1. Mental Health, Religion & Culture
July 2007; 10(4): 363–377
Referrals to chaplains: The role of religion
and spirituality in healthcare settings
KATHLEEN GALEK1, KEVIN J. FLANNELLY1,
HAROLD G. KOENIG2, & REV. SARAH L. FOGG3
1
The HealthCare Chaplaincy, New York, USA, 2Duke University Medical Center,
Durham, USA, and 3Lawrence Hospital Center, Bronxville, USA
Abstract
Given the increasing importance of understanding how healthcare workers interact with
the principal person designated to meet patients’ spiritual needs— the chaplain— the
current study provides an inter-disciplinary perspective of the role of chaplains (and
spirituality) in patients’ emotional, physical, and spiritual health. The study surveyed
a randomly selected national sample of hospital directors in four disciplines: medicine
(n ¼ 278), nursing (n ¼ 230), social services (n ¼ 229), and pastoral care (n ¼ 470).
Participants rated the importance of referring patients to chaplains for four different
areas: pain/depression, anxiety/anger, treatment issues, and loss/death/meaning. Results
revealed significant differences in referral patterns for type of hospital, professional
discipline, the hospital’s religious affiliation, and self-reported spirituality. Results are
discussed in relation to historical views of spirituality and religion within the different
disciplines.
Introduction
Although the importance of religion and spirituality in coping with loss, stress,
and illness has long been recognized (Matthews et al., 1998; Pargament, 1997),
empirical research is just beginning to uncover the causal links between religion/
spirituality and physical and emotional health (Ellison & Levin, 1998; Koenig,
2004; Seeman, Dubin, & Seeman, 2003). Given the centrality of religion and
spirituality in healing, it has become increasingly more important to understand
how healthcare workers interact with the principal person designated to meet
the spiritual needs of patients— the chaplain. In the U.K., the National Health
Service has encouraged hospitals to appoint chaplains for over 50 years, and it
Correspondence: Kathleen Galek, The HealthCare Chaplaincy, 307 E 60th Street, New York,
NY 10022, USA. E-mail: Kgalek@healthcarechaplaincy.org
ISSN 1367-4676 print/ISSN 1469-9737 online ß 2007 Taylor & Francis
DOI: 10.1080/13674670600757064

2. 364 Kathleen Galek et al.
recently updated its guidelines for meeting the spiritual needs of patients
(Department of Health, 2003). By contrast, in the U.S., the value of spirituality
in healthcare has only recently been formally acknowledged through the
mandates of the Joint Commission on Accreditation for Health Care
Organizations (JCAHO) and the Commission on Accreditation of
Rehabilitation Facilities (CARF). These U.S. accreditation organizations have
established only minimal standards that hospitals conduct spiritual assessments
and make ‘‘arrangements’’ for meeting patients’ spiritual needs (CARF, 2004;
JCAHO, 2003).
Chaplains within the hospital setting must often rely on professionals in
other disciplines to make them aware of the spiritual needs and concerns of
patients (Handzo & Koenig, 2004). However, chaplains’ professional relation-
ships with those in other disciplines tend to vary with each discipline’s
perspectives about religion and spirituality. Many nurses, for example,
view spiritual care as an essential component to holistic treatment (Clark,
Cross, Deane, & Lowry, 1991; Narayanasamy & Owens, 2001; Sellers &
Haag, 1998). Many physicians, on the other hand, feel both unskilled and
uncomfortable exploring these concerns with their patients (Koenig, 2004; Lo
et al., 2002).
These divergent perspectives among disciplines are reflected in patterns of
hospital referrals to chaplains. For example, Koenig, Bearon, Hover, and Travis
(1991) assessed the recollections of staff at Duke University Medical Center
regarding their referral patterns and found that 86% of nurses made referrals to
chaplains, compared with 51% of physicians over a 6-month period. Flannelly,
Weaver, and Handzo (2003) found even greater differences between nurses and
physicians when examining actual referrals made during a 3-year study conducted
at Memorial Sloan Kettering Cancer Center. In that study, in which chaplains
regularly recorded the source of each referral they received, nurses made 83%
of all staff referrals of patients to chaplains, whereas physicians made only 3% of
the referrals. Social workers made approximately 4% of referrals to chaplains.
