The College of Pastoral Supervision & Psychotherapy is a theologically based covenant community, dedicated to "recovery of the soul" and promoting competency in the clinical pastoral field.
A recent episode of "Agnes," a refreshingly insightful US comic strip, has the heroine expounding on the topic of a "moral compass" – and ending up noting her "faith yardstick," "devotional scale," and "battery-operated spiritual hedge trimmer." There's nothing like starting with a reasonable notion – that we should proceed deliberately – and driving it into the ground. [Tony Cochran, Creators Syndicate, Inc, 17 June 2006; http://www.creators.com/comics_show.cfm?next=1&ComicName=agn]
As Chaplain Robert Mitchell paraphrased in his well-taken article – "Chaplaincy: The New Profession?" – some of "the most significant parts" of pastoral practice "don't lend themselves" well to "easy measurement and analysis" [après Della Fish & Colin Coles, 1998]. Some of the most significant aspects of pastoral care, counseling, and psychotherapy – and of clinical pastoral education – don't fare well with "tools" such as Agnes', that attempt to measure and weigh religion or to cut relationship down to size.
Managerial technicians approach persons in need without doubt or humility, as if it were really easy to know what is wrong and what to do. Humanistic artists approach persons in need with faith in their working through together, grasping the importance of valuing what is not easily known. Ignorance is bliss. The less one truly knows, the more everything seems clear-cut. Wisdom is – certainly not based on the latest equivalents of a "faith yardstick," "devotional scale," or "battery-operated spiritual hedge trimmer". The more one truly knows, the more everything seems complex.
Robert Charles Powell, MD, PhD is the leading historian of the clinical pastoral movement. As a practicing psychiatrist, his writings reflect his daily investment in his daily clinical practice of providing psychotherapy and care to his patients.
Posted by Perry Miller, Editor at 5:11 PM
Chaplaincy-Spiritual Care Department
Royal Free Hampstead NHS Trust
London, NW3 2QG
Chris Swift, the College’s President, remarked in his introduction to the flier sent out about this Conference that the title “Chaplaincy – The New Profession?” could be read in at least two ways. Is Chaplaincy emerging as a new profession (similar to many other), or does it constitute a new kind of profession? And if it does, how is it distinctive and different?
I hope that over the next few days there will be the space to reflect creatively, on what is shared by our speakers and on what has been published in this area over the past few years, including much contributed by people here this week. The CHCC Conference at Cardiff in 2003 had as its sub-title “Professional Practice - an art or skill”. And part of our reflection this week will, I believe, need to revisit and develop thinking done then by the likes of Peter Speck, Martyn Percy and James Woodward. From a slightly different perspective, over the past few years I have had conversation with a friend from university who is a General Practitioner (GP) and it seems that many of the issues and questions that we are facing are very similar to those that doctors and others in healthcare are having to face as well. And I hope that sharing with you some of the thinking I have done with him may throw some light on our theme this week.
GPs, like the rest of the health service, have had to account for their practice and demonstrate through audit and research the effectiveness of their interventions and to be able to justify, with evidence, the value of their work. And, like many of us, doctors have questioned the value of some of the audits they have been required to do and how best to demonstrate the quality of their work. My friend talked to me about and encouraged me to read a book called “Developing Professional Judgement in health care” by Della Fish and Colin Coles, published in the late 1990’s. In their thinking there are interesting connections with discussions that have raged (or at least simmered) in Chaplaincy. For instance, they draw contrasts between what they describe as a “Technical-Rational” approach to medicine and that of “Professional Artistry”. Reading their work I couldn’t help reflecting on parallels with our own situation. Their main thesis is that some of the most significant parts of medical practice don’t lend themselves to easy measurement and analysis.
