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Selling Spiritual Care, Part II

On December 12, 2017 and again on March 6, 2018, Rev. Eric J. Hall, President and CEO of Health Care Chaplaincy Network (HCCN) and its affiliated Spiritual Care Association (SCA), lobbied  on Capitol Hill “to  support legislation pending in Congress to expand access to quality spiritual care.” (“SCA visits Capitol Hill to increase spiritual care awareness,” myemail.constantcontact.com)  Specifically, “he emphasized the need for federal policies to include chaplains and spiritual care professionals as members of the integrated care teams serving patients, while noting that the American Medical Association recently adopted a resolution underscoring the importance of spiritual care.” (“SCA President & CEO Promotes Increased Awareness, Access to Spiritual Care,” mail.google.com)

Rev. Hall represents two aggressively promoted faith-based chaplain-training organizations professing commitment “to help people faced with illness and grief find comfort and meaning – whoever they are, whatever they believe, wherever they are.” (“SCA visits Capitol Hill to increase spiritual care awareness,” Ibid)  Yet his stated aim in visiting with “key members of Congress” was to “advocate increased awareness of the importance of spiritual care,” not to advocate for increased awareness of the importance of quality health care for everyone – “whoever they are.”

HCCN and SCA’s present emphasis on “the importance of spiritual care” is similar to their urging “consumers and health professionals” a year ago to sign a petition to send a strong message to Congress that “spiritual care matters.” Never mind that millions of Americans, at that time, would have lost their health care coverage if the Republicans’ original American Health Care bill had passed. (See Alberts, ”Selling Spiritual Care,” CounterPunch, April 28, 2017)

My aim in this essay is not to minimize the importance of providing spiritual care for sick persons who are fortunate enough to receive medical care in hospitals and other health care settings.  As a full-time hospital chaplain for over 18 years at Boston Medical Center, I witnessed firsthand the importance of providing spiritual care to countless patients of diverse beliefs. (See Alberts, A Hospital Chaplain at the Crossroads of Humanity)

Rather, my focus is the apparent self-serving motivation of two aggressively promoted clinical pastoral training organizations, whose overriding concern appears to be getting a piece of the health care pieto expand their own livelihood, not the threat of the pie shrinking and diminishing the livelihoods of millions of Americans.  They seem to be more about justifying the access of theirspiritual care services, than about the justice of everyone receiving access to quality health care.  Consider the following realities.

SCA and HCCN CEO Rev. Hall’s lobbying efforts on behalf of “expand[ing] access to quality spiritual care” contain no reference to the reported  “28 million Americans [who] are currently uninsured, and millions more [who] could lose coverage under policy reforms proposed in Congress.”  These alarming numbers should lead all faith-based organizations specializing in the spiritual care of ill persons to advocate access to health care for all Americans, because of the documented “current evidence . . . that health insurance saves lives.” (“The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?,” By Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD, Annals of Internal Medicine, Sept. 19, 2017)

Sadly, it appears Rev. Hall did not give voice to a critical reality: “A comprehensive review of studies, published in the Annals of Internal Medicine, confirms that thousands of people die each year because they do not have coverage. (“Lack of health insurance and U.S. mortality,” Physicians for a National Health Program, www.pnhp.org)  There was also no mention by Hall of “the Gallup-Sharecare Well-Being Index” finding, that “the number of Americans without health insurance rose by 1.3 percentage points in 2017, representing about 3.2 million people.” (“Number of uninsured Americans increased by over 3M in Trump’s first year: Gallup,” By Max Greenwood, The Hill,Jan. 16, 2018)

Similarly, the Henry J. Kaiser Family Foundation published “key facts” on millions of uninsured Americans – “27.6 million in 2016” — whose dire realities seem beyond the scope of Rev. Hall’s lobbying efforts for “expand[ing] access to quality spiritual care.”  The Kaiser Foundation reports that “even under the ACA [Affordable Care Act], many uninsured people cite the high cost of insurance as the main reason they lack coverage.”  Also, “most uninsured people are in low-income families,” with “people of color . . . at higher risk of being uninsured than non-Hispanic Whites.”  And people who are “uninsured are less likely than those with insurance to receive preventive care and services for major health conditions and chronic illnesses.”  Finally, “the uninsured often face unaffordable medical bills when they do seek care.” (“Key Facts about the Uninsured Population,” The Henry J. Kaiser Foundation, Nov. 2017)