In the Koenig et al. (1991) study, differences in referrals to chaplains appeared
to be related to self-reported religiosity of physicians and nurses. Compared with
nurses, physicians in that study were less likely to profess a religious affiliation,
and they were also less likely than nurses to attend religious services on a regular
basis.
These studies, however, may misrepresent the true picture of referral patterns
for at least two reasons. First, nurses have more contact time with patients so they
may be more attuned to their needs, including those in the spiritual domain.
Second, physicians may make referrals through nurses, a possibility that was not
examined by Flannelly et al. (2003) or Koenig et al. (1991). Given these potential
confounds, we decided to conduct a survey of different hospital disciplines
in order to gage their impression of the importance that social workers, nurses,
and physicians place on referring patients to clergy under different sets of
circumstances. The exact same survey was also sent to hospital chaplains for
comparative purposes. Given past research, we hypothesized that nurses would be

3. Referrals to chaplains 365
the most likely to indicate that they would make referrals to chaplains and that
physicians would be least likely to do so.
Methods
Electronic lists containing the names and addresses of medical, nursing, social
services and pastoral care directors were purchased from American
Medical Information, Inc. A total of 4,000 questionnaires were mailed to
random samples of directors in four disciplines (1,000 per discipline) along with
a generic cover letter signed by The Chaplaincy’s clinical director. A reminder
was mailed to all the directors approximately 2 weeks after the initial mailing,
and a second identical questionnaire was mailed 2 weeks after that to encourage
participation.
A relatively low response rate for the medical directors prompted the authors to
take a second random sample from the list for this group. The second sample of
medical directors were mailed the same questionnaire with a different cover letter,
addressed to them by last name and signed by the research director and two
prominent physicians.
Participants
Of the 4,000 questionnaires that were mailed to directors, 1,500 were returned by
respondents from all 50 states. The response rates varied widely by discipline,
with 62.2% of pastoral care directors, 28.8% of social services directors,
and 26.4% of nursing directors returning questionnaires, excluding those
questionnaires that were undeliverable because the director had changed. While
only 10.6% of medical directors in the first sample responded, the response rate
for the second sample was 23.1%. Because of missing data, only 1,207
respondents were included in the analyses: 278 from medical directors,
230 from nursing directors, 229 from social worker directors, and 470 from
pastoral care directors.
Table I shows the demographic characteristics of participants, including age,
gender, and education. The table also shows the distribution of respondents by
geographic region. Of the 1,207 participants, 900 (74.6%) worked in general
hospitals, 78 (6.5%) were in specialty hospitals, 81 (6.7%) worked in psychiatric
hospitals, and 148 (12.3%) were in hospitals that had a combination of these
three types of facilities.
Questionnaire
The first part of the questionnaire obtained information about the demographic
characteristics of the participants, and the characteristics of their institutions.
The demographic characteristics were age, gender and level of education.
The institutional characteristics included patient census, type of hospital, and
whether the hospital was affiliated with a religious denomination. Two additional

4. 366 Kathleen Galek et al.
Table I. Demographic characteristics of respondents by discipline.
Nurses Social workers Physicians Chaplains
(n ¼ 230) (n ¼ 229) (n ¼ 278) (n ¼ 470)
Characteristics % % % %
Gender
Male 7.4 13.1 83.5 62.2
Female 92.6 86.9 16.5 37.8
Age
25–40 3.9 14.0 8.3 4.9
41–50 35.2 33.6 33.1 23.1
51–60 49.6 40.2 35.6 41.8
61þ 11.3 12.2 23.0 30.2
Education
No college degree 4.8 0.0 0.0 0.0
Bachelor’s 29.6 27.5 1.4 11.9
Master’s 61.7 72.1 0.7 70.1
Doctorate 3.9 0.4 97.8 18.0
Region of US
Northeast 21.3 20.1 23.4 18.9
Mid-west 28.7 35.8 31.7 34.8
South 30.9 29.3 25.2 28.9
West 19.1 14.8 19.8 17.4
items asked participants: ‘‘How religious are you?’’ and ‘‘How spiritual are you?’’
