editor's voice (pdf) ben horrocks orin newberry roy f ... · original pre/post-test checklist...

Volume 25 Number 1 • Spring/Summer 2009 Click on a PDF link below to view an article, which will open in a new Window.

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Rozann Allyn Shackleton Editor's Voice (PDF)

Alexander Tartaglia Diane Dodd-McCue Ben Horrocks Ken Faulkner

Enhancing Student Engagement and Critical Thinking During Hospital Orientation for Level 1 CPE Students (free access) keywords: education, methodology, video

Orin Newberry How Many Chaplains Does It Take? The GRASP Method (PDF) keywords: staffing, benchmark, patient/chaplain ratio

Roy F. Olson Forgiveness as a Core Ingredient of Spiritual Care:An Exploration of Four Resources (PDF) keywords: spirituality, reconciliation, empathy

Judith H. Blanchard The Camino Is About Stopping: A Chaplain's Sabbatical Journey (PDF) keywords: pilgrimage, ministry, reflection

Keith W. Goheen Essay - Grief as a Spiritual Discipline (PDF) keywords: reflection, relationship, spiritual guide

Bettyana Bremer On Holy Ground - The Chaplain Never Asked (PDF)

keywords: grief, comfort, death

Marci Pounders Wayne Morris

Poetry (PDF)

W. Noel Brown In the Literature (PDF)

Media Reviews (free access)

Dick Millspaugh Expression of Faith:In Whom We Live (PDF) keywords: God, grace, mystery

Chaplaincy Today • Vol. 25 No. 1 • Spring/Summer 2009 Copyright 2009 Association of Professional Chaplains.Do not reproduce or distribute without permission.

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©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 25 Number 1 • Spring/Summer 2009

Enhancing Student Engagement and Critical Thinking During Hospital Orientation for Level 1 CPE Students

Alexander Tartaglia BCC • Diane Dodd-McCue • Ben Horrocks • Ken Faulkner

Hospital orientation for Level 1 CPE unit is challenging due to the volume of information and the requirement to comply with hospital and regulatory policies. In contrast with the case based, experiential focus of CPE, hospital orientation is content-driven. This pilot project revised hospital orientation to align it with the action-reflection method using video scenarios. Effectiveness was evaluated by assessing student knowledge as well as student and faculty perceptions of the delivery method. Pre-test and post-test results found improved student knowledge in each of four areas studied. Students found the scenarios enhanced critical thinking but were more neutral in recommending them over other methodologies. In contrast, faculty and residents strongly recommended scenarios rather than content-only orientation methods.

ORIENTATION TO THE CLINICAL ENVIRONMENT for students entering an initial Level 1 summer unit of clinical pastoral education (CPE) has become increasingly challenging for CPE supervisors and pastoral care managers. The majority of students have limited experience with, or understanding of, complex health care organizations such as the modern academic teaching hospital. There also is increased demand for compliance with external regulatory agencies such as the Joint Commission as well as state health departments. While the Scope of Practice for individual pastoral care departments may vary, it is common for chaplains to have a breadth of responsibilities in addition to the delivery of spiritual care to patients, families and staff, e.g., multiple hospital-wide programmatic protocols such as advance directives, decedent affairs and bereavement.1

The volume of information included in the CPE student handbook is considerable. Presentations from pastoral care and hospital staff are personnel intensive. The ability of students to capture and retain such information remains an ongoing challenge. The CPE orientation program at Virginia Commonwealth University Medical Center (VCUMC) employs five to

six pastoral care members, plus hospital staff, to deliver approximately twenty hours of Week One orientation. In Week Two orientation, students are introduced to the electronic medical records; they must complete four hours of training and pass a competency test. During these two weeks, students are exposed to complex information without adequate knowledge of the clinical context in which this information is applied. Thus they receive significant information needed to enhance their success while many are still trying to find their way around a hospital.

Student-centered teaching that emphasizes critical thinking is rooted in the tradition of case-based teaching. Instruction using the case method approach emerged as a distinct pedagogical method in the 1960s through the efforts of Harvard Business School, which sought to improve teaching by emphasizing instructor-student relationships. The guiding principles of this method are questioning, listening and responding; leading the discussion process; and nurturing critical thinking through the balancing of discussion direction versus discussion control.2 These apply regardless of the content area.

Alexander Tartaglia DMin BCC serves as associate dean and associate professor, School of Allied Health Professions, Virginia Commonwealth University (VCU). An ACPE supervisor, he is endorsed by the United Church of Christ.

[email protected]

Dr. Diane Dodd-McCue DBA is associate professor, Patient Counseling, VCU.

The Reverned Benj Horrocks MDiv MS currently serves as associate pastor at Beulah United Methodist Church, Richmond, VA. He is a former VCU graduate student.

Ken Faulkner MDiv MA serves as director of pastoral care and assistant professor, VCU.

mailto:[email protected]


CPE has a long history of process-centered teaching through the use of the teacher-learner interaction, which emphasizes critical reflection on case material. It began with Boisen’s study of the living human document through student observation and continued when Cabot and Dicks introduced the verbatim as a method to study the actual helping process. Throughout its history, CPE has employed various case-based methods to assist students involved in learning through the actual practice of ministry. Reflection and critical thinking using cases encountered in the clinical experience are part of the varied methods currently employed in CPE. In addition to the verbatim, these methods may include case histories, critical incident reports, role playing with and without video, dual visitation and interdisciplinary clinical rounds.3 More recently, interest in the use of standardized patients, a method long utilized in medical education, has emerged in CPE.4

Project significance Operational dilemmas confronted by CPE students often require immediate decisions about how to respond to clinically pressing requests for pastoral services. Such dilemmas impact organizational roles and generate conflicting demands, task ambiguity and work overload. Critical thinking requires students to demonstrate the following abilities:

• To conduct a needs assessment.

• To identify critical questions to ask and resources needed or available.

• To establish priorities.

• To meet regulatory or policy standards.

• To encourage collaboration.

• To manage conflict constructively.

The teaching and learning of these skills are embedded in the CPE process throughout the initial summer unit and beyond.

Mastery of orientation content by Level 1 students is necessary for them to be effective in their roles as hospital chaplains and for the continued effectiveness and compliance of the hospital with operational requirements. The critical thinking skills necessary to properly access and process content provided during the information-weighted orientation assist students in their ability to make timely and effective determinations that will lead to quality outcomes within the clinical context.

The VCUMC program has had a growing sense that the common process of delivering orientation is counter intuitive to the action/reflection model of teaching and the clinical method of learning inherent in CPE. For the most part, CPE training is problem based and case focused in its approach. In contrast, the traditional method of hospital orientation is content driven and “rules” oriented. While CPE values student engagement in the process of learning, hospital orientation typically lends itself to more passive learning.

Adult learning in CPE has long promoted the theory that learning occurs best when it is meaningful and applicable to the present context. Orientation tends to focus on information that has future and undetermined relevance. When combined with the expectation that CPE supervisors review program expectations and ACPE policies, the orientation process may significantly delay student opportunity to engage in patient care and supervisor opportunity to make early assessment regarding students’ level of ability and comfort with the clinical setting. Students come into CPE already anxious about the unknown. Often, the volume of information delivered to new interns during orientation heightens anxiety at a time when the facilitation of student readiness to learn requires reducing it.


Project The primary objective of this project was to revise the orientation process in order to align it with the experience-based, action/reflection method already employed within the overall program. Corollary objectives included the following:

• Incorporation of a critical thinking component without increasing the length of orientation.

• Incorporation of a critical thinking component without sacrificing coverage of hospital/departmental policies and procedures.

• Assessment of the utilization of videotaped, case-based scenarios rather than didactic, content-focused delivery of information.

• Enhancement of student engagement in a shared learning experience.

To this end, the Program in Patient Counseling (PATC) at Virginia Commonwealth University (VCU) developed an experiential component through the use of videotaped multistage scenario role plays.

Role play scenarios were developed through focus group discussions with current interns, residents, hospital chaplains and department faculty. They were structured to provide for discussion based on relevant regulatory guidelines, related hospital and departmental policies, type of dilemma (conflict, ambiguity, overload), essential information or resources needed to address clinical situations and possible responses to these. See Appendix A for a sample scenario, “The Advance Directive.” A content-based checklist was developed to assess student learning. While the original pre/post-test checklist included only agree/disagree options, the second post-test was revised to include a “reason” cell. See Appendix B for the revised post-test for “The Advance Directive.” The role play scenarios, and pre/post-tests were piloted prior to use with summer interns.

The 20-hour orientation covered ten major topics. For the purposes of this study, the faculty selected four key components of orientation:

• Advance Directives.

• Ethics Committee and Ethics Consultation.

• Pastoral Care Scope of Practice.

• Pastoral Care in a Multi-faith Context.

The project faculty developed a case scenario for each of these, which included learning objectives, a role play with defined characters and discussion questions for facilitation of reflection on the role plays.

The role plays were conducted using faculty as standardized patients/family members and CPE residents as chaplains. They were videotaped and posted into a Blackboard course using new software available through a grant award from VCU’s Center for Teaching Excellence. The project was submitted to VCU’s Human Subjects Review Board, and approval was granted for the study with “exempt” status based upon its use of existing, standard educational methodologies. Students were informed of the voluntary nature of participation in the pre/post-test component as well as the potential risks and benefits associated with participation. Anonymity was preserved through the use of a numerical identifier selected by the student.

All eleven students enrolled in the 2008 summer intern program chose to participate in the study. None had previous CPE experience. All students had completed at least one year of theological education, with four already holding graduate degrees. They ranged in age from early twenties to


late forties. Eight students were female, three were male. Seven students were Caucasian, three were African American, and one was Asian American. Nine students were mainline Protestant, one was Roman Catholic, and one was Buddhist.

On the evening before each orientation topic was scheduled for review, students were directed to view the videotaped scenario online and to identify key content learned as well as key critical thinking issues raised in the role play. The following day, the faculty member responsible for each orientation component used this assignment to begin discussion. Using the role play as a shared experience backdrop, the faculty member engaged students around key content and critical thinking elements. (A sample video is available for viewing at the following site: http://video.vcu.edu/ramgen/jlodge/patc/patc400/advance_dir.rm Access requires RealPlayer or other multimedia player; however, institutional computer security may prohibit downloading the necessary software).

Assessment Prior to orientation, students completed a content-based pre-test on each of the four selected orientation topics, with ten items related to each. Following each orientation discussion, students completed a post-test comprised of the same items as the pre-test. The students completed a second post-test during the tenth—and final—week of the program. Student evaluation of the use of videotaped scenarios also was conducted during the final week. Following the close of the summer program, five faculty and six residents also completed evaluation forms. The two primary faculty identified with this project did not complete evaluations.

One of the positive outcomes of the first post-test was the identification of information that was potentially ambiguous. In an effort to address this from both a content and critical thinking perspective, the faculty reviewed with students the most frequently missed questions at the end of program week 4. The second post-test was then modified to include a “reason” cell. This helped address the ambiguity factor and determine the thought process for each result.

One example of an ambiguous statement is Advance Directive question 2 (Appendix B): “In Virginia, an Advance Directive applies only if a patient has a terminal illness.” The initial assumed correct answer was “agree” as this is a true statement. However, one could also answer “disagree” and be correct as the statement is only partially true. A patient also has to lack “capacity,” and in Virginia’s Health Care Decisions Act a “persistent vegetative state” is included in the definition of terminal illness. As a result of these findings, the second post-test was modified to include a reason cell. This was added to address the ambiguity factor and to help determine the thought process for each response.

Results The effectiveness of this innovative hospital orientation was evaluated in two ways:

• Assessment of student understanding and knowledge of the four content areas.

• Student and faculty/resident perceptions of the effectiveness of the video scenario delivery method.

Evaluation of understanding and knowledge

The use of videotaped scenarios to introduce orientation topics demonstrated both immediate and sustained acquisition of new knowledge for clinical practice within the hospital setting. Table 1 includes pre- and post-test results. Improvement is demonstrated by a decreased number of incorrect responses. Comparisons of test results show progressive improvement for the majority of students.

http://video.vcu.edu/ramgen/jlodge/patc/patc400/advance_dir.rm


Evaluation of video scenarios The use of video scenarios represents a significant change in the delivery of hospital orientation content. Even if student knowledge and understanding of specific content was improved by the use of these scenarios, endorsement of this delivery method would be premature or questionable if it were perceived as ineffective or undesirable by students and/or by the faculty directly involved in the hospital orientation process.

Overall the students’ evaluation was moderately favorable. The most favorable student responses were associated with the promotion of critical thinking and problem solving. Relative to content areas covered by the scenarios, students found the ethics consultations and multifaith scenarios most useful, the scenario focusing on prioritization moderately useful and the scenario on advance directives relatively less useful. However, students were less inclined to recommend video scenarios over other teaching methodologies.

In contrast with the students’ perceptions of the video scenarios, the faculty/residents’ overall perceptions of the video scenarios were more favorable (See Table 2). They strongly agreed that this methodology promoted an atmosphere of student engagement and student learning. In contrast to the students’ relatively neutral view, faculty and residents strongly recommended video scenarios over content only delivery methods.

Discussion Student Learning

Relative to orientation topic content evaluated across the three points in time (one pre and two post-tests), the results point to improved student understanding in each of the four scenario content areas. Results of the second post-test demonstrate a sustained learning pattern. Also, the relative change recorded for students who initially had the lowest number of correct answers to the survey questions often was dramatic.

It is important to note that initial review of the results of the pre-test and first post-test suggested methodological problems related to the binomial (agree/disagree) response. Subsequent review indicated that a number of scenarios were ambiguous and complex; thus, incorrect answers on the first post-test might be attributed to critical thinking. Revising the second post-test to include a section for student rationale helped to determine the students’ level of understanding as well as to reflect their critical thinking.

Further, the results may reflect differences in student learning styles. The scenario methodology posited that an interactive intervention would produce positive student outcomes. Yet, some adults learn more effectively using traditional didactic or reading interventions.