Even for Americans who are insured, public policy expert Helaine Olen cites “a more pedestrian reality.”  She writes, “Just because a person is insured, it doesn’t mean he or she can actually afford their doctor, hospital, pharmaceutical, and other medical bills.” Her reality check is based on a “report on the Economic Well-Being of U.S. Households,” which “found that 44 percent of adult Americans claim they could not come up with the $400 in an emergency without turning to credit cards, family and friends, or selling off possessions.” (“Even the Insured Often Can’t Afford Their Medical Bills” The Atlantic, June 18, 2017)

The overriding issue for residents in many communities is not “access to quality spiritual care,” but lack of access to quality health care facilities. A Pittsburgh Post-Gazette/Milwaukee Journal Sentinel story reveals a medical catch-22 for economically limited persons. Their “analysis of data for the largest U.S. metropolitan areas shows that people in poor neighborhoods are less healthy than their affluent neighbors but more likely to live in areas with physician shortages and closed hospitals.”  Thus, “at a time when research shows that being poor is highly correlated with poor health, hospitals and doctors are following privately insured patients to more affluent areas rather than remaining anchored in communities with the greatest health care needs.”  The result is that some “230 hospitals opened since 2000 are in wealthier, mostly suburban areas,” and “the number of hospitals in 52 major cities in the United States has fallen from its peak of 781 in 1970 to 426 in 2010, a drop of 46 percent.” (“Poor Health: Barriers to Health Care for Low-Income America,” By Lillian Thomas, et al, newsinteractive.post-gazette.com)

In his March 6, 2018 visit to Capitol Hill, SCA CEO Rev. Hall met with four Republican Congresspersons. There was no reported discussion with them about the recently passed Republican budget that benefits the wealthiest Americans and adds at least $1 trillion to the national deficit.  Nor about “top Republicans” reported to be talking about resolving the deficit by cutting “Social Security, Medicare, and food stamps.” (“Top Republicans are already talking about cutting Medicare and Social Security next,” By Tara Golshan, Vox, Dec. 20, 2017)  Such a Republican move would create even worse economic conditions for millions of Americans, putting quality health care even further beyond their reach.

Another reality confirmed by hard data and facts is the disparities in access to health care, which was not at all included in Rev. Hall’s lobbying “to promote legislative and regulatory initiatives to expand access to quality spiritual care.”  These disparities are reported in a brief issued by the Henry J.Kaiser Family Foundation, which begins: “People of color historically have been more likely to be uninsured and to face more barriers accessing care than Whites.” And, “People of color also have lower utilization of care compared to Whites and have worse measures of health status and health outcomes.”

Furthermore, a higher percentage of nonelderly Hispanic, Black and Asian persons are uninsured than White persons.  But that reality is not meant to minimize another reality: the still uninsured millions of economically impoverished White persons. (“Health Coverage by Race and Ethnicity: Changes Under the ACA,” By Samantha Artiga, Julia Foutz, and Anthony Damico, Jan. 26, 2018)

The above data reveal that poor people – impoverished people of color especially and white persons as well — are the least insured and suffer a greater number of illnesses and deaths.  This reality reveals both the racist and classist status quo of access to health care in America ‘s white-privileged hierarchy of access to the pursuits of happiness and health.  A status quo which the Spiritual Care Association and its parenting Health Care Chaplaincy Network apparently find morally acceptable.

My assumption that these two prominent specialized spiritual care organizations are unconsciously driven by a white-privileged mindset is not only based on the two communications detailing Rev. Hall’s lobbying visits to Capitol Hill. Their literature is also revealing.  Such as the Spiritual Care Association’s “White Paper” on “SPIRITUAL CARE; What It Means, Why It Matters in Health Care.” This document states that “spirituality and religion have always been central to the lives of the vast majority of Americans.”  An expert is then quoted to buttress the statement: “Researcher William Miller claims that ‘most people want to live with better health, less disease, greater inner peace, and a fuller sense of meaning, direction and satisfaction in their lives.’ ” (By Revs. Eric J. Hall, Brian P. Hughes and George H. Handzo, HealthCare Chaplaincy Network, Oct. 2016)

The authors’ own unconscious privileged conditioning in America’s racial and class hierarchy of access to political, economic, legal and religious power is unmasked here.  The authors fail to specify what “better health, less disease, greater inner peace and a fuller sense of meaning, direction and satisfaction” would involve for economically impoverished people of color, poor white persons, LGBTQ persons, immigrants, Jews and Muslim Americans. (See Alberts, “Grandiose Marketing of Spirituality,”Counterpunch, Feb. 24, 2017) Lumping everyone together as “the vast majority of Americans” and “most people” usually means “white” Americans, if the persons using these sweeping categorizations are white.