“Those parts of professional practice which seem routine or are mainly about following procedures may be dealt with for the purposes of accountability by collecting data for audit and individual performance review, as managerial tools. But, we argue here, professional practice contains a major element of artistry and this does not yield simple empirical evidence. We therefore believe that it is important for professionals to be able to reflect upon, articulate and refine and defend their practice……” (Fish, Della & Coles, Colin “Developing Professional Judgement in health care” Butterworth Heinemann (1998) p. 29)
They remind their readers that medicine was originally regarded as an art, but that in the late 1990s those who work in health care professions are “tormented by two incompatible views of professionalism”. On the one hand, they say, reflective practice is hailed as the way forward and on the other there are “demands that bureaucrats should impose system-wide procedures, such as protocols and guidelines, which will require professionals to follow rules and enable them, apparently, to stop thinking for themselves.” (Ibid.p.30)
Beneath these approaches, they argue, lie two different views of what a professional is and how a professional should behave, and that these in turn are influenced by two very different sets of values. The first view they call the “technical-rational” (TR) view, which leads to a competency-based approach to practice and the other they call “professional artistry” (PA) based in serious reflective practice. The first view, they argue, is the one held broadly by the public and politicians, but that in their experience this view doesn’t fit with the experience of practitioners who know that the second view, that of “professional artistry”, is more nearly what practice is actually like. The technical-rational approach tends to be mechanistic and about clear-cut and measurable “delivery” of services. Such delivery might be an appropriate way of describing commercial and market-driven activities like the delivery of newspapers, but the authors question its value in describing the activity of working with patients/clients.
The TR approach to healthcare cuts down the risks incurred when professionals make more of their own decisions. But it assumes that “practice is a relatively simple interaction in which the practitioner gives and patient/client receives, and which can be perfected” . (Ibid.p.32} By contrast, those who favour the professional artistry view of professionalism believe that the TR view denies the real character of both professionalism and practice. They argue that far from being simple and predictable, professional practice involves a more complex and less certain “real world” in which, daily, “the professional is involved in making many complex decisions, relying on a mixture of professional judgement, intuition and common sense, and these activities are not able to be set down in absolute routines, or made visible in simple terms, and certainly are not able to be measured, and which because of this are extremely difficult to teach and to research”. (Ibid. p.32)
The TR approach is based on skills that can be mastered. To quote Fish & Coles once again:
“The identification of those skills, which are superficially reassuring in their ability to be seen and measured, make professional accountability superficially easy. Thus competencies or ‘outcomes’ have for some time dominated many courses of preparation for professional practice….The PA view, in contrast, sees behaving professionally as being concerned with both means and ends. Hence professional activity is more akin to artistry, where only the principles can be pre-determined and practitioners may, in practice, and for good reason need to choose to go beyond them, just as say good artists often go beyond or break artistic conventions in order to achieve an important effect. Thus, in this view, practitioners are broadly autonomous, making their own decisions about their actions and the moral basis of those actions (for which they of course are accountable). In the PA view, the activities of the professional cannot be pre-specified, just as a painter cannot tell you what the picture he or she is creating will be like until it is finished.” (Ibid. p.33)
Nature of professional practice (summary):
• We see professional practice as having the nature of artistry.
• We see practice (rather than theory) as of prime significance and as a proper starting point for professional preparation and development.
• We believe that professional knowledge is created in and during practice.
• We see such knowledge as emerging from critical reflection on, enquiry into and deliberation about experience.
• We believe that it is informed by formal knowledge, which is transformed in practice into becoming personal knowledge.
• We acknowledge practice and theory as developing reflexively together.
• We see professional development as a process of changing people by educating them rather than by changing systems and training people to adapt to them – we see it as a process of evolving change from within rather than imposing change from without. (Ibid. p.44)
The high ground and the swampy lowlands
Fish & Coles also quote D.A. Schon(Schon, D.A. “Educating the Reflective Practitioner” (1987) Jossey-Bass), who talks about the firm ‘high ground’ of practice that represents all that can be easily measured. In chaplaincy-spiritual care terms such things could be the number of people seen or how many services have been conducted. Most of our work, though, is in what Schon calls the ‘swampy lowlands’, where everything is less clear-cut and much more messy. In doctoring terms it is the place where it is not simply a matter of applying theory. It is about engaging creatively with the person and his/her situation and teasing out a way forward using professional judgement, yes, but judgement that has become part of the doctor’s personal being. (Formal knowledge transformed into personal knowledge.)