One limitation of this study is the lack of a control group. While orientation consistently has been the most critiqued element of the summer intern program, no data have been collected to evaluate the traditional didactic only method of presenting the content areas. Thus, it is difficult to assess the extent to which this was an improvement when compared to the traditional didactic/content-based orientation.

Student and Faculty/Resident Assessment

Two conclusions may be drawn from the subjective evaluations completed by these two groups. First, subjective student evaluation of the use of videotaped scenarios failed to reflect the extent of new and sustained student learning. While the reasons for this are open to interpretation, a few possibilities exist. As previously noted, this may well reflect differences in student learning styles. Student evaluations also may reflect consistency with historical feedback that orientation still contains too much information to absorb in a limited time frame. Information and new learning


opportunities may not be immediately identifiable without sufficient understanding of the applicability to the yet unknown clinical context.

Second, evaluation of the orientation initiative was more highly regarded by faculty than by students. This difference may be attributable to the former’s inherent desire for the project to be successful. This possibility is mitigated by the fact that residents, who had considerably less investment in the initiative, also evaluated the project more positively. While no resident referenced his/her own experience of orientation to the hospital during the initial unit of CPE, it is noteworthy that four of the six residents who evaluated this process completed their initial units at VCUMC and thus were recipients of the more traditional didactic method of delivery.

A more optimistic interpretation of the discrepancy is that faculty was able to identify beneficial use of videotaped scenarios in the student intern learning that the students themselves had not consciously internalized. There is some support for the notion that process learning includes the development of learning how to learn.

The evaluation tools did not specifically request comments, another limitation identified in retrospect. Nonetheless, one resident wrote that the scenarios provided critical thinking opportunities that would later benefit the students. A faculty member who facilitated one of the orientation components noted that the new format stimulated significant student/faculty interaction. Students seemed interested in more information and were open to discussion of appropriate clinical responses to the patient care scenarios. The scenarios “allowed the students to project themselves psychologically into the scenarios and imagine their own potential actions and responses.”

Planning for the future

Relative to future efforts to incorporate scenarios into student orientation, four additional lessons were learned.

1. Greater attentiveness should be given to assure that the evaluation methodology is congruent with the objective of increased critical thinking. The initial use of binomial test responses counters the objective to increase student critical thinking and to promote greater recognition of the complexity of the topics covered. In addition, the evaluation tools likely would have produced more meaningful results had a narrative comment section been solicited.

2. Collection of data at multiple points in time is strongly recommended, both to evaluate the effectiveness of content delivery and to identify areas that need clarification.

3. Evaluation of pedagogical methodology from the perspective of both students and faculty/residents is strongly encouraged. Although the primary goal of the orientation scenarios was sustained student knowledge of specific content as well as enhanced student engagement, the faculty’s perspective of the efficiency and ease of implementation is critical for sustaining this orientation delivery methodology in the long run.

4. Even with a change in delivery methodology, orientation still was information and timeframe driven. In retrospect, more attention could have been devoted to exploring dynamics of the pastoral interchanges in each of the scenarios. More extensive discussion around identification of pastoral needs and theological issues raised by the scenarios might have provided valuable opportunity for student reflection and supervisor assessment of future learning opportunities.

Conclusion Sufficient documentation of student learning as well as student and faculty/resident satisfaction with this initiative exists to support repetition and replication. In preparation for the 2009 cohort of


summer CPE interns, VCU faculty plan to make the adjustments noted in this report in developing videotaped scenarios and incorporating the critical thinking field into the pre/post tests. We also have approached colleagues at another academic teaching hospital with the possibility of replicating this study at their hospital-based CPE program. Finally, we invite inquiries and/or participation from others who may be interested in participating in a multicenter study.

1 Formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). 2 Louis B. Barnes, C. Roland Christensen, Abby J. Hanson, Teaching and the Case Method (Boston: Harvard Business School Publishing Division, 1994). 3 David A.Steere, “Clinical supervision in pastoral care,” in David A. Steere, ed., The Supervision of Pastoral Care (Louisville, KY: Westminster/John Knox Press, 1989). 4 Alexander Tartaglia and Diane Dodd-McCue, “Use of standardized patients in CPE and Research at the VCU program in patient counseling,” ACPE Research Network Newsletters 5, no. 2 (Winter 2007) www.acperesearch.net/Newsletters.html.


Appendix A: The advance directive Training objectives

• Understanding of the use of an advance directive including its component parts.

• Understanding of the role of hospital chaplains in facilitating completion of advance directives.

• Assessment of patient understanding of an advance directive.

• Recognition of the role other health care professionals may play in helping the hospital chaplain make determinations of patient understanding and patient competence relative to completion of an advance directive.

Video scenario

Student chaplain background: You are the hospital chaplain paged for a patient wishing to complete an advance directive. You are called to Main 9W, the transplant unit. The nurse tells you that the patient is awaiting a liver transplant.

Role player background: You are a patient who does not appear to pay much attention to what the chaplain is explaining about an advance directive. In fact, when asked if you understand, you repeat back to the chaplain a number of fundamental errors. For example, you mistakenly say that your concern is about financial matters and that's why you want this done now. If the chaplain tries to help you understand, you cut him or her off by saying something like, "I don't have to hear any more of this, I'm ready to sign."

Discussion Questions

• Did the chaplain raise the question of whether the patient understood what s/he would be signing?

• Did the chaplain ask the patient if the patient had discussed this with the person s/he would be designating as the medical power of attorney?

• Did the chaplain consider whether there would be a way to help the patient understand more clearly the intent of an advance directive?

• Did the chaplain consider using other resources, e.g., social worker, nurse, another chaplain, to facilitate understanding?

• Did the chaplain raise the question of, or consider, the patient's capacity or competency to complete an advance directive?

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Appendix B: The advance directive – post-test 2

Identifier/ Last 4 digits of phone number Date

VCU Medical Center Summer Hospital Chaplain Intern Orientation

Please indicate whether you agree or disagree with the following statements. Even if you do not “entirely” agree or disagree, please respond to the category which most closely reflects your perspective. Please do not omit any responses.

Also note: This survey is being used to evaluate the effectiveness of the hospital orientation program and is not being used to evaluate individual summer interns. Your individual results are confidential and individual identifiers are only used as a means of orientation evaluation.

Agree Disagree Reason

The Advance Directive

1. An Advance Directive is a legal document initiated by patients to address their financial obligations.

2. In Virginia, an Advance Directive applies only if a patient has a terminal illness.

3. A standard Advance Directive form is available in each patient care unit.

4. Patients must complete a new Advance Directive each time they are admitted to the hospital.

5. Hospital chaplains are seldom involved in helping patients with Advance Directives and usually only as witnesses.

6. Confirmation of patient understanding is a prerequisite for proceeding with an Advance Directive.

7. One way of evaluating patients’ understanding is by asking them to restate, in their own words, what an Advance Directive means.

8. When there is a lack of clarity about a patient’s capacity to initiate an Advance Directive, legal counsel must be consulted.

9. Patients should discuss the implications of an Advance Directive with the person who is their designated Medical Power of Attorney.

10. Family members are no longer permitted to witness Advance Directive forms.

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Table 1: Student intern test results Each of the orientation topic tests included ten items. (See Appendix B for sample.) All four were administered prior to orientation, immediately following the orientation discussion of each topic and during the last week of the internship. This table shows the number of incorrect answers for each.

Students

A B C D E F G H I J K

Advance Directives

Pretest

Post 1

Post 2

2

0

0

3

1

0

4

3

1

2

1

1

3

1

1

1

1

0

3

2

0

3

0

0

3

1

1

2

1

2

3

1

1

Ethics Committee and Consultative Services

Pretest

Post 1

Post 2

4

3

2

4

2

0

4

4

3

2

1

1

4

1

4

3

0

0

5

4

1

1

1

1

6

2

0

5

2

0

5

0

0

Pastoral Care Scope of Practice/Prioritizing

Pretest

Post 1

Post 2

4

0

2

3

2

0

4

3

2

2

1

0

1

2

3

5

3

0

4

0

0

1

0

1

4

2

1

4

0

0

3

2

0

Pastoral Care in Multifaith Situation

Pretest

Post 1

Post 2

3

2

2

0

1

0

5

2

1

2

0

0

2

3

3

1

1

0

2

0

0

2

1

0

2

1

0

3

1

0

2

1

0

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Table 2: Evaluation of use of videos for orientation The response range is 5 (strongly agree) to 1 (strongly disagree). Responses were received from eleven student interns and eleven faculty/residents.

Student Responses

Faculty/Resident Responses

Question

Range

Median

Range

Median

Increased knowledge of hospital policies

1-5

3

3-5

4

Helped to apply critical thinking to hospital scenarios

2-5

4

3-5

4

Helped to promote critical thinking

1-5

4

2-5

4

Emphasized criteria for problem solving

2-4

4

3-5

4

Emphasized possibility of several right answers

2-5

3

3-5

4

Promoted an atmosphere to enhance student engagement

1-5

3

3-5

5

Promoted learning

1-5

3

4-5

4

Recommended over other content-only method

1-4

3

2-5

5

Usefulness of scenarios in pastoral practice (students only) Advance directive

1-5

3

Scope of practice/prioritizing

1-4

4

Ethics consultation

2-5

4

Multifaith situations

2-5

4

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How Many Chaplains Does Our Hospital Need? The GRASP Model for Pastoral Care Staffing

Orin Newberry BCC

Determining pastoral care needs and securing full-time equivalencies (FTE) to staff them appropriately are ongoing challenges for professional chaplaincy. This article discusses both the contractual and ratio approach to staffing with particular attention to the latter. The author details a ratio model, the Grant-Riverside acuity staffing process (GRASP) that he developed with colleagues at Grant Medical Center and Riverside Methodist Hospital, Columbus, OH. The article includes specifications for this process and an example of its application.

PASTORAL CARE STAFFING IS ONE OF THE MOST CHALLENGING issues chaplains face. This is evident when chaplains seek to convince hospital administrators to retain or to add staff. The challenge also surfaces in making assignments. How may pastoral care staff be assigned in a manner that insures appropriate levels of coverage across multiple settings? How do chaplains assess the equity of workload in departments with more than one chaplain? How do pastoral care departments determine staffing levels that insure adequate pastoral care to patients and their family members? This

article explores two basic approaches to staffing: ratio and contractual.

This discussion begins with two important working assumptions. First, the issue of pastoral care staffing is far too complex to be approached from only one perspective. The focus of this article is on ratio and contractual approaches with particular attention to a ratio model, but it is not the intention of the author to argue for one approach over the other. Also, this does not preclude the possibility of other approaches.

Second, pastoral care at its best is integrated into the institution rather than being considered an optional resource to be called upon when needed. To illustrate the difference, consider pastoral care as a continuum. On one end, the focus is primarily on pastoral care as a resource for the medical unit or hospital to draw upon when requested by staff members or patients. The understanding or contract between the institution and the pastoral care department is one of “we will call you if we need you.” At its most extreme, this approach is restricted to either on-call pastoral care coverage alone or a limited number of staff whose primary focus is responding to crisis calls.

At the other end of the continuum is an approach to pastoral care staffing in which chaplains are integrated into the institution’s day-to-day operation. Integrated pastoral care departments have staffing levels and a mindset that make them valuable and visible partners with other hospital staff to provide care beyond ministry in crisis situations. This consistent pastoral care presence enables the chaplain to establish stronger relationships with staff and to develop a better understanding of the patient population s/he serves. This model paves the way for chaplains to support both the medical unit staff and the patients/families, such as the following: participation in interdisciplinary rounds/case conferences, providing staff development programming, hospital committee membership such as ethics or quality improvement. In addition, increased visibility on the medical units opens doors to regular referrals for patient ministry as well as ministry to hospital staff.

Orin Newberry PhD BCC serves as director, pastoral care, at Grant Medical Center and Riverside Methodist Hospital, Columbus, OH. An ACPE supervisor, he is endorsed by the Alliance of Baptists.

[email protected]



Integrated pastoral care departments may develop services that not only provide these valuable ministries but also translate to cost savings that even skeptical administrators will appreciate. For example, a growing number of pastoral care departments have developed comprehensive protocols related to death and dying that not only provide direct pastoral care to family members at the time of death but also attend to the oversight of many regulatory and paperwork issues related to death. Though hospital administrators may not fully comprehend the ministry of presence, they usually understand the critical importance of regulatory compliance and the time chaplains save nursing personnel. Clinical staff members value the expertise provided by chaplains as the hospital’s experts on matters of death and dying. In addition, time-pressed nurses appreciate having chaplains perform these tasks. Thus, integrated pastoral care departments are in a position to become leaders in the provision of spiritual and emotional care within the institution.

The contractual approach The contractual approach to pastoral care staffing begins with a series of questions:

• What are the institution’s mission and strategic goals?

• What role does pastoral care play in supporting these goals?

• What services does the institution expect from the chaplaincy team?

In short, what is the contract, whether explicit or implicit, that the institution has established with the chaplain or pastoral care department that defines the scope of services to be provided? Often this contract is implicit and informal having evolved between the chaplain and the person the chaplain reports to in the institution. Though this contract has a significant impact on decisions related to pastoral care staffing, its utility extends far beyond this issue. Indeed, it guides day-to-day ministry priorities and becomes the basis for the administration’s evaluation of pastoral services.

One example of such a contract is ministry in the area of maternal and infant care. At one institution, the contract may designate the chaplain as primary coordinator of most, if not all, services to families who have experienced a fetal or infant death. In this case, the chaplain’s ministry would include a wide spectrum of services beyond the provision of pastoral care to the patient/family, e.g., tracking and completing much of the paper work related to the death. At another institution, the chaplain’s contract may be limited to providing direct pastoral care.

It is important to clarify the contract with administration for pastoral care services and to demonstrate alignment between the institution’s mission/priorities and the work of pastoral care. Susan Wintz and George Handzo1 provide an excellent overview of how to assess or survey a hospital as part of the development and presentation of a pastoral care business plan. This article provides an excellent starting point for establishing an explicit pastoral care contract with one’s institution.