There is also Health Care Chaplaincy Network’s document, ‘TIME TO MOVE FORWARD’ (with two Appendices) which calls for “a new model of spiritual care” to address “spiritual pain.”  The “components — . . . designed by and implemented through the Spiritual Care Association – reflect what thought leaders in the field have sought for many years in order to advance the field and give more people in spiritual pain the quality spiritual care they deserve.” (Contributors: Revs. Eric J. Hall, George H. Handzo and Rev. Kevin Massey, May 2016)

This “new model of spiritual care” recognizes that “chaplaincy care had not been able to demonstrate value because defined, evidence-based quality indicators and competencies did not exist.”  Chaplains’ lack of proven “value” is a negative, because “health care providers and payers are increasingly focused on value derived from quality outcomes.”   The “Time to Move Forward” authors stress that all health care services “are being judged – and funded – by the value of what they add to the system with value defined as Quality/Cost.”  And, “in the U.S., the major quality goals are known as the ‘triple aims’: improved medical outcomes, reduced costs, and patient satisfaction.” (Ibid)

Thus chaplains need to demonstrate their worth in the health care marketplace.   They are required to produce “client satisfaction,” which involves accurately assessing and meeting “clients’ spiritual needs.”  Their “value” requires that they demonstrate measurable outcomes: seen in “spiritual care that reduces spiritual distress . . . increases clients’ sense of peace . . . facilitates meaning-making for clients and family members” and “increases spiritual well-being.”  These “Quality Indicators” address the question: “What is quality spiritual care and how do you measure it?” (‘TIME TO MOVE FORWARD,’ APPENDIX: “Quality Indicators,” Released February 17, 2016)

But in asking, “What is quality spiritual care in health care and how do you measure it?,” the authors do not define the nature and causes of “spiritual pain” nor the nature of “quality spiritual care” and how it reduces “spiritual distress,” enables “peace” and ”furthers meaning-making for clients and family members.”  One is left to pursue their meanings in the sources listed at the end of the document’s “Quality Indicators” APPENDIX.

The HealthCare Chaplaincy Network’s“new model of spiritual care” is commendable in its efforts to research and document quality spiritual care. However, this could result in a checklist template approach to spiritual care – with down-to-earth, flesh-and-blood realities spiritually circumscribed.  Still, HCCN’s objective of measuring “quality spiritual care” through evidence-based “patient satisfaction” is greatly needed.

But the fact that most of the “clients” referenced in the HCCN-produced  document “Scope of Practice” are actually patientsin hospitals and other institutional health care settings suggests a business mentality, whose bottom line is not only “client satisfaction,” but justification for professional spiritual caregivers’ receiving a piece of the shrinking healthcare pie. (‘TIME TO MOVE FORWARD,’ APPENDIX: Scope of Practice, released March 16, 2016)  This business mentality may also be seen in the Spiritual Care Association and HealthCare Chaplaincy Network offering fee-based courses in spiritual care to doctors, nurses, social workers and other health care professionals. ( See “Welcome to the SCA Learning Center,” Spiritual Care Association)

Here, the importance of delineating the professional boundaries between physicians, nurses, social workers and chaplains is superficially discussed by the two organizations and remains clouded. (“Spiritual Care: What It Means, Why It Matters in Health Care,” pages 7-8, Ibid)  This expansion of spiritual care training to include most hospital staff is believed to be a marketing effort to grow SCA and HCCN, and further their apparent self-legitimizing role that makes invisible fundamental challenges of race, racism and classism.

