The Chaplain-Physician Relationship

Larry Van De Creek

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9781138988880
• eBook ISBN: 9781317940289
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Learn how to establish and maintain effective relationships with physicians with this authoritative new book. Chaplains will discover a wealth of information and insight into the often strained chaplain-physician relationship and will learn practical steps they can take to strengthen the ties between two very different professions. Each chapter, written by a chaplain with a history of successful collaboration with physicians, features important examples of interdisciplinary cooperative effort in various settings including obstetrics, geriatrics, and outpatient cardiac rehabilitation centers. Hospital chaplains, especially those who wish to improve their relationships with physicians and hospital administrators will find this to be an invaluable book, as will pastoral counselors not presently involved with hospitals who desire to work with physicians in health and illness settings.Highlights of the book include:

• an inside view of medical education and practice, with a description of the dilemmas of medical practice which are very different from those in ministry
• A constructive look at "doctor bashing" in which many chaplains engage, often unknowingly
• a description of pastoral care efforts in discrete patient care areas that involve close relationships to physicians, with an emphasis on friendship and informal contacts
• an overview of a program in which the chaplains's role is expanded to that of a behavioral medicine consultant

The Chaplain/Pastoral Counselor as a Behavioral Medicine Consultant in Cardiac Rehabilitation: A Team Approach

Richard D. Underwood, DMin

Brenda B. Underwood, RN, BSN

Donald Mosley, MD

Richard D. Underwood is Pastoral Counseling Consultant and Co-Clinical Director, Brenda B. Underwood is Cardiac Rehabilitation Manager and Co-Clinical Director, both with the Hypertension Clinic, Center for Health Promotion and Rehabilitation, Humana Hospital-Suburban, 4001 Dutchman’s Lane, Louisville, KY 40207. Donald Mosley is retired from private practice in Cardiology, Louisville, KY 40207.

Send reprint requests to Dr. Richard and Brenda Underwood at the address listed above.

SUMMARY. Pastoral Behavioral Medicine Consultants can make a valuable contribution to the modern hospital particularly if physicians and other health care professionals are joined in offering creative and effective programs for healing. This article discusses several programs in which the traditional hospital chaplain’s role is extended to that of a pastoral/behavioral medicine consultant (PBMC). The examples are meant to stimulate the reader’s interest, ideas and intuition about innovative ways that the modern PBMC can not only survive but flourish in chaplain/pastoral counseling ministries.

The modern hospital is dominated by cost-containment efforts, management by objectives, hi-tech procedures, and the outcome of standardized research studies. These influences continue to bring changes, some of which can impinge negatively on chaplains. Some chaplains have experienced diminished influence within the hospital administration or loss of their jobs.

Chaplains can become creative, innovative contributors amid these changes, however. These contributions depend, however, not only on strengthening the chaplain/physician relationship but on the chaplain’s ability to specialize into pastoral psychotherapy with ill patients. These two factors are dynamically inter-related because strong relationships with physicians often rest with the chaplain’s ability to help them with a specific group of patients. Such efforts require stretching the traditional “hospital chaplain” role into behavioral sciences. That is, the chaplain continues rootage as a minister, but in addition to the tools which come with this identity, uses concepts and interventions developed in the behavioral sciences. We will refer to this re-defined role as a “pastoral/behavioral medicine consultant” (PBMC). The PBMC, for example, could develop special psychotherapeutic skills in the areas of hypertension, cardiology, pulmonary disease, chronic pain, or rehabilitation medicine. No doubt the pastoral identity of the PBMC is somewhat blurred in comparison to the traditional role of hospital chaplain, but its advantages are an innovative integration into the health care system which enables unique contributions and a stronger relationship with the major figures in that system, the physicians.

This article will describe the foundations and the functions of a PBMC in cardiopulmonary rehabilitation with a focus on the chaplain/physician relationship. Principles which have guided the development of these relationships will be briefly discussed. We then turn to a discussion of the principles and practices contained in the program.

THE CHAPLAIN/PHYSICIAN RELATIONSHIP

Strengthening the chaplain/physician relationship faces fundamental problems. Chaplains and physicians have often been ambivalent toward each other. Many chaplains project their unfinished authority/power conflicts onto physician colleagues. Conversely, physicians project their mixed feelings concerning religious, spiritual issues onto the chaplain. These mutual projections naturally lead to confusion, ambivalence, hostility, or distance. The processes are usually unconscious, beyond the individual’s ability to simply change them at will. Personal psychotherapy is the best intervention. If these professional colleagues can resolve these difficulties, they can share strategic opportunities in the helping and healing of individuals and systems in the modern hospital. The analytic-thinking of physicians combined with the more intuitive-feeling strengths of the chaplain play essential roles in aiding the patient. As Bailey and Daniels have pointed out, “the heart of the matter … lies in individuals of each profession coming to know, respect, and understand their opposite members so that they may meet (at the patient’s side) as colleagues and consultants” (1971, p. 21).