The ratio approach The ratio approach to pastoral care staff does not attempt to address the larger question of the scope of pastoral care services. Rather this approach establishes a chaplain-to-patient ratio as a way to guide staffing decisions. The concept of staffing ratios is well established within the health care setting. Hospital administrators rely on ratios when addressing staffing issues for a variety of disciplines. Historically, pastoral care professionals, using their best judgment, have established staffing ratios. Wintz and Handzo provide an excellent review of some of these.2

Though the ratio approach has significant potential, it has several limitations with respect to pastoral care – especially as it has been used historically. First and foremost, there are few if any nationally recognized and accepted benchmarks for pastoral care ratios. For example, the Spiritual


Care Collaborative (SCC), an international group of professional spiritual care organizations, has not established benchmarks.3 Second, the ratios that have been developed tend to take a “one size fits all” approach. That is, one ratio is established for use across all institutions and/or patient populations. This fails to recognize the diversity of settings, the diverse needs of patients within a given institution and the diversity of roles that chaplains play.

In an effort to address staffing issues, chaplains at Grant Medical Center and Riverside Methodist Hospital developed a staffing model for the medical/surgical hospital setting. The Grant/Riverside acuity staffing process (GRASP) model assumes an integrated pastoral care department and establishes a chaplain-to-patient ratio based on a pastoral care acuity assessment of each hospital inpatient unit. GRASP does not preclude the simultaneous use of the contractual approach. Indeed, both are necessary.

The GRASP model establishes a chaplain-to-patient ratio for daytime inpatient coverage only. It assumes that staffing in outpatient settings, e.g. emergency departments, hospice programs, and freestanding or same day surgical centers as well as coverage during evenings, nights and weekends will be determined through a contractual approach. That is, in collaboration with hospital administration, the pastoral care department assesses the hospital’s mission, goals, scope of services and priorities to determine the extent of inpatient on-call and outpatient pastoral care coverage. The limitation of the GRASP to inpatient coverage points to the importance of integrating both the contractual and ratio approaches.

An example at this point may be helpful. Given its mission, priorities and scope of services, a smaller hospital located in a suburban area with relatively few deaths may determine that an on-call arrangement with chaplains or community clergy responding from home is sufficient during night and weekend hours. On the other hand, an urban hospital, which is a level 1 trauma center, may determine that having a chaplain in house overnight and on weekends is an important expression of its mission and scope of services.

Overview of GRASP GRASP begins with a unit-by-unit pastoral care acuity assessment. There are a variety of ways to conduct this assessment, and the process will be shaped, in part, by how the results will be used. The chaplaincy team which developed the GRASP model maintain that it is important to utilize a process that draws on both the perspective of the chaplain who has responsibility for a specific unit and on that of other chaplains or professionals who are not assigned to the unit but who are familiar with most of the other inpatient units. Including professional disciplines such as nursing gives additional objectivity and credibility to the process.

This objectivity and credibility is of particular importance if the assessment is intended to justify current staffing levels or to request additional staffing. If the assessment is to be used to support a request for additional staffing, it is advisable to convene a multidisciplinary pastoral care advisory committee or taskforce to conduct the unit assessments as well as to collect and analyze the data gathered. In addition to increasing ownership of the assessment beyond the pastoral care department, these individuals also may be in a position to advocate on behalf of the department.

If the assessment is only to be used within the department, e.g., to allocate staff, a less comprehensive process may suffice. In this instance, the department manager or a departmental taskforce would conduct the unit assessments as well as to collect and analyze the data gathered. It is, however, still advisable to have chaplains who are not assigned to a given medical unit involved in the assessment process for that unit. The average daily census of each assessed unit must be determined, and to insure objectivity, it is best to secure census data from the institution’s finance department or the unit’s nursing leadership.


Inpatient units are assessed according to the three criteria—visibility, ability, urgency—using a scale of one to four, with one being the highest level. The sum of these three area scores is used to classify the unit by acuity level (A-high acuity to D-low acuity) and to assign a specific chaplain-to-patient ratio. (See GRASP for detail, including the unit assessment form.)

For example, the intensive care unit (ICU) has a visibility score of one, an ability score of two and an urgency score of one. Adding these three numbers gives this ICU a total acuity score of four, which classifies this ICU as A-level/high acuity. This particular ICU has an average daily census of eighteen patients, and the GRASP model specifies a ratio of one chaplain to forty-five patients on A-level units. Thus, according to the GRASP model, 18/45 or .4 of a full-time chaplain’s time should be allocated to daytime pastoral care for this unit. This leaves .6 of this particular chaplain’s time for ministry to other areas.

When determining the available staffing for a given department, the contract approach comes into play. For example, a hypothetical pastoral care department has 3.5 staff members: a full-time department director, a half-time departmental secretary and two full-time staff chaplains. After conducting a staffing analysis using the GRASP model, it was determined that 3.5 chaplains would be required to provide adequate inpatient pastoral care. Though this department has 3.5 staff, the secretary provides no direct pastoral care. Further, the director’s “contract” with the hospital calls for her to spend approximately half of her time on administrative tasks and other duties, e.g., ethics committee chair, leaving .5 available for direct patient care. Thus, the department’s actual pastoral care allocation is 2.5, and an additional full-time chaplain is needed to meet GRASP criteria.

In a similar fashion, based on the contract with their institutions, pastoral care departments must determine how to count the contributions of clinical pastoral education (CPE) students and/or volunteer clergy. For example, some hospitals take the educational demands of CPE programs into consideration and count CPE residents/students as full-time staff.

Conclusion The GRASP model has proven to be very helpful to the pastoral care department at Grant Medical Center and Riverside Methodist Hospital, both to support requests for additional staff and as a guide for allocating pastoral care resources. To date, a handful of other pastoral care departments have used the GRASP model, and their experience supports the validity of this assessment process.

It should be noted that the GRASP ratios were arrived at through the professional judgment of the developers, which is a definite limitation especially if this model is to be used to justify additional staff. The model’s credibility would be enhanced greatly if the assessment process and ratios were supported by wide usage and consensus within the pastoral care community.

Hospital administrators place a strong emphasis on quantitative data for decision making in general. They often utilize consultants who draw upon national benchmark data to assess staffing levels in a variety of disciplines. Though there may be national consulting groups that have developed benchmarks for pastoral care staffing, these benchmarks do not reflect the consensus of the larger pastoral care community. Chaplains who seek benchmarking data often contact a group of comparable hospitals to support their requests. Savvy hospital administrators, however, understand all too well that this provides little in the way of credible data.

Requests for maintaining or expanding pastoral care staffing certainly need to include a contractual dimension as described in this article. These requests will be strengthened by the incorporation of a well-established assessment process and nationally benchmarked chaplain-to-patient data. In the very competitive health care environment, the ability to point out that a hospital’s competitors meet such criteria for pastoral care staffing will make a persuasive argument to maintain or expand staffing levels.


The establishment of a credible model for assessing and establishing pastoral care staffing levels using a ratio approach should be a priority for the pastoral care community. Organizations such as the Association of Professional Chaplains conduct national surveys of salary levels for pastoral care professionals, but there is no similar resource for pastoral care staffing.

The GRASP model is offered to the larger pastoral care community as the beginning of an enhanced process for establishing and supporting pastoral care staffing levels though a ratio approach. The author hopes that it will serve as the basis for a model that may one day become the standard within the pastoral care community. As a credible, internationally based organization, the Spiritual Care Collaborative is well positioned to lead in such an initiative.

Author’s note My thanks to the following team of chaplains from the pastoral care department at Grant Medical Center and Riverside Methodist Hospital, Columbus, Ohio, for their fine, creative work in collaborating with me to develop the GRASP instrument: Anne Money, Donna Morley, Mike Oskin, Corey Perry and Mary Whetstone. The team thanks Stan Mullin, former director of pastoral care at Clarian Health Partners, who contributed the concepts of visibility, ability and urgency around which the model was built.

1 Susan K. Wintz and George Handzo, Chaplaincy Today 21, no.1 (Spring/Summer 2005), 1-10. 2 Ibid. 3 American Association of Pastoral Counselors (AAPC), Association for Clinical Pastoral Education (ACPE), Association of Professional Chaplains (APA), Canadian Association for Pastoral Practice and Education (CAPPE), National Association of Catholic Chaplains (NACC), National Association of Jewish Chaplains (NAJC).


Grant/Riverside acuity staffing process (GRASP) All Rights Reserved. Permission is granted for use of this model on a not-for-profit basis provided credit is given to Grant/Riverside Department of Pastoral Care, Columbus, OH.

Unit assessment

You are asked to assess the pastoral care needs of your respective units. This assessment will measure three basic areas: visibility, ability, and urgency. Each of these three areas and the criteria for defining them are given below. Each unit will receive a score of 1 to 4 in each of the three areas. Further, you are asked to report the average daily census/volume of each unit. This information should be available from the nurse manager of each unit.

Visibility – This is a measure of how routinely visible a chaplain needs to be on the unit. 1. Daily presence: Chaplain has daily, routine presence. Knows patients, families, and staff

well. Aware of issues arising daily. Participates in regular meetings, improvement teams, and the like.

2. Frequent presence: Chaplain knows staff well. Rounds through unit 2/3 times per week. Aware of issues, changes, needs on regular basis.

3. Periodic presence: Chaplain visits unit approximately 1 time per week. Checks with RN manager to see if there are outstanding needs or issues.

4. Infrequent presence: Chaplain only responds to unit when crises arise or chaplain is called.

Ability – This is a measure of how competent the chaplain who is assigned to the unit needs to be and how complex the needs for that unit are.

1. Board certified staff chaplain/advanced or second-year CPE resident: Person exhibiting high competency, capable of managing complex, stressful cases requiring strong interpersonal skills, knows staff and unit dynamics well.

2. Less experienced or noncertified chaplain/first-year CPE resident: Some sophistication and experience needed, number of complex cases is fewer, not necessarily life-or-death issues, though deaths may still be relatively frequent.

3. CPE intern: Fewer deaths, acuity of patients is much lower, no ventilator supported patients, very few crises, and level of complexity is markedly low.

4. Trained pastoral care volunteer: Virtually no deaths. Most patients are ambulatory, and complexity of care is minimal.

Urgency – This is a measure of how urgent the requests/needs of this unit are.

It includes any death/crisis calls, which always require immediate attention. It also assesses the relative triage level and is a measure of how frequently the unit requests pastoral care services.

Answer the following question using the criteria below: How frequently do I, or the on-call chaplain, receive urgent requests/pages from this unit?

1. Virtually daily. 2. 3 – 5 requests per week. 3. 1 – 3 requests per week. 4. 1 – 3 requests per month or fewer.


Unit assessment form

Unit Name: __________________ Average Daily Census/Volume: ________

Unit Description/Types of Patients: _______________________________________

___________________________________________________________________

Unit Rating: Visibility _____________ Ability ____________ Urgency____________

Total Acuity Score: ________

Acuity scale

This is a measure of the acuity of the unit and a corresponding level of coverage. It is assumed that any unit that require less intensive focus may be covered by staff with greater competencies, i.e., a unit that is suitable for an CPE intern to cover may be covered by a CPE resident or staff chaplain.

A Unit score: 3/4 – High Acuity – These units face constant life-and-death issues with very intense and complex family/social/spiritual dynamics. Length-of-stay is frequently high, with very intense medical treatment requirements. The needs of these units are extremely high requiring frequent, highly competent, pastoral presence.

Staffing requirement: Board certified chaplain or highly competent/experienced CPE resident. Staffing ratio maximum: 1 chaplain to no greater than 45 patients.

B Unit score: 5/6 – Medium-high Acuity – These units do not face regular life-and-death issues, though deaths may still be relatively frequent. The complexity of medical care is lower, though some patients may be ventilated and require significant care. Family/social/spiritual dynamics may be significant, but these do not impact the daily care and treatment of the patient as significantly as high acuity units. Average length-of-stay is usually less than seven days. The needs of these units are still quite demanding and require regular pastoral care presence.

Staffing requirement: Noncertified chaplain or less experienced first-year CPE resident. Staffing ratio maximum: 1 chaplain to no greater than 70 patients.

C Unit score: 7/8/9 – Medium-low Acuity – These units experience very infrequent deaths/crises. The complexity of medical care is relatively low, with no ventilated patients and most patients able to ambulate. Family/social/spiritual issues do not pose significant impact on treatment and length-of-stay is usually one to three days. The needs of these units are significantly less demanding and require only periodic pastoral presence.

Staffing requirement: CPE intern/basic student or trained pastoral care volunteer. Staffing ratio maximum: 1 chaplain to no greater than 100 patients.

D Unit score: 10/11/12 – Low Acuity – These units experience virtually no deaths/crises. The complexity of medical care is low, and almost all patients are able to ambulate. Length-of-stay can be measured in hours or a few days. The needs of these units are low, requiring pastoral presence only on referral, usually for such needs as completion of advance directives or the occasional emotionally distraught patient/family/staff member.

Staffing requirement: On-call chaplain coverage for stated needs only or trained pastoral care volunteer.

Staffing ratio maximum: No ratio required.

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Forgiveness as a Core Ingredient of Spiritual Care: An Exploration of Four Resources

Roy F. Olson BCC

Forgiveness is a journey that many who have been wounded find most difficult to undertake. The author has over thirty years of experience as a behavioral health chaplain during which he developed and conducted spirituality groups focused on Everett Worthington’s models of moving from unforgiveness to forgiveness and seeking to reconcile broken relationships. In addition to Worthington’s five steps to forgiveness, this article presents three other resources that chaplains may use to assist patients in realizing these goals.

FORGIVENESS OFTEN IS A PRIMARY SPIRITUAL ISSUE for patients, at least for those hospitalized for psychiatric and substance dependence reasons. The challenge to forgive the Divine, others and oneself is daunting. Yet, if this journey is not undertaken, unforgiveness may grow like dangerous bacteria without the presence of the antibiotic of forgiveness that arrests and sometimes cures it. This article introduces four excellent resources that the author commends to any caregiver who seeks to become a midwife of forgiveness.