The response categories ranged from 0 (Not at all) to 5 (Extremely).
The body of the questionnaire asked participants how important it was
for treatment team members to refer patients to chaplains under various
situations or circumstances. Fifteen situations for potential referral were
listed, based on previous research (Flannelly et al., 2003; Flannelly, Handzo,
Weaver, & Smith, 2005; Fogg, Weaver, Flannelly, & Handzo, 2004). The
response categories were the same as those used for the religion and spirituality
questions.
Statistical analyses
An exploratory principle-components factor analysis with varimax rotation
was conducted on participants’ ratings of the 15 items to identify and group
them into broader categories of issues. Items with factor loadings of
greater than .5 on a given factor and less than .3 on the remaining factors
were retained in the study. The four constructs identified in the factor
analysis are described below. The mean ratings of these four constructs
were used as the dependent variables in a 4 Â 4 Â 4 MANCOVA, with
discipline and type of hospital as between factors. Religious affiliation of
the hospital, patient census, and participants’ age, gender, education,
religiousness, and spirituality were used as covariates, based on past research
(Flannelly et al., 2005).

5. Referrals to chaplains 367
Table II. Factor analysis of the potential reasons for referring patients to chaplains.
Factor/item Factor loadings Cronbach’s
Meaning, Loss, and Death 0.89
Has a pregnancy loss 0.69
Expresses feelings of grief or loss 0.81
Questions the meaning of life 0.82
Is facing impending death 0.79
Expresses feelings of guilt 0.69
Treatment Issues 0.89
Has difficulty with treatment decisions 0.75
Has an unanticipated adverse outcome 0.72
Is noncompliant with the treatment plan 0.81
Has a new diagnosis or change in diagnosis 0.75
Pain and Depression 0.87
Expresses sadness or loneliness 0.72
Is in serious pain 0.70
Is crying or upset 0.73
Anxiety and Anger 0.90
Is exhibiting anxiety or agitation 0.67
Is angry or complaining 0.68
Results
Factor analysis
Factor analysis yielded four general categories or types of issues that encompassed
14 of the 15 specific situations listed on the questionnaire in which one might
refer patients to chaplains. These four constructs were: (1) Meaning, Loss, and
Death—loss, grief, impending death, feelings of guilt, and questions about the
meaning of life; (2) Treatment Issues—change in diagnosis, unanticipated adverse
outcomes, noncompliance, or difficult treatment decisions; (3) Pain and
Depression—crying, feeling sad or lonely, or being in serious pain; (4) Anxiety
and Anger—complaining, expressing anxiety, agitation or anger. Table II shows
the factor loadings associated with the potential reasons for referring patients
to chaplains and the Cronbach alphas for the four factors.
Multivariate analyses
The analyses found statistically significant differences with respect to professional
discipline, type of hospital, and types of issues themselves. Directors from all
disciplines indicated that it was most important to refer patients to chaplains
for issues related to meaning. Other issues were rated significantly lower by
all directors, with anxiety and anger rated the lowest.
Effects of discipline. The analyses revealed a significant main effect for discipline
for all four dependent variables (see Table III). A significant interaction of
discipline and types of issues was also found in that some disciplines rated
the importance of some issues higher than others. Univariate analyses were
conducted to examine these interactions. Orthogonal contrasts showed that

6. 368 Kathleen Galek et al.
Table III. Mean importance of referring patients to chaplains for different types of issues
by discipline.
