CBT)

• guided imagery to rate spiritual pain on numeric scale (self assessment)

• Cognitive Behavioral Therapy13,14

• 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, Qualitative9!

• FICA5!

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

• HOPE !

• Hope, Organized Religion, Personal Spirituality, Effects on Care!

• The Integrative Assessment Tool11!

• How (Informational) + What (Substantive)!

! ! “The questions offer a framework eliciting thoughts, memories and !! ! experiences that give coherence to a person’s life, and help locate !! ! their source of strength or distress be it intrapersonal, !! ! !! ! interpersonal or transpersonal.” - Chung, C.H.

Spiritual Assessment Frameworks (selected)

• Unstructured, Qualitative9!

• 7X79!

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

• Spiritual Pain12!

• 4 Realms: Meaning, Forgiveness, Relatedness, Hope!

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

• Relationships & Connectivity, Meaning Making, Congruence with Purpose

Spiritual Distress• “The disruption of one’s beliefs, assumptions, or values that occurs

when one’s valued relationship with one’s self, others, ideas, nature, higher power, art, or music is threatened or broken.”15!

• Distinct from Social Distress!

• Types: (include)!

• Existential Distress!

• Moral Distress & Moral Injury16!

• 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”17!

• “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” 18(Corley et al., 2001)!

• Moral Injury is common among U.S. combat Veterans and many healthcare workers.

What Do People in Spiritual Distress Say?

• “I’m lost. Nothing makes sense anymore…”!

• “Fine, I’m fine... but at night I feel alone, terribly alone.”!

• “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 planning?

Chaplaincy Interventions!

• Outpatient!

• Children (Memorial Sloan Kettering Cancer Center)!

• HIV Trauma Center19

(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:!

• Contemplative!

• Cognitive Behavioral Therapy!

• Expressive Arts Therapies!

• Examples:!

• Attuned Breath Centering (ABC) 10

!

• guided imagery to treat spiritual pain!

• music therapy - composing together (children, clients, patients; 1:1, groups)!

• art therapy (1:1 & groups)

What about Prayer?

• Spontaneous Prayer

• Adapting Religious Prayers

• Non-Religious, written and Spoken Words

• Prayer through Music, Art, Drama19

• Gatherings, Services with mixed religious,SNR

Stories, Needs, Reflections Caring Community

Turn Our Hearts Around

Moving On: circle of HealingCommunity19

Reflection Board/Reflection Room

Chaplaincy Interventions Experiential

• 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?

• Patients/Clients • Families • Staff • Community • growing Beloved (aka Caring) Community…

SensingWonder.com Celebrating creativity, connection,and community

We are the Potluck!

References1. 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, 2001.

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/CChungLearnProject8.pdf

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/uploads/pdfs/IntegrativeAssessmentTool.pdf

• 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.