BOUNDARY ISSUES FOR PRIVATE HEALERS ADDRESSING THE

SPIRITUAL DIMENSION

CPD Program, October 2013

Ross PittAcademic Advisor, Multifaith Academy for Chaplaincy & Community Ministries

It is now “policy” that spiritual care be integrated into the continuum of care offered by hospitals, aged

care, palliative care, prisons, schools,

universities, Defence Forces, Police &

Emergency Services, etc.

What does this really mean?

What implications does it have for the team?

What boundary issues does this raise?

Over the last 100 years the following development is observable:

Cure of Souls = priests and pastors administering Sacraments, saying prayers, offering moral advice, etc to their own flock

Pastoral Care is defined as having five functions: healing (non-therapeutic); sustaining; guiding; reconciling; nurturing spiritual growth. It offered by Christians (including laity) who represent their Church.

Spiritual Care is offered by representatives of various religions and its goal is to to assist the other person to tap into their own spiritual resources (wherever they got them from) to cope with whatever is confronting them. It is offered to everybody.

Illness ResilienceWellness

Continuum of Care

By this term is meant “joining up the dots” to make sure that patients/clients/residents enter and leave “the system” in a well-regulated way that doesn’t harm them, or abandon them, or otherwise fail to satisfy their care needs.

The rationale for including Spiritual Care in the continuum of care is that patients/clients/residents are not just problems to be solved and that they have better health outcomes and are more compliant and less “difficult” if their spiritual needs are attended to.

Inclusion of Spiritual Care in the continuum of care is one thing.

Integration of Spiritual Care in the continuum of care is another.

INTEGRATION means:•The Spiritual Carers’ role is specified and their performance is regulated• Spiritual Carerers have access to patient/client/resident/inmate data (record keeping in aged care)• Referrals to and by Spiritual Carers• Involvement of Spiritual Carers in care plan pathways• Involvement of Spiritual Carers in team meetings and Ethics Committees

The traditional trichotomy is being vigorously challenged by scientists and philosophers

Instead, a highly reductive materialist position is being promoted:

The idea that all living organisms (including mankind) are simply the result of a long process of selective adaptation to their particular niche environments (Darwinism)

There is no such thing as Mind A person’s consciousness of being a

thinking, deliberative acting self, with free will, is an illusion

Spirit, too, is an unnecessary residual categoryBecause mankind does not possess an

animating force different to other animals

Three questions:How does pastoral care differ from spiritual

care?

Can spiritual care really be integrated into the continuum of care?

What are the implications for multidisciplinary clinical practice?

Pastoral Care v. Spiritual Care

Pastoral Care has the following characteristics:The Carer is a sponsored representative of a

religious body with a MISSIONThis applies across all institutional settings (viz.,

hospitals, hospices, aged care facilities, mental health services, prisons, schools, Defence Force bases, etc)

The Carer is not a staff member or contractors/he is either a volunteer or is funded by the

sponsoring religious groupThe framework within which the care is offered is

predominantly (not exclusively) religious

Pastoral Care v. Spiritual Care

The institution sees Pastoral Care from a “rights” perspective. The availability of pastoral care facilitates the

institution’s legal obligation in relation to people’s rights to practice their religion as they choose.

The institution sees pastoral carers as “outsiders” with closely restricted access to data about patients, residents, clients, inmates, etc.

Pastoral Care v. Spiritual Care

Spiritual Care differs from Pastoral Care in the following ways: It focusses on the third part of the BODY-MIND-

SPIRIT trinity But recognises that it is only part of the equation

It is not necessarily religiously oriented It is accepted as relevant to what health etc

practitioners concern themselves withIt affects health etc outcomes (somehow)

Spiritual Care has subsumed Pastoral Care

Institutions in Queensland now want Spiritual Care not Pastoral CareSee Queensland Health’s Framework document of

November 2009They want it offered to everybody (irrespective of

religious commitment)They want it integrated into the continuum of careThey regulate who provides it (by appointment

processes) and how they do it (by accountabilities in Duty Statements etc)

PROBLEMS• Carers:

– Are motivated by their religious commitment to offer care to others

– Identify spiritual issues by reference to their own spiritual formation in their own religious tradition

– Describe their roles/function in religious terms – Use the resources of their own spiritual formation

when caring for others– Adopt a religiously inspired “anthropological”

understanding of what it means to be a human being (e.g., humankind are “damaged goods” who need to be restored to right relationship with their God; humans need enlightenment because they naturally tend to be self-delusional)

PROBLEMSPatients, Residents, Clients, Inmates etc:

Generally do not have a meaningful connection with a religious body (e.g., less than 11% of nominal Roman Catholics attend Mass regularly)

Often describe themselves as spiritual but not religious

Operate from a different “anthropological” understanding of what it means to be a human being (e.g., more akin the Maslow’s concept of “Eupsyche”)

Where do Mind and Spirit fit in Medicine?