The bullet about formal knowledge transformed in practice into personal knowledge reminds me of a priest I used to talk to who said that although he had been trained as a counsellor he felt that to relate to people as a priest, as a fellow human being, he didn’t draw consciously on his counselling training in the hope that what he had learnt had been integrated into the person he had become. He was then meeting people person to person rather than as priest/counsellor to client.
If we think for a moment of the rise of professionalism within the Anglican Church in particular, there have been many studies that show how the distinctive training and dress and status of the clergy developed through the 19thC. But I believe there was, and is, a price to be paid for such separation from other people. And for chaplains there is also, perhaps, the temptation with all this talk of “professional identity” of portraying ourselves as experts in religion and spirituality. We may all need to find and develop some focussed area in which we can specialise, such as pregnancy loss or teaching or ethics. That may be important. But even if we can be said to be expert in our own spirituality, we cannot be experts in someone else’s. And who are the experts in dying, surely only those who are themselves going through the process? The rest of us may be sensitive companions for part of that journey, but no more. Stanley Hauerwas wrote in his book “The Suffering Presence”: “Only when we remember that our presence is our doing, when sitting on the ground seven days saying nothing is what we can do, can we be saved from our fevered and hopeless attempt to control others’ and our own existence…” (Hauerwas, Stanley “The Suffering Presence” p.81) And like the good teacher we will face in the same direction as those with whom we work, rather than instructing them in the “truth” de haut en bas.
Perhaps one of the paradoxes of what we offer as chaplains is that the more we are formed by our practice, the more we reflect on what we do and who we are, the more we come to realise that we know very little for certain. But we may gain confidence that what we have to offer is the ability to stay with difficult feelings and emotions and questions and so help people live with how they are feeling and begin to make their own sense of what is happening to them. Our role is surely often simply that of companion to those who like ourselves, are journeying from birth to death, living with the uncertainty and mystery of it all. I say “simply”, but of course we all know it is hard to do, and so do other discerning health care professionals. That is why people are often referred to us or ask to see us at such times.
So one of the questions with which I feel we need to continue to struggle is about where our talk of professionalism is leading us. Is it in the direction of making us feel more ‘expert’ because we have defined our discrete area of competence? This may lead to greater respect from our healthcare colleagues. In the present climate we may feel we need to do this to ensure we keep our jobs. But is there the danger that if we are seen as experts, as specialists, this may distance us unhelpfully from those with whom we work? Perhaps the unique contribution we have to offer lies more in the way in which we are with people and the way in which we may help them work through whatever is happening to them . ( cf. Mowat, Harriet & Swinton, John op.cit. p.51f) Engaging with people in this process involves great skill and sensitivity. It involves expertise even if the work does not feel a distinct specialty; but just because it is less well defined it may lead to a more vulnerable, a more human and therefore more creative connection with the people we meet. But like all work in the ‘swampy lowlands’ it may be hard to audit, hard to research.
Fr Christopher from the Roman Catholic Benedictine Community at Worth Abbey spoke the other week on Radio 4’s Sunday Programme. (As a chaplain I had the luxury of still being in bed at the time!) He was talking about the experience of having had those six men staying with them for the “reality TV” programme and the interest it had generated in the general public. He said that many people had contacted them and the Community had had to think how they could talk about their way of life with those who had no religious background. One of the ways they had thought of was to discuss the meaning and value of humility. So many of us are driven to succeed because we crave some sort of status. But in talking of humility, Fr Christopher spoke of its roots in the Latin for “earth”. If we are truly earthed, truly grounded where we are, he suggested, we will discover an integrity that won’t be threatening to others because it doesn’t need to prove itself, doesn’t need to compete.