Clinebell (1971) has suggested five essentials for strong physician/clergy relationships: (1) mutual understanding and appreciation of each other’s unique competencies, views, insights and contributions to the helping-healing enterprise; (2) willingness and the opportunity to communicate; (3) openness to learn from each other; (4) a robust sense of professional self esteem; (5) more frequent opportunities to work together in helping the same patient/parishioner (p. 15). These fundamentals are similar to those given by a prominent pastoral care/counselor to the author (RU) as he developed stronger physician relationships: To take initiative, make friends and grow up professionally with selected physicians (Oates, 1977). The following descriptions are illustrative of how the authors work together in practical ways.

CARDIOPULMONARY REHABILITATION

Historically, medical professionals have vigorously debated the varied etiologies of heart/lung disease. Research has produced many theories, i.e., heredity, high cholesterol, smoking, obesity, lack of exercise, Type A behavior and stress, without consensus of agreement (Underwood, Underwood, 1989). In the 1976 Council on Rehabilitation, “… agreement was reached about the fact that modern medicine is far from having solved these various problems of diagnosis and treatment, and many further studies will be necessary to define proper methods of assessment to the psychological and therapeutic tendencies” (Stocksmeier, 1976, p. 3). Conclu sions drawn from this meeting were that further interdisciplinary teamwork between related fields must be achieved in order to provide comprehensive care for persons adjusting to the emotional, physical and spiritual trauma of heart and lung disease. The PBMC has much to contribute to the team because of training and experience in integrating behavioral, psychological, attitudinal, and belief systems principles. Perhaps, better than any other health care professional, the PBMC brings a holistic appreciation for human healing. Out patient rehabilitation programs provide opportunities for the healers of the body or physicians and healers of interpersonal and intrapsychic problems, the PBMC, to collaborate.

Heart and lung patients enter rehabilitation programs having survived the danger phase of their physical/emotional/spiritual crisis. Ideally, rehabilitation signals the beginning of the opportunity phase. A good therapeutic alliance between patient, family and the entire medical team, along with a healthy human atmosphere, is essential for optimal growth. Working as a part of the team, the PBMC can make at least three contributions to the development of such a growthful atmosphere: interdisciplinary consultation, travel study programs, standardized stress management programs and counseling. Each will be discussed. The article concludes with a discussion of our work in the blood pressure clinic.

Interdisciplinary Consultation

Working from an understanding of healthy systems variables, the PBMC can collaborate with the rehabilitation staff to create an environment in which persons can accomplish their goals (Beavers, 1977). Some of these goals include exercise compliance, risk factor and Type A modification, self esteem enhancement, increased self confidence, regained control/responsibility for their lives, a more balanced, mellow approach to life and value or meaning in life reevaluation.

Seven variables are descriptive of these themes and will illustrate this approach. The first variable is that an open system is made up of the following beliefs. (A) Human needs are best satisfied in relationships. Even casual contact with the cardiac/pulmonary patient illumines the importance of a caring comment or simply listening to their story. Stimulating interaction between the staff and patients brings out common concerns and altruism. (B) Cause and effect of behavior are interchangeable. One patient described their interrelation in the following words. “The first few weeks in the rehabilitation program, treading the mill and cycling were, for me, hell-paid. This is my future? Within a month or so, my spirits lifted. Was it the physical exercise – the release of endorphins? Was it the morale building from the staff’s expertise and encouragement? Was it the camaraderie of the fellow sufferers? It was the combination, and the benefits were evident. I liked going. I made friends. I slept. My heart condition improved!” (C) Human behavior is a result of many variables. Rather than seeing patients as crocks, trouble makers, hyper, rigid, or “spaced out,” the staff may try to understand why persons behave the way they do, so appropriate interventions can be designed. Regular staffings provide opportunities for the entire interdisciplinary team to learn from each and design effective interventions. For example, a research project correlating Jungian-Keirsey character temperament traits with the incident of heart disease has been invaluable. Not only did this project identify dominant traits, (sensate-judging), which were statistically significant in the cardiac population, the implications of the study have had far reaching benefits in understanding, treatment techniques, and relationship enhancement (Underwood, Underwood 1989). Furthermore, the discussion of the psychological type material has enriched staff colleagueship. (D) Human beings are finite and limited – that self esteem lies in competence not omnipotence. Therefore, an open system needs to emphasize individual development rather than competition and facing one’s anxiety rather than avoiding it. The trauma of a heart attack or the first severe pulmonary attack generally brings an individual face to face with his/her finitude. Oates (1955) summarizes an earlier Freudian understanding as he describes the effects of a person’s first serious physical illness in the following statement:

They have unconsciously, as Freud said, been living under the illusion that death would happen to everyone except them. Now the presence of pain thrusts the factuality of their humanity upon them; the rude awakening to their finitude is at hand in the form of an illness. Their anxieties over their economy, their family and their work all become acute. (p. 33)

The heart attack brings the shocking reality to the individual that he/she is not immortal, that in essence, existence will end at some future date. Tillich (1952) describes the anxiety that grows out of such an awareness as the threat of non-being. Perhaps for the first time, the person is forced to consider his/her own fate or death.

If the Type A behavior research is valid and one of the key traits is insecurity covered by overachieving, another dynamic appears for the heart patient. A person who has deep insecurities gets caught in the vicious cycle of needing to gain more power and prestige. The manner in which he/she finds meaning and purpose in life causes goals to be blurred. Unclearly focused goals cause one not to have a sense of direction, resulting in an unclear meaning and purpose in life. Tillich (1952) says emptiness and meaninglessness produce a second kind of anxiety. According to him, the center of one’s life must find a meaning which organizes and gives purpose and value to his life. The lack of meaning and purpose gives rise to isolation, which leads to anxiety. As a person reflects on the heart or pulmonary attack experience and looks down the road to recovery, a reevaluation of those values which are important is undertaken. Working with and through the rehabilitation staff, a PBMC can stimulate interactions that enable patients in practical ways to face limitations and feel acceptable in spite of insecurities. Further, Oates (1955) discusses the results of such acceptance:

These inferiorities then become his bond of unity with the rest of human kind, not badges of his isolation from others. They become, not blind driving forces that compel him unconsciously to present a superiority facade that accentuates other peoples differences from an inferiority to him. Rather, his inferiorities become masks of the dying of an old self and the birth of a new life of inner security. These inferiorities are no longer the tortuous treadmill of one feverish act of meritorious appeal for approval after another until one faints from exhaustion (or lung/heart attacks). These masks of inferiority become transformed into alters of acceptance by grace, unearned, unmerited, unsought for – gifts of the Spirit of God. (p. 40)

The second variable a PBMC stimulates is an intentional openness to other’s view points, lifestyles, value systems, and perceptions which leads to a respect for differences. A former patient’s comment captures this variable, “as a result of listening to other participants and the staff in group discussions, I have realized that there are many ways of thinking and doing things other than the way I think and do them, especially in relation to my partner.”

The third variable involves making a strong effort to share power in cooperative ways with the patient. Patients need to be encouraged without brow beating and coercion to grow and develop.

The fourth variable is a strong emphasis placed on each patient becoming more autonomous so that each can take full responsibility for his/her own health. Another former patient’s words describe this variable in the following comment: “I am able to do something to help myself. I am not totally dependent on the effects of drugs, surgery, my family, or the staff for positive results, however essential they are. My self confidence is fortified and, with it my hopefulness. This is a splendid gift to my mental attitude.” Sensitive consultation with staff can challenge them to face their own need to be needed. The result, rather than over involvement, can generate interdependence.

A fifth variable is a real effort to give persons permission to be all they can be through the honest and appropriate expression of their feelings. Like any human relationship, it is sometimes difficult for the staff to hear strong expressions of certain emotions such as anger, hurt, inadequacy, fear, guilt, and concern about death and sexuality. A professional’s uncomfortableness with such passion might lead to avoidance rather than sensitively inviting the patient to share such feelings. Simply being able to discuss these feelings often leads the patient to genuine healing. As a result, an atmosphere of caring, warmth, humor, and hope may be enhanced.

The sixth variable involves persons being encouraged to develop their problem solving and negotiation skills. Rather than offering simple and often unrealistic answers, staff members can serve as enablers by providing support, care and information.

Finally, a healthy environment facilitates a person’s quest for finding meaning in their experiences so that they can move...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• CONTENTS
• Foreword
• Introduction
• Understanding Physicians: An Educational History and Brief Practice Profile
• Building Mutual Trust and Respect Within the Chaplain/Physician Relationship
• Developing Chaplain/Physician Relationships in Obstetrics
• Strengthening Chaplain-Physician Relationships in Long-Term Care Settings
• The Chaplain/Pastoral Counselor as a Behavioral Medicine Consultant in Cardiac Rehabilitation: A Team Approach