Medicine Nursing Social Services Pastoral Care Main effect of
(n ¼ 278) (n ¼ 230) (n ¼ 229) (n ¼ 470) discipline
Types of issues M SD M SD M SD M SD F 2
Meaning, Loss, 3.15 0.85 3.38 0.76 3.26 0.08 3.74 0.55 14.64* 0.19
and Death
Treatment 1.93 0.89 2.37 0.87 2.16 0.96 2.82 0.74 28.63* 0.18
Issues
Pain and 1.91 0.80 2.25 0.79 2.04 0.94 2.68 0.74 23.04* 0.14
Depression
Anxiety 1.56 0.86 1.84 0.93 1.63 0.94 2.47 0.84 30.06* 0.17
and Anger
* p50.001.
pastoral care directors gave importance ratings that were significantly higher
than the importance ratings given by the other three disciplines on treatment
issues, F(1, 1199) ¼ 148.54, p50.001, pain and depression, F(1, 1199) ¼ 90.92,
p50.001, anxiety and anger, F(1, 1199) ¼ 150.30, p50.001, and loss, death, and
meaning, F(1, 1199) ¼ 65.30, p50.001. Pastoral care directors believed it was
moderately to very important to refer patients to chaplains for these issues. With
the exception of meaning, loss, and death, participants in the other disciplines
generally thought it was somewhat or moderately important to refer patients to
chaplains for the kinds of reasons included in the survey. Although medical
directors’ ratings were the lowest for all types of issues, planned comparisons
found no difference between medical, nursing, and social service directors.
Effects of hospital type. Significant effects of hospital type and the interaction
of hospital type and type of issue were found for all four dependent variables
(see Table IV). An orthogonal comparison of psychiatric hospitals with all
other types of hospitals revealed that staff in psychiatric hospitals rated all
four categories of referrals lower than did staff in other types of hospitals.
The four factors include treatment issues, F(1, 1205) ¼ 33.50, p50.001, pain
and depression, F(1, 1205) ¼ 20.01, p50.001, anxiety and anger, F(1, 1205) ¼
38.11, p50.001, loss, death, and meaning, F(1, 1205) ¼ 21.11, p50.001.
No other planned comparisons among hospitals were significant.
A significant interaction between discipline and type of facility was found for
loss, meaning and death, F(1, 1182) ¼ 2.15, p50.05, but this mainly reflects the
substantial differences in the importance ratings that psychiatric staff gave to
the four types of issues. While psychiatric staff tended to generally agree with
staff from other hospitals that patients should be referred to chaplains for issues
related to meaning, loss, and death, they were substantially less likely to think
it was important to refer patients for treatment issues or emotional issues, espe-
cially anxiety and anger. Subsequent analysis revealed that medical and nursing

7. Referrals to chaplains 369
Table IV. Mean importance of referring patients to chaplains at different types of hospitals.
Types of hospitals
Psychiatry General Specialty Mixed Main effect of
(n ¼ 77) (n ¼ 899) (n ¼ 78) (n ¼ 148) hospital type
Types of issues M SD M SD M SD M SD F 2
Meaning, 3.03 0.08 3.42 0.02 3.42 0.08 3.56 0.06 6.91* 0.03
Loss, and
Death
Treatment 1.76 0.01 2.37 0.03 2.37 0.10 2.44 0.08 12.77* 0.03
Issues
Pain and 1.77 0.09 2.24 0.03 2.28 0.09 2.29 0.07 8.49* 0.03
Depression
Anxiety and 1.25 0.10 1.90 0.03 1.86 0.10 2.04 0.08 13.99* 0.05
Anger
* p50.001.
directors in psychiatric hospitals gave the lowest ratings to all types of issues,
F(1, 1197) ¼ 6.14, p50.05.
Effects of religion and spirituality. Participants who worked in religiously affiliated
hospitals were significantly more likely to believe it important to refer patients to
chaplains for all four types of issues. Participants’ rating of their own spirituality
was also significantly related to the four types of issues: treatment issues,
F(1, 1201) ¼ 21.83, p50.001, pain and depression, F(1,1201) ¼ 21.20,
p50.001, anxiety and anger, F(1,1201) ¼ 14.07, p50.001, loss, death, and
meaning, F(1, 1201) ¼ 28.50, p50.001. Participants’ self-reported religiosity did
not significantly affect the importance ratings, except in instances relating to loss,
death, and meaning, F(1, 1201) ¼ 4.00, p50.05.