Medicine advanced to its present stage by focusing on the body by adopting the paradigm of SYSTEM:Respiratory systemDigestive systemCardiovascular systemLymphatic systemUrinary systemEndocrine systemNervous systemReproductive system???Mental Health

Medicine’s current focusThe body’s various subsystems are tightly

integrated (e.g. the Renin-Angiotensin-Aldosterone system)

The body is not a “closed system” because it is affected by the physical environment (e.g., toxins), genetic predispositions, and the lifestyle choices of its “owner”

An increasing list of social “maladies” are treatable by medical intervention

The medicalisation of everything

Sexual dysfunction and poor performance

Infertility

Compulsions (alcohol, drugs, gambling, etc)

Criminality (chemical castration, anger, etc)

Grief

Fears and phobias

Body enhancements

Inattention and lack of alertness

Continuum of Care’s current challenge

Can MIND be explained as just a set of ontologically* objective biological processes?

Can SELF be explained in similar terms?

Can such “mechanisms” be explained whereby the structures of the SELF interact with the structures of the MIND in order to produce qualitative subjectivity?

* = its beginnings can be sourced

FORMS of KnowledgeWe are dealing with different forms of

knowledge:Physical Sciences are one form of Knowledge

(What is it? How does it work?)Medicine is another (What to do next?)MIND (SELF) and SPIRIT are yet others (Why is this

so?)

Boundary IssuesPastoral Care (versus Spiritual Care) does not

raise many boundary issues unless the carer strays into another party’s role:

Medical (offering opinions)Nursing (doing things for patients etc)Psychologists (offering CBT type interventions)Social Workers (organising things for patient/family)Other Allied Health such as Physios etc (doing

alternative therapies)

Boundary Issues (cont’d)Spiritual Care, on the other hand, raises

important issues about the scope and focus of the continuum of care: Is the scope solely on the body and brain?

To the exclusion of Mind & Spirit Is the focus solely on identifying problems that

can be resolved by clinical interventions?To the exclusion of assisting people to deal with their

own issues using their own resources

Scope of the Continuum of Care

Criteria for assessing the real scope of a continuum of care: Is health and well-being addressed or just illness

and accidents?Are the patient/resident/inmate’s religion and

spirituality seen as purely personal issues? Is a spiritual needs checklist part of the system?Are spiritual carers involved in: clinical team

meetings? Case Plans? Pathways and Protocols? Is a spiritual carer on the Ethics Committee?

Focus of the Continuum of Care

Criteria for assessing the real focus of a continuum of care:Are we identifying problems to be solved or issues

to be addressed?Are we doing something FOR the person or WITH

the person or to help the person HELP THEMSELVES?

Is attention being given to all of the BODY/MIND/BRAIN/SPIRIT continuum or only part of it?

What understanding of a human being underpins the focus of attention?

Boundary Issues that then arise for Spiritual Carers

HospitalsAccess to relevant data to do your job Inclusion in Care Plans & Pathways & ProtocolsReferrals to/from other practitionersGetting important information included in the NotesGetting acceptance of a different Ethical frameworkGetting acceptance of being independent of the

system and not a deliverer of consent for organs etcDealing with relatives on behalf of the other staffSpotting problems that might go unseen and knowing

how to express your concerns professionally

Boundary Issues that then arise for Spiritual Carers

Aged CareGetting residents’ Spiritual Care (versus just

religious needs) needs included in the Care PlanBeing kept closely informed about the mental

state and physical status of the residentsWorking closely with Care Plan writers, social

workers, diversionary therapy staff and volunteersProgramming and conducting events like memorial

daysHelping people to understand what is happeningCalming down distressed people

Boundary Issues that then arise for Spiritual Carers

Palliative CareTaking the pressure off really busy staffKeeping residents’ morale upHelping residents with End of Life decision-makingKeeping an eye out for distress, service failures, etcSupporting relatives

Mental HealthSpotting problems and doing referrals professionallyTaking the pressure off really busy staff

Boundary Issues that then arise for Spiritual Carers

PrisonsAbiding by the “nothing in: nothing out” ruleDealing professionally with bloody-minded

custodial staffSpotting problems and alerting staffOffering low level mental health careAssisting with the rehabilitation programAssisting with post-release programs

Boundary Issues that then arise for Spiritual Carers

SchoolsLow level counsellingReferralsLiaison with parentsMajor eventsPolly-filling

UniversitiesProvide a safe place to explore spiritual issues Integrate into University campus lifeBe available during periods of high pressure Provide an ear for students to talk about bad sexual

experiences

Boundary Issues that then arise for Spiritual Carers

Defence ForcesDeliver the “character building” programWork really closely with families (many

dysfunctional) Loss & grief issuesSpotting PTSD issuesSexual harassment issues