Five steps to forgiveness A middle-aged woman I’ll call Miriam was a patient in a hospital-based day treatment program for adults with mood disorders. Typical attendance for a spirituality group in this program was twenty or more persons. Miriam sat on my far left. I could barely see her out of my peripheral vision. The topic was

“forgiving those who have wronged us.” As it unfolded, I noticed Miriam was becoming physically agitated. Then she began to mutter under her breath. Finally she stood up, shouted, “This is a bunch of crap,” and stormed out of the room. In the days that followed, her self-destructive thinking increased to the point that she was hospitalized. I made two attempts to visit her but each time she angrily told me to leave. She did not want to talk with me.

Eventually, two spirituality groups were developed utilizing the forgiveness models of Everett Worthington, a psychologist and professor at Virginia Commonwealth University.1 The first focused on his “five steps to forgiveness.” The second group described a process for those who seek to reconcile a broken relationship.

From my experience with Miriam, I learned that a calm, methodical introduction to the first group was essential. I began by asking for a show of hands as to how many in the group had at least one person in their lives that they had never been able to forgive and secondly, how many thought that it had something to do with their need to be in this program. Typically half or more raised their hands for the first question and almost all of those hands went up again for the second. I learned to warn the patients that the content of the forgiveness group would be controversial, challenging, radical and possibly triggering and that if they needed to leave the group they had my permission in advance. It was not unusual to have at least one person leave.

Roy F. Olson DMin BCC (retired) currently serves as one of the on-call chaplains at Sherman Hospital, Elgin, IL. He is endorsed by the Evangelical Lutheran Church in America (ELCA). This article stems from his many years of service as a behavioral health chaplain, most recently at Alexian Brothers Behaviorial Health Hospital from which he retired last June.

[email protected]



I learned to inform the program staff whenever the forgiveness group was scheduled so that they could be prepared for possible fallout. I am grateful to that team for their collaboration and the trust and respect they placed in this work.

Empathy is the basis for Worthington’s model and he states very clearly that God must play a role in the healing of unforgiveness. At the core of his model lies a radical idea based upon research he has done with those who are trying to forgive. If one forgives in order to feel better, it does not last. Instead, one must make the far more difficult journey toward developing empathy for the perpetrator and eventually give what usually is an undeserved and unearned gift of forgiveness, often because the perpetrators have never taken responsibility for their actions.

In the forgiveness sessions I conducted, I briefly outlined Worthington’s description of the journey into unforgiveness and more carefully explored the journey to forgiveness. Each has five stages. Unforgiveness results from

• A transgression,

• Perception of offense and hurt,

• Resulting hot emotions like anger and fear,

• Rumination, which lasts until

• Unforgiveness has made a permanent home in the psyche.

Worthington devotes a chapter to each of the five stages of forgiveness:

• Recall the hurt but with enough detachment to explore it from a fresh perspective.

• Develop empathy for the perpetrator in three ever more challenging levels—shallow, middle and deep.

• Give the altruistic gift of forgiveness. He explicitly names the importance of his Christian background and the necessity of a role for the divine. Granting the gift of forgiveness may or may not be done in person, due to issues of safety or to the inaccessibility of the perpetrator.

• Commit publicly to forgiveness, recognizing that if this is only an internal process, it will not prove to be lasting.

• Hold on to the forgiveness. He describes strategies to accomplish this.

The second spirituality group explored the stages of reconciliation in which two persons may engage in order to restore a broken relationship. Briefly, using the metaphor of approaching a bridge from opposite sides and meeting in the middle, Worthington devotes a chapter to each of the four stages in this model:

• Decide whether or not to try to reconcile.

• Initiate discussion, probably with a therapist guiding the process.

• Detoxify, i.e., remove the negative elements from the relationship.

• Restore or reach a new level of devotion.

Worthington provides many practical suggestions for utilizing both processes. They may be more suitable for a pastoral counseling or therapy setting, as this is primarily a group rather than an individual model. In a psychiatric treatment setting, the goal of these two spirituality groups was to


introduce the difficult path of forgiveness to the patients and to claim a central role for spirituality. Often, requests for individual chaplain visits followed the group experience.

My third attempt to visit Miriam on the inpatient unit met with a more positive response. She had mellowed considerably and spoke openly about the horrific abuse she had received from the parent who had died in the previous year. She thanked me for getting her started on the forgiveness journey, even if had been very difficult for her at the beginning. In time, she returned to the same day treatment program where it all began. When she attended the spirituality group on forgiveness, she smiled and asked if she could address the group. She told her story about how she had reacted initially to the idea of forgiveness and how she was on that forgiveness journey now.

Beyond revenge Michael McCullough begins Beyond Revenge with the following story.2 Chante Mallard became front-page news. After a long night of partying, drunk and high, she drove her car straight into a man walking along the highway. Catapulted over the hood, he came to rest wedged into her windshield, his head and upper torso inside her car. After stopping to try to figure out what happened, in her drugged confusion, she panicked. She decided to drive her car home and into her garage. Despite his pleas for help, Mallard, a nurse’s aide by profession, let him bleed to death in her garage. The medical examiner stated the victim would have lived if she had called for help. Instead, she entertained her boyfriend in her home that night. With the help of friends she eventually dumped the body in a nearby park and joked about it all.

Chante Mallard was eventually arrested. She was convicted of murder and sentenced to fifty years in prison. At her sentencing hearing, Brandon, the son of the man that she had allowed to die in her garage, made a victim impact statement. Instead of insisting on the severest of penalties, the son spoke to the court and Mallard’s family, “‘There’s no winners in a case like this. Just as we all lost Greg, you all will be losing your daughter.’ Later, Brandon would go on to say, ‘I still want to extend my forgiveness to Chante Mallard and let her know that the Mallard family is in my prayers.’”3

McCullough, a professor of psychology at the University of Miami, asserts three core truths:

• Revenge is a built-in feature of human nature.

• The capacity for forgiveness is also a built-in feature of human nature.

• To make the world a more forgiving, less vengeful place, don’t try to change human nature, change the world!

Firmly planted in evolutionary theory, he amasses a significant body of research from the social and biological sciences, including studies of the behavior patterns of primates, dolphins, hyenas, goats and fish; the experiments social psychologists love to do with university students; game theory; and computer simulations.

He challenges the formulations of the monotheistic religions and much of Western literature, rejecting their conceptualization of revenge and forgiveness as a disease/cure model. In that model revenge is a virus that invades a vulnerable host; forgiveness is an external force that must enter the host to treat and cure revenge. Instead, from an evolutionary perspective, he views revenge as functional. He maintains that revenge was adaptive in that it

• Deterred aggressors from aggressing a second time by actual or threatened revenge.

• Warned would-be harm doers to back off, leading to a deterrence that prevented aggression in the first place, i.e., if you don’t take or threaten revenge, you are labeled an easy mark and become susceptible to being taken advantage of.


• Coerced “free riders” to cooperate. A free rider is defined as the person in a group that is loafing and not carrying a fair share of the burden. The threat of ostracism (revenge) brings the person back into line. (Think of resistant members of CPE groups or congregations!)

Likewise, from an evolutionary perspective, forgiveness has adaptive functions. Animals and humans hesitate to inflict revenge on any blood relative for it threatens to reduce the success of their gene pool. Even with nonrelatives, survival in a hostile environment depends upon forming cooperative alliances. We are forgiving towards neighbors and friends because at some level we need to cooperate with them. Stress and anxiety increases in humans and primates when conflict erupts and remains unresolved.

In what ways is forgiveness instinctual or hard-wired into human existence? While clinical psychology makes the distinction between forgiving without continuing a relationship and reconciliation that seeks to restore a relationship, McCullough believes that both are rooted in the same internal process and exist along a continuum of experience. Survival in a hostile environment requires communal living and cooperation, which provides the impetus for seeking forgiveness. Anxiety is an unpleasant outcome of unresolved conflict, and both animals and humans are wired to overcome this. Biological measurements show that stress and anxiety decrease when one moves in the direction of forgiveness and reconciliation.

Three conditions awaken the forgiveness instinct:

• Empathy for those who have harmed them, which is easier if it’s a blood relative.

• Seeing potential value for maintaining or attempting to restore the relationship.

• Safety, i.e., having assurance that the other party can no longer inflict harm or is sincere in promising not to do so.

Three gestures signal the desire to pursue forgiveness:

• Apologies, including five key ingredients—carefully chosen words, an admission of responsibility, an explanation/clarification of why the hurt occurred, an offer of reparations and a promise not to repeat the action.4

• Self-abasing displays and gestures (body language).

• Offer of compensation. (The amount is less important than a genuine offer.)

McCullough maintains that the major world religions exhibit the desire for revenge and the desire for forgiveness both in their historical behaviors and in their sacred texts. His conclusion about how to move forward deserves a hearing and may resonate with the core convictions of chaplains, pastoral counselors and clinical educators.

If you want religious groups around the world … to be forces for forgiveness, you need to create the conditions that will cause them to perceive that forgiveness is in their best interests. When you do, they’ll emphasize the doctrine and traditions that favor forgiveness. If those religious groups perceive instead that revenge is the behavioral option that will work best for them, then that’s what you’ll get from them … . The challenge for harnessing religion’s power to motivate forgiveness is to create the kind of socio-political world in which religious groups can’t help but perceive that forgiveness is in their best interests. In figuring out how to make these kinds of sociopolitical realities happen, we’d be fools not to try to work with reformers within those traditions who can offer help and guidance.5


Transcending tragedy The bucolic serenity of Amish life in Lancaster County, Pennsylvania was irreparably shattered on October 2, 2006, when a monstrous deed was done. Some would later say it was their 9/11. A lone gunman, Charles Carl Roberts IV, burst into a one-room schoolhouse of twenty-six children, aged six to thirteen, in the community of Nickel Mines. He brought with him guns and supplies intending to barricade himself for a standoff. The teacher snuck out a side door and ran for help. He dismissed other adults who happened to be present and all the boys. He announced his intention to molest the ten remaining girls. The police arrived more quickly than he expected, disrupting his plans. About twenty minutes later shots were fired inside the school and out the window at them. They rushed into the building as Roberts shot himself and discovered Roberts had murdered five of the girls, execution style. Five survived.

As the news spread, large numbers of law enforcement and community service personnel, including grief counselors, responded to the disaster. It also rapidly became a media event. Huge vans with satellite dishes and reporters with cell phones further shattered Amish life. The media came to report a story of evil, hatred and violence; thus, they were totally unprepared for what gradually became a story of grace and forgiveness. The Amish community quickly realized that the surviving Roberts family members, which included his wife, three children and the children’s grandparents, were also victims of this tragedy. They searched for them to offer their compassion and forgiveness. When the Roberts family gathered to bury Charles at the local Methodist Church, more than half of the attendees were Amish.

The question lingered as to whether Charles Roberts was a monster. How could one develop empathy for him, something both Worthington and McCullough have suggested is necessary in order to move from revenge toward forgiveness? One of the surviving children reported that Roberts said to the girls, “I’m angry at God and I need to punish some Christian girls to get even.”

During the standoff, Roberts called his wife on his cell phone to say he was not coming home and that he had left notes for everyone. He was angry at God, he said, for the death of their firstborn daughter, Elise, who had lived for only twenty minutes after her birth nine years earlier. In the note to his wife Roberts had written, “I’m not worthy of you, you are the perfect wife, you deserve so much better …. I’m filled with so much hate towards myself, hate towards God, and an unimaginable emptiness. It seems like every time we do something fun I think about how Elise wasn’t here to share it with us and I go right back to anger.”6

There was speculation that Roberts might have been abused as a child but no solid evidence of it was uncovered. What would the chaplain’s assessment be of Roberts’ spiritual condition at the time of the shooting?

In their book, Amish Grace: How Forgiveness Transcended Tragedy, Donald Kraybill, et al., have written a meticulously detailed and emotionally moving account of the events surrounding the school massacre and the response of the Amish community to the murder of their children.7 Their knowledge of Amish life is extensive. After telling the story at some length, they explore the history of the Anabaptist movement, including its many early martyrs and how literal adherence to the teachings of Jesus, especially forgiveness, is a way of life.

The presentation of this tragedy and its aftermath, especially the insistence of the Amish that they must forgive, gives spiritual caregivers much upon which to reflect. Amish grief is not stoic denial, yet there is no room for anger at God. (The reluctance to support anger in general or anger at God is also part of the spirituality of addiction recovery.) Submission or surrender to the will of God is a core element of their spirituality. Because this tragedy fell upon more than one family simultaneously, an entire community took up the task of forgiveness together. Yet a deeper understanding of Amish life reveals that grief and forgiveness are communal tasks whether or not


there were multiple victims. Their way of life rejects much of the individualism in mainstream American culture that suggests forgiveness is an individual decision and task. It is not left to one person or one family to manage hate, bitterness and resentment; these are absorbed and overcome by the entire community.

Chaplains know the difference between ministering to a nuclear family coping with tragedy and joining in the ministry of a large extended family who gathers to grieve together. The Amish in this story testify not only to their belief in forgiveness but also to the difficulties inherent in practicing forgiveness. There is no denial of how long or difficult maintaining their stance of forgiveness will be. They fully acknowledge it will be an ongoing struggle. These events and their response to them raise challenging questions. Do representatives of the church sometimes counsel or insist upon offering forgiveness too quickly, especially in cases of abuse? Is God’s forgiveness conditional or unconditional—does God’s forgiveness depend upon our willingness to forgive? Kraybill wrestles with these and other complicated questions.