Overall, physicians self-ratings of religiousness and spirituality were substan-
tially lower than that of other health professionals in the study. To examine
religious and spiritual differences among the disciplines more closely, we
performed a 4 Â 2 MANOVA with discipline as a between factor and religion
and spiritual as the within factor. A significant main effect of discipline was found
for both dependent variables. An orthogonal contrast between medical directors
and directors from social work and nursing revealed that physicians perceived
themselves as significantly less religious, F(1, 1204) ¼ 20.68, p50.001, and also
less spiritual, F(1, 1204) ¼ 90.65, p50.001. Not surprisingly, pastoral care
directors rated themselves as significantly more religious, F(1, 1204) ¼ 69.19,
p50.001, and more spiritual, F(1, 1204) ¼ 178.03, p50.001, than did the other
three disciplines.
Differences in self-reported spirituality, F(1, 1203) ¼ 10.95, p50.001, and
religion, F(1, 1203) ¼ 8.88, p50.001, were also found to vary by geographical
region. Of all four regions, participants from the South rated themselves
the highest in both religiosity and spirituality. By comparison, those living in

8. 370 Kathleen Galek et al.
the Northeast gave themselves the lowest ratings on both religion and spirituality.
Moreover, Southerners viewed religion and spirituality as being more closely
related than participants from other regions, while those living in the West viewed
the two concepts as being the most distinctly different.
Discussion
The present study contributes to our understanding of interdisciplinary
perspectives on religion, spirituality and chaplains within the healthcare system,
all of which are important areas for study since patients’ spiritual needs often go
unmet in hospitals and other healthcare settings (Clark, Drain, Malone, 2003;
Lo Brown, 1999; Narayanasamy Owens, 2001). Directors in each of the
surveyed disciplines (medicine, social work, nursing, and pastoral care) indicated
that it was most important to refer patients to chaplains for issues related to loss,
meaning, and death. Other issues were rated significantly lower by all directors,
with anxiety and anger rated the lowest. Interestingly, pastoral care directors
gave importance ratings to all four categories of patient problems that were
significantly higher than those assigned by the other three disciplines.
Nurses and physicians, devoted to caring for patients and curing their ills,
rightly pursue medical treatment until they feel they have done all they can for the
patient. It is not surprising, therefore, that patients are often referred to chaplains
only when medical interventions can no longer help the patient. For some
healthcare professionals, such a referral at this point would be untimely. Yet, for a
trained chaplain embarking with a patient through the valley of the shadow of
death, this can become one of the most rewarding parts of the patient’s journey.
For dying patients, evaluating what their life has meant, what it has contributed,
what is still left to do, how death will be faced, and what lies beyond assume
primary importance. For the patient facing these issues alone, end-of-life can be
both frightening and overwhelming. Yet, for the patient who explores them with a
compassionate, supportive presence, this time can often bring peace and spiritual
growth in the midst of chaos.
While nurses, physicians, and social workers indicated it was important to refer
patients to chaplains for end-of-life issues, they thought it much less important
to make referrals for issues related to treatment, pain and depression, and
anxiety and anger. Only directors of pastoral care believed that it was moderately
to very important to refer patients to chaplains in order to cope with these types
of issues. This may be because many healthcare professionals do not see a link
between physical symptoms and spiritual issues, and as such they tend to treat
these issues as medical or emotional as opposed to spiritual. Unlike chaplains,
most healthcare professionals would not think to connect unresolved grief,
chronic anxiety or demoralization with unresolved spiritual issues.