In our thinking about chaplaincy as a profession (even as a new profession) perhaps we might build in that sort of perspective drawn from religious roots, so that our professionalism will not be driven by a perceived need for status, linked to power and control, but will be grounded in the integrity of our faith/life formation. There is still some mileage, I think, in the old understanding drawn from the traditional Christian language of the village “parson” being the representative “person”. (Clearly this thought comes from the Christian tradition, and I would be interested to hear if this also makes sense from Muslim, Jewish and other religious perspectives, as well.)
Formation happens all the time and at its best leads to the integration of the person so that experience and learning become part of the person one is rather than items to be retrieved for use when needed.
Some of you may know Eric Fromm’s work “To have or to be” in which he discusses these two distinct ways of living. The “having mode” he suggests leads to a person who may have much knowledge and many skills to apply, but who nevertheless cannot relate easily as one human being to another, because that knowledge and those skills are not integrated into the person’s life. Perhaps our professionalism as chaplains is therefore not so much about having, possessing, a “body of specialist knowledge” as being committed to a way of working, a way of being with people that is formed and deepened by continuous reflective practice with colleagues and others. In the words of Fish and Coles, our formal knowledge will then become personal knowledge. We will learn not simply by applying theory, but by the creative process of being with people and then reflecting on that experience. There is always the danger that “professionalism” of the wrong kind will distance us from those with whom we work while reassuring management and ourselves that we are exercising distinctive knowledge and skill that make us indispensable!
Steve Nolan, in the most recent College Journal compares what chaplains do with the interventions of other healthcare professionals. “Each of our colleagues” he writes, “has something specific to offer from their particular discipline. As chaplains, on the other hand, unless specifically requested for a sacramental or other specifically religious intervention, we arrive in the nakedness of our own being.” (Nolan, Steve Journal of Health Care Chaplaincy Vol. 7 No. 1 p.18 ) (I am reminded of those cartoons of doctor and patient in Sheila Cassidy’s book “Sharing the darkness” in which they begin fully clothed with the doctor in collar and tie behind a desk and end up sitting facing each other totally naked.)
Nolan then talks of what he terms “psychospiritual care” which he says “differs from other kinds of psychological care, and from a (secular) humanist approach, by the fact that it is totally dependent on the personal work of the individual psychospiritual carer, in a way that is not the case for any of our healthcare colleagues. As chaplains, Nolan says “we offer our patients our own psychospirituality” .( Nolan, Steve, op.cit. p.19) Or as I might put it, drawing on Fr Christopher, what we as chaplains offer patients and others is grounded or earthed in our own psychospirituality.
Many of these issues have been raised in the excellent report on healthcare chaplaincy in Scotland “What do chaplains do?” co-written by John Swinton and Harriet Mowat, two of our speakers tomorrow.
In discussing Chaplaincy as a new profession, the report suggests that “Chaplaincy is, in significant ways, different from many of the other healthcare professions” . ( Mowat, Harriet & Swinton, John “What do chaplains do?” (2005) p.51) The report say that Chaplaincy can be understood as “an example of a new (post-modern) profession wherein the expert and discrete knowledge related to the profession lies in the method of identifying need rather than in the act of providing a solution” . (Ibid. p.51)
The new professional uses interpretive and inductive skills starting from the “data”, in this case the spiritual need as expressed by the unique individual before them. This, the authors suggest, “is quite different from the more established professions where expert knowledge imposes solutions upon perceived problems”,( Ibid. p.51) (though similar in many ways to the professional artistry advocated by Fish and Coles described earlier). The uniqueness of chaplaincy, they suggest, is found “in the process of chaplaincy rather than in the particular tasks that chaplains participate in. In other words, it is the unique configuration of the various tasks of chaplaincy (listening, talking, seeking need etc.) that makes it unique and different, rather than the particularities of its tasks, which are often carried out but configured quite differently within other professions”. (Ibid.p.52) “However, the strength of chaplaincy – its intuitive, skilled discernment – may, the report suggests, also become its greatest weakness. Set in the context of a health system anxious to delineate role, measure outputs according to concrete measures, and assess practice on the basis of productivity, chaplains may find themselves focussing on end results to the detriment of process…….” (Ibid. p.52)
That sets out clearly the problem we face. Can we find a way that identifies and values the professionalism shown in the way we work, in the process, rather than trying to justify our role in end results, (whatever that might mean in chaplaincy terms).