Those of us who work alongside counseling colleagues are aware that they perceive their task as moving persons from an identity as a victim of a tragedy to that of a survivor. Kraybill suggests this Amish story raises the possibility of moving to a third stage. Renouncing the right to remain bitter about the outcome of the shooting means one becomes “a hero instead of a victim in the story.”7 Not that the victims claim to be heroes or heroines, but in our telling of their stories, they are perceived as such. I would suggest that our role as caregivers is not only to help victims, when ready, to move toward empathy and walk the perilous path toward forgiveness. It is also to tell to one another—and to all who will listen—the many remarkable stories of people who were able to forgive. The stories of Miriam, Brandon and the Amish are only a few of the stories we could tell.

The power of forgiveness These three excellent resources may deepen the chaplain’s understanding of forgiveness both from a psychological/clinical and from a spiritual/theological perspective. The final resource is The Power of Forgiveness, an excellent DVD production that includes eleven chapters.8 Two of the three authors mentioned earlier in this article are featured. Everett Worthington is shown teaching in his psychology classroom and conducting a group therapy session. He tells his own tragic story of the brutal murder of his mother and his challenge to forgive the perpetrator. Donald Kraybill retells the story of the Nickel Mines tragedy. In addition, a number of spiritual leaders from various faith traditions, including James Forbes, Elie Wiesel, Thich Nhat Hanh, Marianne Williamson and Thomas Moore, share their perspectives on the subject of forgiveness.

Lengthier stories include the portrayal of the legacy of hatred in Northern Ireland’s long-standing conflict between Catholics and Protestants. Community leaders have come together to address their concern that unresolved conflict and hatred is being passed on from one generation to another without interruption. In response, they have designed forgiveness curricula, which are being implemented in elementary school classrooms. These do not directly address the historic political conflicts. Rather, through story telling and conversation they introduce forgiveness concepts and practices into the daily classroom experiences of elementary school children.

Elie Wiesel reflects on his experiences in Auschwitz and asks a poignant question. Are some human deeds too horrible to be forgiven? Included are excerpts from his address to the German Bundestag in Berlin in which he asks the leader of the Bundestag if the time has not come for him to ask for the forgiveness of the Jewish people for what the Third Reich had done in the name of Germany. Later, in an address to the Knesset of Israel, the German leader does exactly what Wiesel requested.

Another story focuses on the aftermath of 9/11 through the eyes of a widow whose husband died in the Twin Towers and two mothers whose sons also died that day—one a firefighter and the other an office worker. They question the wisdom of the all-out effort to remove the remaining debris as


quickly as possible. They visit the dump where it was deposited, searching in vain for a gravesite and a sense of closure. After an interview with the priest of St. Paul’s parish near ground zero, who hopes to create a garden of forgiveness nearby, the three women visit such a garden, which is under construction in Beirut, Lebanon. Alexandra Asseily, who provided the vision for the Lebanese garden, sees it as a place where historic religious conflicts existing over many centuries may begin to heal.

The final story is that of two remarkable men, who united in a mission to speak to schoolchildren about their experiences. The son of Azim Khamisa was murdered in a senseless act of violence. Ples Felix is the grandfather and guardian of the teenage boy who committed that act of murder. Azim is a Sufi Muslim, whose spiritual advisor suggested that if he was ever going to overcome his grief he would have to commit himself to an act of charity. He decided to develop a foundation to educate young people about the evils of violence. He asked Ples, a Baptist from the American South, to help him. On their journey together, they became best of friends. Azim eventually became able to forgive Ples’ grandson, which led him to forgive his parents’ abandonment of him in his childhood. Ples, in turn, was able to forgive himself for his failures in raising his grandson. This is the story they tell to the schoolchildren.

As chaplains we willingly—and sometimes unwillingly—absorb pain, grief, hate, bitterness and resentment. We are committed to steering those who appear ready and able toward the perilous pathway to forgiveness. These four resources provide excellent assistance in our own journeys as agents of forgiveness.

1 Everett Worthington, Five Steps to Forgiveness: The Art and Science of Forgiving (New York: Crown Publishers, 2001).

2 Michael E. McCullough, Beyond Revenge: The Evolution of the Forgiveness Instinct (San Francisco: Jossey-Bass, 2008).

3 Ibid., xiv.

4 For a humorous account of how not to apologize, McCullough cites Bill Clinton’s many failed attempts to apologize to the

American people for his White House dalliance and Trent Lott’s failed attempts to apologize for his misplaced praise of

Strom Thurmond’s run for President as a segregationist.

5 Ibid., 222-23.

6 Donald B. Kraybill, Steven M. Nolt, David L. Weaver-Zercher, Amish Grace: How Forgiveness Transcended Tragedy (San

Francisco: John Wiley & Sons/Jossey-Bass, 2007), 25.

7 Ibid., 140.

8 Martin Doblmeier, The Power of Forgiveness (DVD: www.journeyfilms.com, 2007).

http://www.journeyfilms.com


The Camino is about Stopping: A Chaplain’s Sabbatical Journey

Judith H. Blanchard BCC

To utter “walk” and “stop” in the same breath seems something of an oxymoron—especially when the “walk” is a thirty-six day trek across France and Spain. The author, a chaplain gifted with a rare sabbatical, completed this journey with “three amigos” in summer 2008. This article, distilled from her journey on the Camino de Santiago de Compostela, urges chaplain colleagues to discover their individual ways of stopping.

SUMMER 2008 BROUGHT A RARE GIFT to me as a chaplain: a two-month sabbatical, my first in twenty-nine years of ordained ministry. The time was spent walking the 500-mile pilgrim route known as the Camino de Santiago de Compostela. Camino simply means “way” in Spanish, the Way of St. James. My three companions and I walked from St. Jean Pied de Port in southwestern France, across the Pyrenees, through Pamplona where the bulls ran a few days later, across the wheat fields of the Meseta, through lush vineyards and Galicia’s eucalyptus forests to Santiago in northwest Spain and its beautiful cathedral dedicated to St. James. It took us thirty-six days, and

except for blisters and some tired muscles, we arrived safely for the Feast of St. James on July 25.

My mind still is filled with gorgeous scenery, hospitable people and the life of wandering on foot, much as Jesus and his disciples must have walked. In the intervening months, I have tried to distill some of the learnings of this journey, especially as they pertain to our discipline of chaplaincy. The foremost insight is about stopping.

At the end of day five of our trip, one of our foursome had developed severe blisters on her feet that required her to take a bus to our day’s destination, a town called Estella. Apparently blisters are not unusual at this point on the Camino, because the Cruz Roja (Red Cross) had set up a foot clinic just a few doors down from our pilgrim hostel. The clinic had a delightfully jolly Basque doctor, with long, curly hair and brown legs in Bermuda shorts. He giggled readily at the pilgrims’ complaints and gave out bear hugs, while speaking no English, and, it seemed, minimal Spanish!

His assistant and translator, Simone, was a stunning young woman from Brazil. She had attempted to walk the Camino, despite having had four open-heart surgeries. When she experienced difficulty breathing, her doctors told her that her heavy backpack was straining her still-healing sternum, and she should not continue the walk. Greatly disappointed, but having fallen in love with a volunteer at the clinic, Simone decided to stay and help other pilgrims. She was sympathetic to my companion’s blistered feet and swollen ankles, and she wisely confided, “The Camino is about stopping.” Not about the walk itself, but about stopping.

Her words hit home in multiple ways and situations. The sabbatical was about stopping my normal day-to-day ministry at the hospital, filled with rushing from one emergency, trauma or tragedy to another; responding to pages, voice-mail and referrals. In its place was a totally different activity, one that was physical and strenuous but also often isolated and contemplative.

Stopping came in the form of needing to ask directions when we couldn’t find the yellow arrows or scallop shells that point the way. Stopping came as we waited in the heat of the day with our

The Reverend Dr. Judith H. Blanchard DMin BCC serves as Protestant chaplain at Maine Medical Center, Portland, ME. She is endorsed by the United Church of Christ.

[email protected]

http://www.spain.info/TourSpain/Grandes%20Rutas/Rutas/Rutas/0/Camino%20de%20Santiago?language=EN



backpacks lined up next to those of other pilgrims at the door of a hostel not yet open. Stopping came as I retraced my steps to locate my sunglasses, walking stick or some other item I had left behind.

More importantly, it was stopping old habits of impatience, judgment and what the Buddhists call the “monkey mind” of distracting thoughts, plans and scatteredness. These keep me from being in the present moment and staying focused on each step toward a deeper relationship with God, with my companions, with those around me, in an attitude of gratitude and prayer.

Joyce Rupp, a Roman Catholic sister and prolific author, was one of my inspirations for walking the Camino. She undertook it some five years ago at the age of sixty. The title of her book about that journey came from the advice of another pilgrim: “Drink more water and walk in a relaxed manner.”1 Like Rupp and her companion, we sometimes felt the pressure to hurry our walk in order to get a bed in the next pilgrim hostel. In Rupp’s words,

Our unspoken motto became: Push onward. Push forward. Push, push, push. Rush, rush, rush. We soon discovered that the rushing and pushing caused us to lose our enjoyment of the walk itself … [we] had a good talk and both agreed the stress of hurrying denied us our inner harmony and the spiritual adventure of the Camino. We decided to slow down … [we] reminded each other of this often by simply saying: Time to stop hoofing it!”2

The lesson of stopping comes home to me again and again in my ministry and in the ways I refresh myself when the ministry day is done. I make it a practice to stop at the local YMCA on my way home from the hospital. Here I spend an hour in physical exertion that helps me lay down the emotional exertion of the day. My obsessing about the day’s deaths, traumas, pain, and suffering are put down for the moment. As I sweat on the cross trainer or stationary bicycle, I read novels and short stories. The Maine snow piles up outside, and life comes back into proportion; I let God be God. The Camino continues to teach me about self-care and about my small role in God’s colossal economy.

The stopping also underlines new priorities I place on patient/chaplain encounters. Like other health care providers, I find myself too often focused on numbers, quotas and recordkeeping. “The clock is ticking, there are ten more new admissions to see before the day’s end,” my internal supervisor admonishes. Then I meet Mr. S. The social worker has asked for a pastoral care consult on this man with a PhD in theology, now suffering from dementia. Confined to a wheelchair and a bit scruffy in hospital pajamas, he has a vacant look. “How much time do you have?” he asks as I pull


up a chair. My Camino clock reminds me that I have all the time it takes to listen, to affirm, to be present. We don’t talk theology; we talk about his Airedale terriers and how he misses walking them; how he’s terrified that he won’t ever get to see them again.

Rupp’s final lesson of the Camino is a reminder to pause and reflect, which she describes as “my inner stop sign. In my hurried life, it is essential to ‘stop, look, and listen’ before crossing to the next piece of life’s journey.”3 Like Rupp, I often paused at the top of a rise, to catch my breath, sure, but more importantly, to look back on the gorgeous countryside and to congratulate myself on the distance I had traveled. Stopping is important for looking back, for staying in the moment, and for re-orienting oneself for what lies ahead. It is in stopping that gratitude can grow.

Rupp writes of her beloved companion, Father Tom Pfeffer, who died suddenly just six months after their return to the United States.

Tom said, “I thought about the many little things that really helped our pilgrimage.” … bunk beds by a wall to provide a tiny bit of privacy, ladders between the top and bottom bunks making the climb up and down easier, those little bits of shade on the mesa, soft grass cushioning our weary feet, village fountains to fill our water bottles, stones, logs, and benches on which we sat when we needed a rest. His naming of these things restored my gratitude for them.4

Since the Camino, reflection has become a much more integral part of my ministry in the hospital in two concrete ways. I now keep a book of deaths that occur in the hospital with contact information for the next of kin. At the end of the year, I write personal notes to these families with remembrances of their loved ones and how they have touched my life.

I also close each day with a discipline of gratitude. Before retiring, I spend time remembering the human vistas that have passed before me, the companions on my daily walk, and I thank God for them and for the privilege to accompany them as their chaplain. Like Tom, it’s the little things that I remember:

• “Hey, Church Lady!” and a warm smile from a unit clerk.

• A “chance” encounter with a patient’s wife even though he was not on my list of new admissions to see.

• An e-mail from a daughter sitting vigil with her father in our hospice house, giving thanks for all the prayers coming their way.

• The two-year-old with forearm immobilized under an IV needle, gamely “driving” a red wagon being pushed by his chaplain with chemo pole in tow.

• A maintenance man holding out my glove as I retrace my footsteps back to the office at the end of a long day, certain that I had lost another one for good.

Looking back on today with gratitude deepens my prayer life, restores proportion to that which may feel like failure, and gives me a sense of eager anticipation for tomorrow.

As I reflect on my sabbatical journey, I am filled with gratitude to my chaplaincy board which approved the time away and to the Louisville Institute for a grant that not only paid for my time in Spain but also for my replacement at Maine Medical Center. I find myself zealous to spread the word to chaplain colleagues: find a way to put a sabbatical into your contract! It’s not clear to me why our parish clergy and academic colleagues have this gift almost automatically. We must find a way as a profession to claim this time for rest and renewal, and there are resources available to underwrite the costs.


We all need to find ways for significant stopping in our lives. Yours may not be a 500-mile walk. There may be a book in you that needs writing; a research project that always gets back-burnered in the press of daily tasks; a language you have wanted to learn or a spiritual practice that seems to evaporate with the first page of the day; a call to create space for deepening your prayer life, the well of your compassion. Whatever it may be, dream big! Make it happen!

1 Joyce Rupp, Walk in a Relaxed Manner: Life Lessons from the Camino (Maryknoll, NY: Orbis Books, 2005). 2 Ibid., page 54, 57. 3 Ibid., page 252. 4 Ibid., page 251.


ESSAY

Grieving as a Spiritual Discipline

Keith Goheen

I BREAKFASTED WITH GRIEF THIS MORNING. Then we got ready for work and made the short commute to our hospital. We barely had time to settle into the office when the pager began its disquieting dance. Grief and I were needed in the emergency department (ED).

In the ED, I met with a family and my Grief met theirs. I listened to the concerns of staff, and our Griefs mingled. Then upstairs, to provide support to a returning stroke patient whose familiar Grief has remained strong and open. My Grief, that sturdy gateway into the soul, and I were welcomed into the room. Some time in the early darkness, Grief and I will turn for home and take our rest until we are called again to the service of others.