These differences in perspective among the disciplines may partly reflect
disparate views regarding the chaplain’s role. While healthcare professionals
may have experience with community clergy (who often do not have the
extensive clinical training intended to prepare them to deal with an array

9. Referrals to chaplains 371
of patient problems), they may not be aware of the comprehensive training
required to become a qualified chaplain. To become a certified member of
the Association of Professional Chaplains requires a minimum of four years of
undergraduate and three years of graduate training, along with 1,625 hours
of clinical supervision (Danylchuk, 1992). Thus, it is important for chaplains to
connect with other healthcare professionals in ways that help them understand
what chaplains actually do in ministering to patients, family, and staff. Through
such dialogue with chaplains, healthcare professionals may discover that
chaplains have the capacity to substantially aid patients and staff with a wide
variety of psychological, spiritual, and other hospital-related problems.
Religious and spiritual influences
Directors working in religiously affiliated hospitals were more likely than directors
at facilities with no religious affiliation to believe it was important to refer patients
to chaplains for all four types of issues. These findings indicate that the culture of
an institution may influence the attitudes of its clinical staff about the importance
of religious interventions and the importance of chaplains themselves. This may
partly reflect the active promotion of such values by the institution and/or the
common values of clinicians who choose to work at such institutions.
The current study found that participants’ perceptions of their own spirituality
influenced the importance they placed on referrals to chaplains. Specifically,
higher levels of self-reported spirituality were associated with increased likelihood
of referring patients to chaplains for all types of issues. Higher levels of religiosity
were associated with increased likelihood of referring patients to chaplains only
in situations related to loss, meaning, and death. Overall, physicians rated
themselves as significantly less spiritual and less religious than did the other
healthcare professionals in the study. Medical directors were also the least likely
to recognize the importance of referring patients to chaplains for any of the issues
covered by the survey.
Our findings show that individual values, particularly the strength of one’s
sense of spirituality, clearly influence one’s attitudes about the importance of
chaplains and the types of activities they perform. Although it was not the
intended purpose of the study to look at such differences, the national scope of
the sample allowed us to examine regional differences in religion and spirituality.
When we examined responses from individual regions of the United States— the
Northeast, Midwest, South, and West— we found some interesting variations.
Of all four regions, participants from the South viewed themselves as being both
the most religious and the most spiritual. By comparison, those living in
the Northeast gave themselves the lowest ratings on both religion and spirituality.
We also looked at how intertwined spirituality and religion are in the hearts and
minds of those living in different regions. Southerners saw religion and spirituality
as being more closely related than any group in the US, while those living
in Western states saw the two concepts as being the most distinctly different.
Such differences may reflect to varying degrees the impact of urbanization and

10. 372 Kathleen Galek et al.
industrialization in the Northeast, the organizing centrality of Christianity in the
South, and the openness of the West to incorporating Eastern-based philosophies
into their belief systems.
Spiritual care in mental-health settings
Significant differences in referral patterns were also found between types of
hospitals. In particular, medical and nursing directors in psychiatric settings felt
that it was less important to refer patients to chaplains for all types of issues than
did directors at general hospitals, rehabilitation facilities, long-term care facilities,
and other specialty hospitals. Given the training of professionals in psychiatric
settings, it might make sense that they would see themselves as better able than
chaplains to cope with patients’ agitation, depression, and anger. Chapman and
Grossoehme (2002) provide limited data on psychiatric nurses indicating that
this appears to be the case, at least for depression. It does not follow, however,
that they should be less inclined to refer patients to chaplains to deal with
issues of loss, meaning, and death, which fall within the traditional realm of
the chaplain.
Chapman and Grossoehme’s (2002) findings are of additional interest because
they show that nurses in psychiatric units make fewer referrals to chaplains than
do nurses on other units in the same hospital. The authors conducted an
18-month review of adolescent patients’ records (ages 10–22) in a pediatric
hospital that contained a psychiatric unit. In all hospital units except psychiatry,
nurses made 77% of referrals to chaplains, with the remaining 23% being self-
referrals. This picture was reversed for the psychiatric unit, where only 10% of
referrals to chaplains were made by nurses, and the remaining 90% were self-
referrals. Roughly half of the psychiatric nurses’ referrals to chaplains were for
anxiety or fear, whereas most of the self-referrals from psychiatric patients were
for guilt issues (36%). None of the referrals from psychiatric nurses were for guilt.