One might argue that economic political and legal concerns of patients are the domain of social workers.  Of course, social workers utilize community resources on behalf of patients.  But these broader concerns involved in caring for “the whole person” are also the domain of specialized spiritual caregivers.  Such holistic spiritual caring is grounded in the chaplains’ own faith traditions.  As the Book of Proverbs states, “Speak up for those who cannot speak for themselves, for the rights of all who are destitute. Speak up and judge fairly; defend the rights of the poor and needy.” (31: 8-9)  And as Jesus said, “The thief comes only to steal and kill and destroy.  I have come that they may have life, and have it abundantly.” (John 10: 10)

“Spiritual pain?”  If a hospital chaplain were to say to a patient, “Within the past 12 months, did you run out of the food and not have money to get more?,” and the patient says “Yes,” would that patient’s lack of food cause “spiritual pain?”  If a chaplain were to ask, “Do you have trouble paying for medicines?,” and a patient states “Yes,” does that cause spiritual as well as physical distress?  If a chaplain might say to a patient, “Do you have trouble getting transportation to medical appointments?,” and the patient answers “Yes,” does that reality adversely affect the patient’s spiritual well-being?  If a chaplain were to inquire of a patient, “Do you have trouble paying your heating or electric bill?,” and the patient says “Yes,” does that cold fact dishearten his or her spiritual peace of mind?  If a chaplain were to say, “Do you have trouble taking care of a child, family member or friend?,” and a patients nods “Yes,” how might that concern undermine “meaning-making?”  And if a chaplain thought of asking, “Are you currently unemployed and looking for a job?,” and a patient says, “Yes, and I’m an undocumented immigrant,” how might that condition confine a patient’s faith, and how should a chaplain respond?

Most of the above are screening questions Boston Medical Center (BMC) intake staff  ask patients. Similar kinds of questions should be part of a chaplain’s frame of reference in attempting to discern and address the economic, political, legal and religious causes of many patients’ “spiritual pain.”

The HealthCare Chaplaincy Network and its affiliated Spiritual Care Association emphasize that treating “the whole person” should include spiritual as well as medical care.  Yet their “new model of spiritual care” lacks any substantive reference to the economic, political and legal realities – similar to BMC’s screening questions — that often reinforce or undermine the spiritual peace and empowerment of “the whole person.”  An example of this lack is their “Scope of Practice” document that defines the chaplain’s role as including “integrat[ing] knowledge of specific community-based resources such as hospice, home health, long-term-care, counseling, and grief and bereavement services into discharge and continuity of care plans.”

The community resources listed in HCCN and SCA’s “Scope of Practice” document are important to access on behalf of patients.  But these resources are likely to cost money, which white persons are more likely able to afford.  The two organizations’ lack of referencing community-based political, economic, housing, legal, civil and human rights support and advocacy groups is assumed to betray a white-circumscribed mindset of these spiritual care specialists.  If questions regarding a patient’s economic, political and legal realities are determined to be beyond the “scope of practice” of chaplaincy-training organizations, the organizations should stop talking about providing “quality spiritual care” for “the whole person.”

HCCN and SCA’s “Scope of Practice” guide stresses that a chaplain develop “cultural competency.”  Here “the chaplain provides client-centered, family-focused spiritual care that understands and respect diversity in all its dimensions and takes into account cultural and linguistic needs.” (Ibid)  Such cultural competency is important.  Missing, however, is political competency, which enables a chaplain to understand and address the political, economic, legal and even religious forces that contribute to the ill health and spiritual distress of patients and their families.

But political competency is a mine field for chaplains and other faith leaders.  Today’s Exhibit A is House of Representatives Chaplain and Jesuit priest, Fr. Patrick J. Conroy who was recently fired by Speaker Paul D. Ryan, allegedly for praying for divine guidance for the Republican-controlled Representatives as they deliberated overhauling the tax code to the tune of $1.5 trillion.  Conroy’s prayer: “May all members be mindful that the institutions and structures of our great nation guarantee the opportunities that have allowed some to achieve great success, while others continue to struggle.”  His prayer for the Representatives continued: “May their efforts these days guarantee that there are not winners and losers under new tax laws, but benefits balanced and shared by all Americans.” (“Firing of House Chaplain Causes Uproar on Capitol Hill,” By Elizabeth Dias and Sheryl Gay Stolberg, The New York Times, April 27, 2018)

That was not the kind of spiritual guidance the Republican-controlled, wealthy-favored House of Representatives had in mind.  Chaplain Conroy said that Speaker Ryan told him, “Padre, you just got to stay out of politics.”  Nor was Ryan the only Representative turned off by Conroy’s prayer. Conroy reported that “a staffer . . . said, ‘We are upset with this prayer; you are getting too political,’ which, suggested to Conroy “ ‘that there are members who have talked to him about being upset with that prayer.’ ”(“Ousted House chaplain: Ryan told me to ‘stay out of politics,’ ”By Julia Manchester, TheHill,April 26, 2018)