Grief and I have known each other for a long time. Truth be told, we grew up together, but it has taken most of a lifetime to become friends. In my youth, I kept to the sunny side of the street, seldom looking across life’s highway and into Grief’s shadowed path. We only came face to face at certain tragic intersections.

In time, I began to study Grief, at a distance of course, and with the intention of becoming Grief’s master. I treated Grief like a sickness, something to be endured and eventually overcome, or perhaps resolved, to use the sterile, objective language of the mental health sciences. Grief appreciated my newfound interest, but the distance between us narrowed only slightly. To re-enter my life, Grief still needed to rush in while making a great to-do.

The Jewish sage Koheleth writes in the book of Ecclesiastes: “Wise men are drawn to the house of mourning …”1 How strangely true this has been for me. As a hospital chaplain, I make my living in a house of mourning. It is here that I have learned to welcome Grief as a friend, a guide, a mentor—and why not? Grief is everywhere. Whenever change is accepted into this world, I see the face of Grief. Whenever change is denied in this world, Grief’s deep eyes dare me to look inside and know the fullness of the truth.

Grief comes to me as a daemon,2 a spiritual guide, a companion, who shares my bread of brokenness and cup of loneliness. Grief’s faithfulness is steadfast, befitting a gift of God. Grief has been at my side when dark nights of scarcity have sapped all vision, and Grief has steadied me when the luster of abundance has staggered me with its fierce glare. I am learning to trust Grief’s somber voice as a conduit of wisdom reaching beyond my limited and limiting awareness.

Early in my practice as a chaplain, I found myself feeling overwhelmed by the relentless current of grief flowing through this place. It was sink or swim, so I took Koheleth’s words to heart and chose a small ritual to keep my spirit afloat. I sought to become one with the prevailing current and began inviting Grief into my awareness, asking Grief to join me in my work. As I grew in my comfort with Grief, I was surprised to learn how close we really are. I expected Grief to come and go as some outside intruder, but now I find that Grief lives within me. Grief is a citizen of my psyche, at times ignored, but never ultimately dismissed, an inhabitant of my soul to be cherished and nurtured.

Keith Goheen MDiv serves as chaplain at Beebe Medical Center, Lewes, DE. An APC associate chaplain, he is endorsed by the Unitarian Universalist Association.

[email protected]



My relationship with Grief is complicated by Grief’s love of masquerade. Once, I saw one of Grief’s faces very clearly and thought, now I know Grief! But Grief never tires of creating new forms and keeps showing up with wildly different looks. Some faces are frightening, some alluring. Grief can be sickly or mad, bold as lightning or subtle as dew. Living in such a dynamic relationship requires a great deal of trust, a willing patience and a gentle humor. Grief may come in many guises, but when tenderly encouraged, Grief will always unmask. Like me, Grief longs to be known in all Grief’s complexity.

Talk about complex relationships—I was shocked to discover that Grief is married! I would have never guessed that Grief and Love were so closely bound! Now though, I see their marriage makes perfect sense. They complement each other so divinely that sometimes it’s hard to tell them apart. Amid the drama of living, I suspect they often borrow each other’s masks in order to teach my spirit equanimity.

Informed by the growing intimacy of our relationships, my ritual of invocation has become more integrated. No longer do I invite Grief and Love with unique prayers at separate times. I welcome them together, asking that their united and uniting power heal the fragmented places in my emotional and spiritual worlds so that in turn, I may be a healing presence to others.

When I take the hands of patients and look into their faces, I pray their Griefs and Loves be present in those same faces. When I listen to their stories, I pray for my Grief and Love to listen too and to prompt me when the patients’ voices of Grief and Love appear so that together we may honor their presence. Then I give thanks, for this timely and timeless meeting in which soul friends have met, assured that God is present to our communion.

Sometimes, like this morning over breakfast, the memory of someone whom Grief and I have come to know returns to my awareness. What to do with this unbidden guest? Once, I would have found a diversion, turning toward some important busy work and away from whatever blessings of wisdom the memory might bring. Now I am more hospitable and make a place at the table of my thoughts and dreams for this latest holy guest. Then I ask Grief and Love to join us, and I pray holding this memory and the soul from which it emanates with reverent compassion.

Through Grief, I have been given a great treasure. In learning to be more fully present to Grief, I am learning to be more present to Love. As in all other relationships, I am practicing balance, exercising the pastoral art of drawing close without clinging, being with the reality of Grief in ways that are neither neglectful nor obsessive. I have found it helpful to discern between my relationship with another person’s Grief and my reaction to the intensity of its expression. The touchstone that grounds me in this practice is unconditional Love.

As a hospital chaplain, I am schooled in the clinical practices of grief therapy, and I find these skills of great value in the course of my work. But the exercise of clinical skills is not the fulfillment of my vocation. I am called and trained to serve a greater Love, and to love is to grieve. So I devote myself in service to the daemon of Grief, so that through this increasingly hospitable relationship, I may learn more fully the wisdom of Love.

1 Jaroslav Pelikan, trans., “Ecclesiastes 7:4,” Sacred Writings, Judaism: The Tanakh (New York: The Jewish Publication Society, 1985), 1448.

2 James Hillman, The Soul’s Code: In Search of Character and Calling (New York: Random House, 1996), 8.


ON HOLY GROUND

The Chaplain Never Asked

Bettyana Bremer

I CANNOT SAY THAT I WAS SURPRISED to receive my sister’s call that morning. “Dad’s in congestive heart failure again. He quit breathing for a while before they could get him intubated so we think he has suffered a brain injury, and his kidneys aren’t functioning. You need to come home.” My father’s battle with heart disease had been going on for years and now at 63 years old his body was too tired to continue the fight.

As I drove the five hours to the hospital, I reflected on our years together. They were years filled with pain and fear. My father’s alcoholism filled him with rage and violence and we spent our days looking for hiding places to escape him. Over the years I had grieved our relationship many times. As I walked into the hospital room I was surprised at the grief I had left. I was overwhelmed by sorrow. My body ached with the weight of it all.

For two days we kept the vigil in ICU waiting for his heart to finally give up this fight. He was surrounded by his family, each of us reflecting silently on our own private pain. At times we reached for each other, but there were few words spoken. It seemed there should be so much to say, but none of us had the courage to give our words a voice. Finally, it was over. The machines that

provided life to him were removed. He was free from the pain of alcoholism and heart disease. One by one my sisters left the room, until I, his oldest, was left alone.

I marveled at this massive man who laid so still and silent in death. I had an awareness of peace. I was surprised by this feeling of peace as I had never experienced this feeling in his presence before. I touched him, feeling no need to hide. I picked up his hand and I was fascinated by how big his hands were. I placed my hand in his, noticing how small my hand was, and yet how much alike our hands were. I laid my head on his chest and wept. I wept because for the first time I felt safe with my dad and the little girl within me longed to be held by him.

I became aware that I was not alone in the room anymore. The chaplain had arrived. As I felt a hand placed on my back, I took comfort from this presence who stood silently as I cried. It felt good to have someone willing to journey with me through this valley of death. Then I heard these words, “I know that you have prayed for God to let your father live, but God has said no and now you must let him go.” The break in empathy was so profound that I physically jolted. I thought, “How could this chaplain know what I had prayed for without asking?” In that moment I felt like I was a task to be accomplished. I felt that the chaplain did not want to know what I was experiencing, but rather wanted to move the grieving daughter on and check this death off the list. “Please go away. I want to be alone now.” I lied.

How could I tell this chaplain that my prayer for my father was never that he be miraculously allowed to live? Why would I wish for him to spend one more minute in a broken body and a life that was defined by regret? A few months before he died he began to pray and make his peace with God. My faith leads me to believe that in death my father is experiencing more life than he ever knew in this world.

Bettyanna Bremer BA serves as associate chaplain at Great River Medical Center, West Burlington, IA. An APC student affiliate member, she is endorsed by the Church of the Nazarene.

[email protected]



My sorrow was not for my father; rather, it was for a little girl who longed to be held by her father, who would never know the comfort of his embrace. The chaplain will never know the meaning of my tears because this question was never asked. The assumption broke empathy.

I had very wise CPE supervisors teach me a few things about pastoral care. First of all, assumptions almost always break empathy. Secondly, our patients are desperately wanting to tell us what they are deathly afraid to say. As pastoral caregivers we have to create a holding environment that provides a safe place for our patients to share their secret fears. And finally, never let tears go unnoticed.

I really wish this chaplain had said to me, “Can you tell me about your tears?” I would have appreciated someone to journey with in that valley. It would have been really meaningful to me to share the secret heartache of a little girl, longing for the love of her father.

©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 25 Number 1 Spring/Summer 2009

Poetry

The Chimney Swift

I saw a little bird oncetrapped in my fireplace.In a panicked rush of brown wings beating out an infinite tempo,it flailed again and again,hurling itself against the fire screen,desperate to free itself.Exhausted, it hid under a logto catch its breath,afraid of the unknown giant in the roomwhose only thought was how to set it free.

I called Animal Control.

The officer knelt before the fireplaceand stared into the sooty darkness.“Oh, it’s a chimney swift,” she said.“Sweet little birds. Docile. Sometimes they justLose their way.”And just like that, she deftly grasped thechimney swift,Held it in her hand,Softly whispered words of reassurance,And set it free.

I saw a woman oncetrapped in a cageof soccer netting draped around her bed.It was the only way to keep her safe, the nurses said.Connections in her brain No longer kept her movements in control.Clinically known as Huntington’s Chorea,this unseen ghoul madly turned her intoa freakish marionette thatflailed and floppedin grotesque contortions.Hitchcock could not have done it better,in shocking angles of film noir.

She was safe in the cageBut not free.

I called on God.The woman and I prayed together, oh so softly. She chirped outa feeble “Amen,” as her body jolted,struggling against itself.I could not hold her,Could not even keep her hand in mineDuring the briefest prayer.But she knew the way home.There was a moment of stillnessHer hair damp on her forehead,limbs akimbo, the faintest smileHer eyes sought mine.And I knew that one day God would hold her firmly in his hand,Quieting and soothing her exhausted soul.And just like the little chimney swift,whisper words of reassuranceand set her free.

Marci Pounders BCC

©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 25 Number 1 Spring/Summer 2009

Stroke

Imagine you are in a dreamWhere you are running, Desperately reaching Through the curtain of a misty fog.You know what you knowYou are who you areand yetYou are not you.Connections once establishedIn the mysterious nooks and cranniesof the brainnow weep much as a buttered English muffin might do;Oily, slightly burned,Half eaten, sitting forlornly on the plate.You look at the muffin – or is it a communion wafer?Not quite remembering what it is for.And in a rush of frustrationYou know enough to know You don’t know.And you weepForlornly on your bedFeeling half-consumed, incompleteAngry, frightened at the unknown, wonderingWhy?Why? Why?Who am I now?And where is God?And what is that bread for?

Marci Pounders BCC

The Unseen Presence

Light, DarkJoy, Sorrow

Laughter, TearsLife, Death

A heart that danced lies broken on the cool tileSounds of weeping echo long and mournful

Loving hands reach out to holdCaring hearts yearn

And the unseen presence settles quiet over every aching soul

Light, DarkJoy, Sorrow

Laughter, TearsLife, Death

The dancing heart lies still, fastened to cruel timberA mother’s cry rings out loud to the heavens

Gentle hands reach out to holdThe heart of God yearns

And the unseen presence settles quiet over every aching soul

Wayne Morris BCC

The Reverend Marci Pounders MDiv BCC serves as palliative care chaplain at Baylor University Medical Center, Dallas, TX. She is endorsed by the Episcopal Church USA.

[email protected]

The Reverend Dr. Wayne Morris DMin BCC serves as staff chaplain at Comanche County Memorial Hospital, Lawton, OK. He is ordained by the Cooperative Baptist Fellowship.

[email protected]




In the Literature

Nancy Berlinger. “The nature of chaplaincy and the goals of QI: Patient-centered care as professional responsibility,” The Hastings Center Report 38, no. 6 (Nov/Dec 2008): 30-33. • Quality improvement (QI), by whatever name it is known, has been a focus within health care administration for over a decade. Berlinger’s thesis is a simple one: it is time for chaplains to commit themselves, completely, to the tasks and challenges of QI. “The goal of patient-centered care should be strongly identified with the profession.” She asserts that such care is one that chaplains can contribute to significantly and measurably. Her argument is that QI is not something that chaplains should know about and have happening around them; it must be on the working agenda of any pastoral care department. She examines the issue of how to select particular QI goals, the ethics of how to proceed, and the tactics for doing so. She then moves from theory to the practice of implementing specific QI projects. In this section, she provides a useful example of one chaplaincy department’s experience when they took a first step to embrace patient-centered care.

William J. Bryan. “Lessons from the Exodus elders,” Journal of Religion, Spirituality & Aging 21, no. 1/2 (Jan/Jun 2009): 17-35. • As spiritual

growth is a lifelong process, Bryan suggests that senior adults need biblical models to assist them in continuing the process of spiritual growth and development. He finds that the Old Testament elders Moses, Joshua and Caleb had three common elements in their spiritual growth and development: faith, prayer and sacrificial service. These elements correlate with Erik Erickson’s desired outcomes of the adult psychosocial development process: fidelity, love, care and wisdom. Bryan challenges seniors and religious communities to use this model and provides practical suggestions for supporting the continued spiritual growth and development of senior adults.

