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June 17, 2015

The Current Crisis in Healthcare Chaplaincy and Spiritual Care--By Raymond J. Lawrence


Almost a century ago Anton Boisen changed the face of pastoral work. He taught religious professionals to be healers. Listening to persons suffering mentally or physically was his central theme. To get their stories. To make connections where connections were apparent. To support self-awareness and self-discovery. "It's not what the minister says to the boy (sic) but what the boy says to the minister," he proclaimed. By the time he died his followers were legion. And they, as he, had learned much from the psychoanalytic movement. The role of the minister was transformed in Boisen's own lifetime. He was a religious giant of the twentieth century. Because of him many teachers, preachers, and evangelists morphed by the middle of the century into competent psychoanalytically informed counselors and therapists.

This year a little book containing nine clinical pastoral cases appeared under the title Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy, edited by George Fitchett and Steve Nolan. If this book, and others like it, carry the day we will write fini on Boisen's clinical pastoral movement and all that it represented. Boisen and his inheritance will have been trumped by a new form of evangelism. And then it will be only a matter of what the minister says to the boy. Religious proselytizing and browbeating will have replaced pastoral care and counseling. It's not a pretty picture.

This reversal of the Boisen tradition is well documented in Chapter 1, containing the first of nine revelatory clinical cases presented in this book. It documents with specificity the new order of chaplaincy, or spiritual care, as it is unhappily being called of late.

The patient is a 12-year-old girl stricken with a daunting disease, cystic fibrosis. Her options are limited. Her life likely will be short and confined, under conditions of rather extreme isolation from peers and loved ones. Her family's home is a long distance away, and she is alone most of the day. She has had more than one hundred surgeries in her short life. The chaplain generously notes at least ten substantive visits with her over the course of a year, visits that included burdensome infection-control measures such as gowns, face masks, and gloves. In short, the patient presents a heart-rending case that is almost unbearable to read.

The chaplain in question, who claims to have been trained in the Boisen tradition, turns the Boisen model on its head. Instead of seeking to hear the voice of the young girl in a desperate plight, he moves to instruct her in the practices of Christian piety. He is hell-bent on persuading her to pray. He's as heavy-handed as an evangelist at a tent revival calling for a belief in Jesus.

To give him due credit, the chaplain who has known the patient over a five-year period, generously spends significant time sitting with the young patient playing board games and drawing. These activities might have led to some opening in the patient whereby she might have been empowered to share some of her painful experience, which to any observer would appear unspeakably grim. But the chaplain can't wait for the patient to start feeling free to talk. He wants her to pray and to talk to God, and without delay. In nine of the ten noted visits the chaplain lobbies for the girl to talk with God and to pray.

In the fifth of the recorded visits the chaplain believes he has hit pay dirt when the patient tells him she believes that God is helping her by telling the doctors what to do. It would seem that the girl is grasping for straws, hoping to get the Chaplain off her back. She now has some God-talk to give back to the eager chaplain.

Hoping for a 12-year-old to open up enough to talk candidly with an adult, even after a 5-year relationship, may be more than can be wished for, so the chaplain's failure to hear the authentic voice of the patient may have been predestined. However, the chaplain's perpetual beating of the drum for prayer and God surely voided any hope of the patient's sharing anything significant about her own grim experience. She undoubtedly feels harassed by a propagandist.

The nadir of the chaplain's inappropriateness came on a visit to the outpatient clinic where he found mother and daughter together for the first time. He asked the girl "how she and God were doing." Such a question to a preadolescent could be considered crazy-making, as well as inappropriately evangelistic. Human beings who are sane will never know how they are doing with God - if indeed there is a God.

In his many visits it would have been sufficient for the chaplain to have asked simply, "What's it like for you here in isolation?" or "What's it like for you being so far from home in a strange place?" or "What's it like for you to have to protect yourself with all this gear and equipment?" or "How much do you miss your family?" She may or may not have ever been able to respond freely and talk about herself in that way with an adult stranger in the form of a chaplain. But we can be sure she would have understood the questions. However the question, "How are you doing with God?" is not a question she would have any way to answer. Even the chaplain, if he were honest, would be flummoxed by such a question put to him.

I suggest here that the failure of this chaplain to ask questions that might have evoked the girl's pain and sorrow and despair can be explained by the chaplain's avoidance of pain in his own life. That would mean, in Boisen's terms, that his own counter transference inhibited his ability to touch the girl's pain. He preferred to take the role of religious functionary, defending himself against the profound pain he likely would feel in identifying with her should she disclose herself to him. Boisen's clinical training movement was designed to engage pastors with their own unconscious and transferential material, which in turn sensitizes them and makes them aware enough to hear the pain of others. This chaplain would likely benefit from further clinical training, where with a competent supervisor he might understand what is buried in him that leads him to look away from the terrible pain of this 12-year-old.

As we in CPSP struggle to promote the inheritance of Boisen's teaching, we will have to do battle with the surging influence of such propaganda as this case and this book presents. It will not be easy. The purveyors of this new direction in chaplaincy - this new spirituality - are formidable, supported by millions of dollars in foundation monies. The future of a credible, therapeutic pastoral role is at stake. If we do not succeed in countering this alliance of superficial religiosity and money, the Boisen tradition of the psychologically competent pastoral clinician will vanish from our culture, and religious leadership will fall entirely in the hands of those with a competency level of used car salesmen and traveling evangelists.

For reviews of the other eight cases in the book, please contact Raymond Lawrence by email:

Posted by Perry Miller, Editor at June 17, 2015 10:48 AM

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