These findings about nurses may seem surprising since nursing has a history
of affirming the importance of religion and spirituality (Clark et al., 1991;
Post, 1992; Sellers Haag, 1998), and nursing explicitly incorporated spirituality
into its clinical diagnostic nomenclature in 1988 (North American Nursing
Diagnosis Association, 1992). Indeed, the founder of modern nursing Florence
Nightingale taught that spirituality was intrinsic to human experience and
compatible with scientific inquiry (Macrae, 1995).
The findings of Chapman and Grossoehme (2002) are less surprising when
we look at the culture of mental-health services, which stands in contrast to the
legacy of attitudes within nursing. Whereas the founder of modern nursing,
Florence Nightingale, taught that spirituality was intrinsic to human experience
and compatible with scientific inquiry (Macrae, 1995), the founder of modern
psychiatry, Sigmund Freud (1962), spent time trying to discredit religion in
his writings as the ‘‘the universal obsessional neurosis of humanity; like the
obsessional neurosis of children’’ (p. 43). Moreover while the discipline of
nursing has explicitly recognized the importance of spirituality in its clinical

11. Referrals to chaplains 373
diagnostic nomenclature since 1988 (North American Nursing Diagnosis
Association, 1992), psychiatric nosology has tended to denigrate spirituality
and religion. Post (1992) chronicles the negative bias against religion apparent
in the DSM-III-R (the diagnostic standard in psychology and psychiatry)
which used religious behavior in 23% of its examples of psychopathology.
However, on an up-note, not only have negative illustrations of spirituality
been eliminated from the DSM-IV (American Psychological Association, 1994),
but an entry has been included that highlights religious and spiritual problems,
such as experiences that involve loss or a questioning of faith. The inclusion
of this code may increase the sensitivity of mental health professionals to these
types of issues.
Two related articles about clients and staff of mental-health services in
Somerset, UK provide some interesting insights (Foskett, Marriott,
Wilson-Rudd, 2004; MacMin Foskett, 2004). Clients not only indicated that
they wanted to talk about their spirituality and find meaning in their suffering,
but also viewed their spirituality as a resource and felt frustrated that staff
either ignored their spirituality or viewed it as a symptom of their illness
(MacMin Foskett, 2004). Staff insisted on treating only the medical aspect
of clients’ illness, thwarting clients’ search for meaning and undermining its role
in recovery. A study of a mental-health facility in the U.S. reported similar results
in that patients felt that their religiosity and spirituality were important sources of
comfort and support that staff mainly ignored (Fitchett, Burton, Sivan, 1997).
Moreover, even though studies have found religion to provide comfort to
psychiatric patients (Neeleman and Lewis, 1994), a study by Neeleman and
King (1993) found that the majority (58%) of psychiatrists surveyed at London
teaching hospitals had never referred patients to clergy, and more than half of
those thought it was a patient’s responsibility to initiate such contact.
Interestingly, Foskett et al.’s (2004) study including nurses, social workers,
psychologists, psychiatrists, and occupational therapists found that staff were
split in their opinions about whether religious beliefs protect people from mental
illness (39%) or contribute to mental illness (45%). These disparate opinions
presumably affected their inclination to refer clients to chaplains or other clergy.
Sixty-one percent said they had never referred a client to clergy, whereas 34%
said they had done so at least once. Staff responses were similar when
specifically asked about referring clients to chaplains, with 63% indicating they
had never done so, and 28% saying they had done so ‘‘occasionally’’ or
‘‘very occasionally.’’ In the opinion of at least one staff member, ‘‘This is not
the role of staff’’ (Foskett et al., 2004, p. 16).