Raymond De Vries, Nancy Berlinger, Wendy Cadge. “Lost in translation: The chaplain’s role in health care,” The Hastings Center Report 38, no. 6 (Nov/Dec 2008): 23-27. • The authors maintain that if chaplaincy wishes to be recognized as a profession, it must describe what constitutes “quality” in the area of patient care. Unfortunately, chaplaincy work is hard to measure. These authors—two sociologists and a research scholar/volunteer for a chaplaincy service—all support the work of chaplains. This article presents their observations, reflections and a series of discussion points about the nature of chaplaincy as a profession. They believe that in order for chaplaincy to have a viable and strong future, chaplains must describe how their profession and their day-to-day work in the hospital contribute to health care and to the ongoing task of quality improvement. The authors frame their comments within a professionalization model, describing from a sociological perspective the challenges in following such a model. In the final section on self-interest and public interest, they point out what they see as weaknesses in the Association of Professional Chaplains (APC) 2007-08 strategic plan goals and suggest ways these may be addressed. If you read no other paper on chaplaincy this year, read this one.

R. der Graaf, Johannes Van Delden. “Clarifying appeals to dignity in medical ethics from a historical perspective,” Bioethics 23, no. 3 (Mar 2009): 151-60. • The concept of dignity is an important and fundamental one in medical ethics. However, as it is considered a kind of self-evident truth, its meaning is not always well-defined,. These authors seek to bring clarity to this concept via historical perspective. On the basis of historical texts, they propose a framework for defining the concept. Using this framework, they describe and illustrate four different forms,

W. Noel Brown STM BCC is the editor/publisher of The Orere Source, a bimonthly publication of summaries of pastoral and other literature of potential value to chaplains. These summaries of articles have been selected from this database.

[email protected]



each of which has several features in common: reference to the “special status of human beings”; a basis in essential human characteristics; vulnerability, i.e., it may be lost or violated. The authors maintain that by being explicit about the meaning of the concept, dignity—at least in its Kantian and relational understanding—will continue to play an important role in discussions of medical ethics.

Janet Foggie, Chris Levison, Iain Macritchie, David Mitchell. “Spiritual and religious care capabilities and competencies for health care chaplains,” Scottish Journal of Healthcare Chaplaincy 11, no. 2 (2008): 2-6. • Since 2002, health care chaplains in Scotland have been engaged in a process to identify and describe standards of competency. They have done so for several reasons, not the least of which is the fact that they now provide pastoral care in an environment in which everyone works within a competence-oriented focus. This means that everyone must provide care in ways that are explicitly described, and according to standards of competence that may be assessed. In this article, the authors, who have been deeply involved in this process, examine the document “The Spiritual and Religious Care Capabilities and Competencies for Health care Chaplains.” They describe its history, the process of writing, the process of consultation, and the document’s impact on their profession. Their central message is that capabilities and competencies are “an essential component of the development of chaplaincy as a modern health care profession.” This is an important document for chaplains outside Scotland for several reasons. First, the authors use language about chaplaincy that both coincides and differs from that used in the United States. This difference will challenge U. S. chaplains to consider their work from new perspectives. Second, Scotland has constructed a career path for the hospital chaplain, something that has never been formally done in the United States. Third, they include an outline for a post-graduate qualification to strengthen chaplaincy training. This brief article provides much food for thought.

Gordon Hilsman, Juan Iregui. “When physicians open their souls,” Health Progress 89, no. 6 (Nov/Dec 2008): 34-38. • Does a chaplain’s pastoral care extend to the doctors of an institution? Hilsman and Iregui say yes and describe a program they began in October 2007. Hilsman is a chaplain and ACPE supervisor; Iregui is a palliative care physician. Both work in the Franciscan Health System in Tacoma, Washington. They are not attempting to nurture physician’s souls; rather their program is designed to help physicians nurture one another. They describe the theoretical model behind their belief that shared mutual vulnerability may support healing and integration. They also relate how they organize groups as well as some of the resistance they have encountered and the results of their work. They conclude with a description of the three benefits they see arising from their program: personal integration of the participants, physician retention and support of the mission of their institution.

Stephen M.W. Hutchison, Iain Macritchie, Terry Veitch. “Cancer pain and the importance of faith in addressing suffering beyond the physical,” Scottish Journal of Healthcare Chaplaincy 11, no. 1 (2008): 17-20. • A palliative medicine doctor, a chaplain and a liaison mental health nurse present a case study, which describes the care of a terminally ill stomach cancer patient. This patient, who is a Christian with a denominational background that emphasizes an angry and judgmental God, is described by the health care staff as “difficult.” This paper demonstrates that, with good teamwork involving the chaplain, the woman’s pain—physical, emotional and spiritual—was resolved to the extent that she described herself as able to “live life to the full,” including an enjoyment of art and literature. She subsequently asked the chaplain to conduct her funeral.

Martha R. Jacobs. “What are we doing here? Chaplains in contemporary health care,” The Hastings Center Report 38, no. 6 (Nov/Dec 2008): 15-18. • This is the introductory essay to a group of four essays about professional chaplaincy, primarily health care chaplaincy. Jacobs is a chaplain in New York and managing editor of the e-newsletter PlainViews. In this piece, she tackles the complicated task of explaining what it is that chaplains actually do in health care facilities, how chaplains get their jobs, what their focus is (or should be). Jacobs calls for the standardization of chaplaincy practice and urges greater dialogue between chaplains and other health care professionals. Her insights concerning what chaplains are doing and the context within which they


are currently functioning make this article stimulating reading for all chaplains who are mindful of the future of their profession.

Geoff Lachlan. “Mindbody care—the ultimate patient experience?,” Scottish Journal of Healthcare Chaplaincy 11, no. 2 (2008): 10-15. • By 2007, the National Health Service of Scotland had decided to officially foster and require the provision of spiritual health care for all its patients. Part of the question then became how to get that message across to hospital administrators and to the fourteen area boards who managed health care services? With the help of the Scottish Inter Faith Council, surgeon Geoff Lachlan was hired to explain the importance of spirituality in health care. In this article, Lachlan briefly describes what he was asked to do and how he went about preparing for the task. He describes the official documents that support the place of spiritual care in the modern hospital. In addition, he details the evidence for the link between religion/spirituality (R/S) and health, including the concept of psychoneuroimmunology as the field that brings together R/S and health. More recently, the Scottish Government’s Health Directorates have begun a new initiative called “Better Together – Scotland’s Patient Experience Program.” To Lachlan, such a program places the experience of the patient at the center of health care delivery planning. He sees chaplaincy “finding itself in a crucial supporting role in patient care: ‘care of the spirit,’ as a vital part of the holistic care of the patient ….” (p. 14) For a copy of the document that philosophically undergirds Lachlan’s work, go to www.scottishinterfaithcouncil.org/28.html and click on the “Chaplaincy” tab, then on the title “Religion and Belief Matter.”

Chris Levison. “Revising the guidelines: Steps along the way,” Scottish Journal of Healthcare Chaplaincy 11, no. 2 (2008): 7-9. • There are many differences between the way health care is provided in the United States and in Scotland. In the latter, health care is managed and implemented within a countrywide program, with all of the advantages and problems associated therewith. Within the last decade, for reasons described in another article in the same issue (see Foggie et al.), chaplaincy has been required to look closely at all aspects of itself. Levison, who is the spiritual care advisor at NHS Education Scotland, describes the content of the “Revised Guidelines on Spiritual Care and Chaplaincy in NHS Scotland 2008.” The vision and the language may be useful for chaplains outside Scotland and provide encouragement for the tackling of some issues within U. S. chaplaincy. Consider the implications of NHS Scotland’s statement that the term “spiritual caregiver” is not restricted to chaplains. Further, spiritual care service provided in hospitals is to be “person-centered and inclusive, for those of any faith community or none because people with beliefs and values do not necessarily belong to any of the traditional faith communities or belief groups.” (p. 7) The work of chaplains is described as that of “pastoral care and encounter in a nonjudgmental context, accepting people as they are and enabling them to make use of their own resources, spiritual or religious, to cope, to reconcile, to heal or to accept and find what peace they can during times of ill health.” (p. 7) Levison refers to questions that have exercised the Scottish group and which also are alive and well elsewhere. For example, who are the chaplains of the future, and how will they be related to specific faith communities is an issue currently under consideration by representatives of the Judeo-Christian and the Muslim communities. Another issue that has been sitting in the too-hard-to-deal-with box is how to provide pastoral care for those whose health needs are being met in the community rather than in a hospital. In addition to these two, Levison notes about a dozen issues that need further attention in Scotland.

Michael E. McCullough, Brian L. B. Willoughby. “Religion, self-regulation and self-control: Associations, explanations and implications,” Psychological Bulletin 135, no. 1 (2009): 69-93. • Religion is a powerful force in the lives of many people, notwithstanding the different faces that it presents. There have been strenuous research efforts to understand whether and how religion affects health, producing results associating religion and health-related outcomes that are both puzzling and suggestive. The authors of this paper report a comprehensive review of the research literature that may help to explain why religious people tend to live slightly longer lives; suffer less from depressive symptoms; avoid trouble with drugs sex and the like; do better in school; enjoy more stable and satisfying marriages; and more regularly visit their dentists. They explore the idea that some types of religious behavior simply foster self-control and that it is partly through this


association that religion makes its contributions to health and well-being. This idea has a long history, going back to Emil Durkheim in the early twentieth century. After examining much research, McCullough and Willoughby conclude that self-control as a factor in good health does have reliable empirical support.

Margaret E. Mohrmann. “Ethical grounding for a profession of hospital chaplaincy,” The Hastings Center Report 38, no. 6 (Nov/Dec 2008): 18-23. • This is the second in a collection of five essays in this issue of The Hastings Center Report dealing with hospital chaplaincy. Mohrmann is interested in the fundamental attributes of chaplaincy—what makes it distinctive and whether a rationale can be created that will provide a basis for the profession that is at times hard pressed to rigorously define itself. As she notes, simply defining what hospital chaplains do as “pastoral” is no longer adequate for a number of reasons. In seeking to construct an adequate theoretical foundation for chaplaincy, Mohrmann asks two basic questions. What makes the care chaplains provide different from the care provided by other health care team members, given that many different people in the health care setting provide spiritual care? Is “pastoral” the best adjective for describing the sort of care chaplains give? Her responses alert readers to the inadequacy of the usual answers. She begins her pursuit of an adequate description of chaplaincy by identifying a robust “chaplaincy ethics” through broad questions. Is a professional ethic for hospital chaplaincy better understood as a theological-religious ethic for a particular kind of health care professional, or as a health care ethic for a particular kind of theological-religious-pastoral professional? To whom are chaplains responsible? She frames the issue as an “ethic of accountability.” In this regard, she examines the need to set, monitor and enforce standards. This brings her to another substantial and challenging question, i.e., what else? Chaplains may be technically competent in terms of standards thinking, but are there further considerations relative to theology? Mohrmann suggests that chaplaincy should bear the responsibility for creating “sacred space” in health care. They should remind their colleagues that patients, through their need for care, their illness and their dying, bring questions of “lasting spiritual significance” and that it is the chaplain’s task to create places where such ultimate concerns may be raised, acknowledged and honored. Mohrmann concludes this article with a discussion of chaplaincy ethics as an ethic of ministry.

Susan Stranahan. “A spiritual screening tool for older adults,” Journal of Religion and Health 47, no. 4 (Dec 2008): 491-503. • Stranahan, whose professional affiliation is not stated, works in a Florida retirement community. In order to identify spiritual distress in the older adults living in her community, she has created a 20-item list to be used as a screening tool. She developed this new tool as none had been designed for older adults. Further, she maintains that the assessing the spiritual well-being of older adults is important to encourage prompt referrals to the chaplain. She assumes that not every chaplain has time to assess the spiritual distress of each person entering a retirement community; therefore, an assessment tool that could be used by other staff as a triage step will be useful. She discusses the difficulty in defining spirituality and spiritual health as well as the methodology of creating an assessment tool, including reliability and validity. The screening tool she developed accompanies the article. Stranahan is starting where many chaplains would if they wished to undertake a piece of research. Reading the description of her process in this project will be educational for such a chaplain. Her literature review of the definition of spirituality and the theoretical developmental frameworks are brief but useful as is her discussion of what is meant by “spiritual health.”

John Swinton. “Identity and resistance: Why spiritual care needs ‘enemies’,” Journal of Clinical Nursing 15, no. 7 (Jul 2006): 918-28. • The area of spirituality has been one of growing interest for nurses in the last ten to fifteen years, as it has for chaplains, though the latter usually come to the subject with a different perspective. Yet, while much has been written about the positive aspects of spirituality, almost no critique of the ways that spirituality and spiritual care are understood have been offered by nurses—or by chaplains for that matter— despite the fact that there are key issues that require careful critique and considered reflection. Swinton has been a nurse, a chaplain and is currently a professor of practical theology and pastoral care. He argues that nurses— and I would suggest, chaplains as well—need to listen carefully to the criticisms of spirituality and spiritual care


offered by the “enemies” of such care who come from within the profession. If one listens carefully to these voices, one will hear them highlight issues vital for the development and forward movement of spirituality. In Swinton’s words, “One of the key features within the field of spirituality-in-nursing is the general assumption that spirituality and religion can and indeed should be separated from one another. It is assumed that, while only some people are religious, all people have spirituality. Religion is understood as just one of the many ways in which a person can express his or her spirituality. There are of course significant philosophical and theological problems with this distinction, which some critics of spirituality have been quick to highlight. These critics argue that the idea that spirituality is a generic, human universal downgrades the possible ultimate significance of the particular (religion) and opens the way for a commodification of spirituality, which is very much in line with Western consumerist assumptions. Like cornflakes or blue jeans, we find a spirituality that suits our personal taste and go with that until it ceases to fulfill our needs; then we move on to another form of spirituality. Such an approach to spirituality is very different from the approach of the major religious traditions. It is therefore debatable whether such understandings of spirituality are actually compatible with religious understandings.” (p. 920) Swinton urges nurses to develop spirituality as a specific field of inquiry with its own bodies of knowledge, methodologies, assumptions and core disciplines. Is the same not true of ministry, including pastoral care?