The Spiritual Care Association and HealthCare Chaplaincy Network know where their bread is buttered.  Advocating for access to quality health care for everyone would not set well with numerous political powers that control the health care – and other wealthy-favored- — purse strings.  Thus it is much wiser to lobby for “access to quality spiritual care” than also for “benefits balanced and shared by all Americans,” as Chaplain Conroy prayerfully urged.

Along with political competency, missing also from SCA and HCCN’s “Scope of Practice” is community competency.   Urban policy specialist Dr. James Jennings writes of the importance of moving “from cultural competency to community competency.”  Jennings states that the “delivery of health care services is limited and incomplete in responding to health challenges in US low income urban communities . . . where problems of poverty, unemployment, bad housing, toxic air, and dirty streets are found in greater levels than other places.”  He says that “community health centers must move beyond simply being culturally sensitive or reflective of local groups.”  Which means: “Those interested in enhancing the well-being of residents in low-income and impoverished neighborhoods must become familiar with discourses and strategies which reduce wealth and power inequities,” and work with “non-health organizations seeking to challenge the local and spatial manifestations of inequality.”  Jennings links “better health for all people with a more just society.” (“Community Health Centers in U.S. Inner Cities: From Cultural Competency to Community Competency,Ethnicity and Race in a Changing World: A Review Journal, Winter 2009)

In an earlier article, “Much Needed Prophetic Voices,” I surveyed the monthly newsletters (for a year) of the Association for Clinical Pastoral Education (ACPE), which describes itself as “The Standard for Spiritual Care & Education,” and as “the premier, DOE [Department of Education]-recognized organization and that provides the highest quality CPE [Clinical Pastoral Education] programs for spiritual care professionals of any faith and in any setting.” (“ACPE: About Us.”www.acpe.edu)  My survey found little data to support ACPE’s stated “Vision . . . to create measurable and appreciative improvement in spiritual health that transforms people and communities in the US and across the globe.” (“ACPE: Vision,”www.acpe.edu)  There was no “measurable and appreciable” research, education or commentary on how physical, emotional or spiritual effects of economic inequality, racism, xenophobia, Islamophobia, homophobia, or the militarization of America are undermining the “spiritual health . . .  [of] people and communities in the US and across the globe.” (“Much Needed Prophetic Voices,”Counterpunch, Nov. 28, 2017)

I emailed my article that was critical of ACPE to the organization’s Executive Director/CEO, Rev. Trace Haythorn, Ph.D.  I was pleasantly surprised by his reply.

Rev. Alberts,

You may be pleased and/or surprised to know that the ACPE Board of Directors just appointed a national advocacy committee, something missing in all CPE-related organizations until now [italics added].  I look forward to their leadership in advocating for CPE and the people we serve. (Nov. 28, 2017)

Rev. Haythorn’s recognition that advocacy committees have been “missing in all CPE-related organizations until now” is revealing.  His response is also hopeful, in that ACPE is initiating a much needed model for other faith-based organizations — including SCA and HCCN — that train and certify specialized spiritual caregivers working in healthcare institutions.  Whether ACPE’s advocating for the people who need medical care becomes as important as advocating for its spiritual services remains to be seen.

Lobbying for “quality spiritual care” for “the whole person” must include lobbying for quality health care for all persons.  This is the business of spiritual care professionals, and not only of the social justice arms of their faith groups. Indeed, empathy and advocacy are interrelated.

More articles by:

Rev. William E. Alberts, Ph.D., a former hospital chaplain at Boston Medical Center, is both a Unitarian Universalist and United Methodist minister. His new book, The Counterpunching Minister (who couldn’t be “preyed” away) is now published and available on Amazon.com. The book’s Foreword, Drawing the Line, is written by Counterpunch editor, Jeffrey St. Clair. Alberts is also author of A Hospital Chaplain at the Crossroads of Humanity, which “demonstrates what top-notch pastoral care looks like, feels like, maybe even smells like,” states the review in the Journal of Pastoral Care & Counseling. His e-mail address is wm.alberts@gmail.com.

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