Culture of psychiatry
Psychiatrists, like other physicians, tend to be less religious than their patients
(Neeleman King, 1993; Neeleman Persaud, 1995) and the general
population (Curlin, Lantos, Roach, Sellergren, Chin, 2005; Oyama
Koenig, 1998). While this may be partly due to self-selection among individuals

12. 374 Kathleen Galek et al.
who enter medicine, the culture of psychiatry probably contributes to this
situation. The culture of psychiatry and its specific knowledge base, educational
curriculum, nomenclature, professional organizations, and standards of practice
all diminish, if not dismiss, the importance of religious practices and beliefs
(Breakey, 2001; Coyle, 2001; Foskett et al., 2004; Neeleman Persaud, 1995;
Sansone, Khatain, Rodenhauser, 1990). As a branch of medicine, the
philosophical foundations and practice of psychiatry are rooted in scientific
materialism and determinism (Blass, 2001; Foskett et al., 2004; Levin, 1994;
Neeleman Persaud, 1995). Although the tenants of science are not opposed
to religion, Silvestri, Knittig, Zoller, and Nietert (2003) suggest that training
in medicine focuses so much on scientific reasoning that it tends to preclude
discussion or exploration of issues of religion and faith. Historical events, such as
Freud’s open hostility to religion, have also led psychiatry to ignore religion
(Breakey, 2001; Freud, 1962; Neeleman Persaud, 1995).
However, the culture of psychiatry is becoming more open to religion and
spirituality (Blass, 2001). In the U.S., not only have negative illustrations of
spirituality been eliminated from the DSM-IV (American Psychological
Association, 1994), but also courses on religion have greatly increased in medical
schools in recent years (Puchalski, Larson, Lu, 2001), which may counteract
some of physicians’ reasons for not addressing spirituality with their patients—the
belief that they are not adequately trained, are uncomfortable with the topic,
and do not think it is their role (Koenig, 2004). Nonetheless, it is not yet clear
to what degree these changes have helped to close what has been called the
‘‘religiosity gap’’ in psychiatry (Coyle, 2001).
Conclusions
There is a growing body of evidence suggesting that religious beliefs impact
patients’ treatment decisions as well as their physical and emotional health.
In a study of patients with advanced lung cancer, Silvestri et al. (2003) found that
when deciding between different treatment options, patients ranked their faith
in God as second among factors influencing their chemotherapy treatment
decisions, followed by the ability of treatment to cure the disease, side effects,
family doctor’s recommendations, spouse’s recommendation, and children’s
recommendations. Both patients and caregivers rated faith in God as second to
only their oncologists’ recommendations. By contrast, physicians in that study
believed that a person’s religious faith should be the least important factor
patients should consider when weighing treatment options.
To the degree that faith plays a large role in patients’ decision-making and
coping with illness, it would behoove healthcare professionals to seek the advice
of chaplains. Moreover, to the extent that healthcare professionals do not see
the relevance of referring patients to chaplains for treatment issues, this creates
a professional gap in patient care that leaves patients without guidance and
counsel regarding religion, spirituality, and related issues.

13. Referrals to chaplains 375
Nonetheless, there is a growing consensus that healthcare professionals should
be at least aware of their patients’ spiritual needs and concerns (Neumann
Olive, 2003; Olive, 1995). King and Wells (2003) go further, suggesting that it is
not enough to just address these issues, but that professionals should convey their
patients’ beliefs and values to other members of the treatment team. Like King
and Wells (2003) and Koenig (2002, 2004), Puchalski and Romer (2000)
emphasize the need to move ‘‘back to those compassionate, caregiving
roots of the patient–doctor relationship’’ (p. 129), and certainly chaplains can
help healthcare professionals fulfill this goal (Handzo Koenig, 2004;
VandeCreek, 1997).
Acknowledgements
The authors gratefully acknowledge the generous support of the John Templeton
Foundation, The Arthur Vining Davis Foundations, and The Starr Foundation.
The authors also thank the research department’s Research Librarian,
Helen P. Tannenbaum, and Research Assistant, Kathryn Murphy, for their
assistance in preparing this article.
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