Referrals To Chaplains The Role Of Religion And Spirituality In Healthcare Settings


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Referrals To Chaplains The Role Of Religion And Spirituality In Healthcare Settings

  1. 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: ISSN 1367-4676 print/ISSN 1469-9737 online ß 2007 Taylor & Francis DOI: 10.1080/13674670600757064
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. References American Psychological Association. (1994). Diagnostic and statistical manual of mental disorders: DSM-IV (4th ed.). Washington, DC: Author. Blass, D. M. (2001). A conceptual framework for the interaction between psychiatry and religion. International Review of Psychiatry, 13, 79–85. Breakey, W. R. (2001). Psychiatry, spirituality and religion. International Review of Psychiatry, 13, 61–66. CARF International. (2004). Standards Manuel. Tucson, AZ: Commission on Accreditation of Rehabilitation Facilities, International. Chapman, T. R., Grossoehme, D. H. (2002). Adolescent patient and nurse referrals for pastoral care: A comparison of psychiatric vs. medical-surgical populations. Journal of Child and Adolescent Psychiatric Nursing, 15, 118–123. Clark, C. C., Cross, J. R., Deane, D. M., Lowry, L. W. (1991). Spirituality: Integral to quality care. Holistic Nursing Practice, 5, 67–76. Clark, P. A., Drain, M., Malone, M. P. (2003). Addressing patients’ emotional and spiritual needs. Joint Commission Journal on Quality and Safety, 29, 659–670. Coyle, B. R. (2001). Twelve myths of religion and psychiatry: Lessons for training psychiatrists in spiritually sensitive treatments. Mental Health, Religion and Culture, 4, 149–174. Curlin, F. A., Lantos, J. D., Roach, C. J., Sellergren, S. A., Chin, M. H. (2005). Religious characteristics of U. S. physicians: A national survey. Journal of General Internal Medicine, 20, 629–634. Danylchuk, L. S. (1992). The pastoral counselor as mental health professional: A comparison of the training of AAPC fellow pastoral counselors and licensed clinical social workers. Journal of Pastoral Care, 46, 382–391. Department of Health. (2003). Meeting the religious and spiritual needs of patients and staff. London: National Health Service. Ellison, C. G., Levin, J. S. (1998). The religion–health connection: Evidence, theory, and future directions. Health, Education and Behavior, 25, 700–720.
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