What do chaplains do at the bedside?
Our code of conduct hopefully precludes the worst excesses of unprofessional behaviour. Is it possible for a chaplain to do other damage? Yes, of course. An insensitive intervention with someone, say, who has attempted suicide, might prove fatal. But I would suggest that no amount of courses or qualifications will, in themselves, guarantee that a chaplain’s visit will be helpful (or to quote one A&E sister when interviewing for a new chaplain “I’m going for the one who I don’t think will make a situation worse!) What an individual chaplain brings to the bedside is him or her self. They will be formed by their religious knowledge, their own spirituality, their knowledge and skills around counselling and communication. Hopefully these will be more or less integrated, so that the patient they see will meet a person and not simply a functionary with letters after their name and certificates in their back pocket. This could equally be said of the relationship between a patient and a good doctor, nurse or occupational therapist. But unlike other health care professionals we, as chaplains and volunteers, have very little, if anything, that we have to do. We can go ‘empty handed’ and be perhaps the only health care professional who can be totally patient-led (unless we feel bound to follow the wishes of relatives or Faith Community). But in this lies our strength. By meeting people as equals, without an imbalance of power, there is a chance for something creative to happen.
Some of you may have read “The Art of Conversation” by Theodore Zeldin, a small book in which he discussed how rare it is for people to make real conversation. His argument is that, although rare, when such conversation happens, when there is a real connection between people, something creative happens, something new emerges. I believe such conversation lies at the heart of what chaplains have to offer and that the experience that Zeldin describes is the experience of many of us here and why we are chaplains and volunteers in the first place. But how we describe that experience in ways that can be valued in the modern NHS is our current challenge.
But perhaps we could discover a way of doing just that by demonstrating with good research the value in the process of the care we offer; how we can be formed professionally through being rooted in our faith/life tradition; how we can transform our knowledge and skill from being external to us and formal into being personal and integral to who we are; how we can continue to develop our practice though serious reflection with others, and by doing so build and value the art of offering religious and spiritual care, the art of responding to spiritual and religious needs.
The Rev.Robert Mitchell, Chaplain at the Royal Free Hospital in London,presented the above paper at the annual meeing of the College of Health Care Chaplains in Durham, England on July 3-6, 2006.
The Pastoral Report reported on this conference while providing a URL to the College of Health Care Chaplains website where you will be able to listen to Robert Mitchell's presentation as well as many others who presented during the event.
Posted by Perry Miller, Editor at 9:50 PM
July 4, 2006
I'm writing to you from Durham, England where I am representing CPSP at the annual meeting of the College of Health Care Chaplains [CHCC].
It is an impressive meeting. Rev.Robert Mitchell, Chaplain at the Royal Free Hospital, gave the first presentation last night where he beautifully captured the work of the chaplain as an artist relying on the intuitive and creative in contrast to those who seek to provide solutions and measurable outcomes as proof of their effectiveness and competence.
I've met and talked with many of the CHCC members who have gathered for this three day study course. One thing that becomes clear is how dedicated and spirited this community is in its efforts to establish their unique place as health care providers. Chris Swift, CHCC President, provides wise and steady leadership for the CHCC and its members as they travel on the cutting edge of health care chaplaincy in this country negotiating the tricky waters of the National Health System.
In many ways the CHCC reminds me of the spirit of CPSP in its willingness to be creative and to do a new thing with courage and audacity. The CHCC and the CPSP are kindred spirits.
I encourage you to go to the CHCC website where you will find photos, MP3 audio files and text from the conference that will be posted almost as soon as each presentation has ended. These new postings will continue until the conference ends on Thursday, July 6.
Go to: http://www.healthcarechaplains.org
Perry Miller, Editor
Posted by Perry Miller, Editor at 4:18 PM