Derrell R. Watkins. “Spiritual formation in older persons,” Journal of Religion, Spirituality & Aging 21, no. 1-2 (2009): 7-16. • The author examines the definitions of spirit, spirituality, spiritual wellness and spiritual formation. Such issues as relationships with God, self, others and the environment also are considered. Watkins suggests a process by which older persons may experience spiritual growth and development in every facet of their lives. The article is the first of ten in this issue. The following issue will be devoted to different aspects of the spiritual development of older persons.

Hayley S. Whitford, Ian N. Olver, Melissa J. Peterson. “Spirituality as a core domain in the assessment of quality of life in oncology,” Psycho-Oncology (2008): 8 p. • Is spirituality, or spiritual well-being, a core component in a person’s quality-of-life (QOL), thus needing to be evaluated when completing a health assessment? Within the United States, the answer to this question would probably be an automatic yes, with the support of research such as that published by Chaplain George Fitchett and colleagues. (See “Measuring spiritual well-being in people with cancer: The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale [FACIT-Sp],” Annals of Behavioral Medicine 24, no. 1 [Winter 2002]: 49-58 and “A case for including spirituality in quality-of-life measurement in oncology,” Psycho-Oncology 8, no. 5 [Sept/Oct 1999]: 417-28.) However, the inclusion of spirituality when assessing QOL is not automatic in cultures less religiously inclined. Thus, this paper from Australia begins by asking whether spiritual well-being is a core domain (component) in a person’s QOL? A total of 490 cancer patients with mixed diagnoses completed two questionnaires: the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being (FACIT-Sp) and the Mental Adjustment to Cancer (MAC) Scale. FACIT-Sp assesses physical, social/family, emotional, functional and spiritual well-being in persons who are chronically ill. It includes an overall measure of QOL. The authors followed in the footsteps of the authors of the second study referred to above. Based on their findings, the authors’ answer to the question is yes. Further, they believe that their results strongly support use of a biopsychosocialspiritual model for assessing and understanding oncology patients. They conclude that “By failing to assess spirituality, the ‘true’ burden of cancer is likely to be miscalculated.” They also make it clear that they see this is an overall finding and that there remain fine details that need to be understood as well. They point to the concept of meaning and meaning making. Preliminary work already has shown that meaning making as a coping style has several possible ways of helping people and that the concept of meaning is a multifaceted one. For example, meaning may have two different levels—global and situational—and these be further divided. The researcher’s task is to clarify further how people make meaning. The chaplain’s task is to understand exactly how their patients make meaning and to be able to assist them in this venture.


Expression of Faith

In Whom We Live

Dick Millspaugh BCC

Dear God, Good and gracious are you. Mysterious and troubling is your spirit. Unknowable, unperceivable is your will. Beyond thought is your way. When thought and perception fail You are there; Yet there is no there Where you are. All we hold fast in you Is but our own imagining, For you exist not there And beyond here. In you is grace. In you is love. In you is peace. Not as this world gives do you give. In us is the mystery of faith. We trust in that which we cannot see. We hope in that which is not yet. We yearn for what we do not have. Yet it is in our not having That you come. It is in our blindness That your light shines. It is in our not yet That you exist as our eternal now. It is in our hunger That you are our food. In these mysteries, we seek to live. In these unknowns, we seek to be understood As much as we seek to understand. In these empty spaces, we seek to be loved, And there and then you appear, once more. Amen.

Dick Millspaugh MDiv BCC is chief, chaplain service, at the VA San Diego Health System, San Diego, CA. He is an ordained elder in, and endorsed by, the United Methodist Church.

[email protected]



Media Reviews

Jewish Visions for Aging: A Professional Guide for Fostering Wholeness Dayle A. Friedman (Woodstock, VT: Jewish Lights, 2008, 236 pages, hardcover)

Jewish Visions is a fine compilation of Rabbi Friedman’s inestimable contributions to the field of aging over the past dozen and more years. This book has many new insights while also updating previously published ideas, including material drawn from the anthology she edited, Jewish Pastoral Care: A Practical Handbook from Traditional and Contemporary Sources, 2nd Edition (Jewish Lights, 2005). This reviewer contributed a chapter to that volume, “Para-chaplaincy: A Communal Response to the Ill and Suffering,” to which she specifically refers in this new book.

Jewish Visions for Aging is also a guide for Jewish professionals fostering wholeness. It divides into five sections: text and tradition, aging and meaning, family caregiving, spiritual accompaniment in aging, and concludes with aging and community.

This book is aimed at a readership that is reasonably familiar with the nuances of such Hebrew terms as midbar, kavod, tzelem and Torah. Friedman defines these words, but then uses them metaphorically. Readers who are not so familiar with these ideas, whether Jewish or non-Jewish, may have to work a little harder to apply these concepts.

Most chapters feature sections titled “For Further Investigation” and “Resources,” which allow the interested reader to pursue additional avenues. The book concludes with a glossary and index.

Rabbi Friedman has developed a wonderful program termed Hiddur: The Center for Aging and Judaism. Quite appropriately, she refers to it in the book. It is located at the Reconstructionist Rabbinical College in Philadelphia where she is a member of the faculty (www.hiddur.org).

Jewish Visions for Aging: A Professional Guide for Fostering Wholeness reviewed by David J. Zucker PhD BCC, Rabbi/Chaplain, Director of Spirituality, Shalom Park, Aurora, CO.

Finding God in the Shadows: Stories from the Battlefield of Life Marsha Hansen and Peter Huchthausen (Minneapolis, MN: Augsburg Books, 2008)

Finding God in the Shadows is a compilation of short stories describing the difficult places in which military personnel find themselves. The authors assert that all of the vignettes are true. Although these stories are placed in the context of war, their intent is not to offer a theology of war but simply to examine issues of faith and ethics through these described experiences.

Marsha Hansen is an educator, freelance writer, concert vocalist, and former United States naval officer. She also is the author of My Soul is a Witness (Augsburg 2006). Peter Huchthausen is a retired Captain in the United States Navy, currently living in Normandy, France. He has authored a number of books, including Shadow Voyage (2005), America’s Splendid Little Wars (2004) and Hostile Waters (1998). The authors state that the purpose of this volume is “to help those who wish to practice what the prophet Micah taught: God’s will is that we do justice, love mercy, and walk humbly before our God.”

The 25 stories are action packed and often read like a suspense novel. Each follows a similar pattern. Along with the incident in war, the authors place a Scripture reading, which they feel draws a parallel between the real incident and the vignette from biblical literature. This template draws out common themes of justice, love and mercy. The central question that the authors ask the reader, regardless of the circumstances, is “Will I see the


image of God in others and let this guide what I think, what I feel, what I say and what I do?” I found this format as intriguing as the stories.

The professional chaplain in the military, VA hospital or VFW may find this volume of particular interest. Each reflection points to a way that one might process decisions, not only in time of war but in everyday life. For example, the first story, the “Battle of Pilar Pass” describes a situation during World War II when fighting stopped momentarily—miraculously on both sides—because an 8-year-old female, wounded and bleeding, walked down the road toward certain disaster. The accompanying scripture suggests ethical action. In this story, a military chaplain, or a chaplain working with the current population of wounded warriors, may find descriptions that are inspiring and a wellspring of hope and comfort.

It would be a caricature to say that these stories/vignettes have been written with a feel good intent. They challenge one’s comfort zone. A theological educator might use these vignettes sporadically in offering wartime scenarios for theological reflection. Some details are R-rated and are not for the faint of heart. Professional chaplains in all specialties will no doubt come away with a greater sensitivity to the challenges faced by the men and women of the United States armed forces.

Finding God in the Shadows: Stories from the Battlefield of Life reviewed by Beverly C. Jessup DMin BCC, CPSP Diplomate, Pastoral Supervision, Clinical Director, Pastoral Care, FirstHealth Moore Regional Hospital, Pinehurst, NC.

Desire: The Journey We Must Take to Find the Life God Offers John Eldredge (Nashville, TN: Thomas Nelson, Inc., 2008, 230 pages, softcover)

Eldredge joins the “journey” metaphor with the idea of “desire,” and a dynamic learning process begins. He encourages his readers to “take the journey of desire, the path of learning to listen to desire, and sort it through, and find in it the treasure God has for us.” (p. ix)

This journey will take some time. Many of the chapters begin with the continuing story of a sea lion living in a desert. He has lost his dream of living in the sea. This story provides a narrative quality to the different twists and turns that keep occurring throughout the journey with desire. Some lingering is required to digest the short quotations that begin each chapter as well as longer ones within the text. Eldredge’s transparency helps his audience to identify with their own journeys.

The way in which Eldredge links faith, prayers and hopes to desire will be appealing to believers: “In other words, those who know their desire and refuse to kill it, or refuse to act as though they don’t need help, they are the ones who live by faith. Those who do not ask do not trust God enough to desire. They have no faith.” (p. 59) Regarding the prayers of the psalmist and the persistent widow, Eldredge writes, “Their humility allowed them to express their desire. How little we come to God with what really matters to us. How rare it is that we even admit it to ourselves.” (p.61)

For those willing to invest enough energy to take a journey with desire, this book provides practical insights relating to career, marriage, addictions, success, failure and intimacy. The opportunities for spiritual growth may be transforming. For example, the chapter titled “The Grand Affair,” reveals the nature of intimacy between a man and a woman, between God and the church, and between God and persons. These intimate relationships in the context of scripture, provide insights about our love relationships with God, with one another and with heaven. Readers may find the gender references difficult to integrate into their thoughts; nevertheless, these references may serve to clarify what one believes and disbelieves about these relationships.

The strength of this work is the practical manner in which it illuminates the individual’s daily experiences with desire. This is achieved through the sharing of experiences that readers may recognize as their own. These clearly reveal which desires that are realistic and unrealistic, hopeful and unhopeful, owned and disowned. One may argue that the use of scripture gives the impression of being a proof text; however, more often than not, the


original meaning is applied with fairness.

Chaplains may find help for ongoing self-care. Clinical Pastoral Education supervisors may find a helpful resource to help students connect with their individual levels of self-awareness. Indirectly, spiritual care of patients, families and support group members is enhanced by carefully translating insights. The journey metaphor serves well as a means for reflecting on one’s progress as persons and professionals.

Desire: The Journey We Must Take to Find the Life God Offers reviewed by Michael G. Davis DMin BCC (retired) Hernando, MS.

Health Care Reform Now! A Prescription for Change George Halvorson (San Francisco: John Wiley & Sons Inc., 2007, 360 pages, hardcover)

I had some initial skepticism when I saw that the author of this book was the CEO of Kaiser Permanente. However, even though he writes from a particular point of view, he obviously has a great deal of familiarity with the subject matter.

We all are aware that spending on health care in our country has skyrocketed. Halvorson points out the drastic unevenness of this spending: 1 percent of the population spends 35 percent of the health care dollars. Five chronic diseases account for the majority of these costs: congestive heart failure, asthma, diabetes, coronary artery disease and depression.

Halvorson notes that the current system provides incentives for doing lots of procedures, rather than for improving health. “We have over nine thousand billing codes for individual health care procedures, services and separate units of care. There is not one single billing code for patient improvement. … Hospitals make absolutely no money from an educated, enlightened, and personally empowered asthma patient who recognizes his or her symptoms at an early stage and then takes the steps necessary to avoid an emergency room visit or a hospitalization.” (pp. 16-17)

It certainly makes sense to support the procedures, providers and clinics that actually improve patients’ health. The author points out that data is needed along with the ability to share it among the various health care entities. If you were diagnosed with a particular type of cancer, wouldn’t it be helpful to know the success rates of different clinics for treatment/cure? Such data obviously would provide the clinics with the incentive to improve these rates.

Halvorson believes that large private employers, rather than government, should take the lead in initiating changes, and he elaborates on a plan: “The new marketplace will not exist until someone is hired to make it happen, so we need vendors who can transform the infrastructure and performance of care in clearly defined ways.” (p. 174) He sees these vendors functioning as the wholesalers in the health care marketplace. He favors a health care sales tax to fund universal coverage. This was the method used ten years ago to fund MinnesotaCare, a plan that certainly helped members of my family who live in that state.

For the author’s vision to become a reality, huge changes would be needed in how American health care does business. Few would argue with the fact that huge changes indeed are needed.

My only complaint with this book is the author’s repetitive, wordy style. A good editor would have shaved the manuscript by a hundred pages.

Health Care Reform Now!: A Prescription for Change reviewed by Mark A. Bonnema MDiv BCC, Staff Chaplain, Swedish Medical Center, Seattle, WA.

Hospital Stay Handbook: A Guide to Becoming a Patient Advocate for Your Loved Ones Jari Holland Buck (Woodbury, MN: Llewellyn Publications, 2007, 232 pages, softcover)

This book relates the story of the sudden hospitalization of the author’s husband Bill for pancreatitis, which


progressed to multiple organ failure, infections, seizures and nearly every close brush with death that one might imagine. Bill spent six out of the next eight and half months dependent on life support in four different U. S. hospitals.

The author provides fourteen key recommendations and six checklists designed to assist the reader in evaluating hospitals, lining up needed information, preparing legal documents and preparing for a loved one’s medical procedures. She does an admirable job of defining terms that are used casually in the health care setting and most likely seem like a foreign language to patients and their family members.

She outlines questions to ask, data to collect related to hospital policies and procedures, accommodations for family/caregivers, patient rights and patient confidentiality. A section on financial matters warns caregivers to be alert for durable medical equipment given to patients. This may help to avoid duplication and unnecessary billing.

Most helpful, perhaps, is the section “Lessons in Advocacy.” Reprinted with permission is “The National Patient Safety Foundations Consumer Fact Sheet: The Role of the Patient Advocate.” I found it to be clear, concise and without personal bias. In a similar vein, the section, “Laying the Groundwork for Effective Negotiation,” provides basic skills for negotiating effectively whatever the issue.

Buck provides the reader with valuable resources, sample patient forms, Web sites, general tools, patient advocates and palliative care resources. Her Web site provides a downloadable version of a “Care Team Notebook,” a listing of medical terminology and highlights of recent news on the U. S. health care system and various media resources. (www.hospitalstayhandbook.com).

This book was previously published in 2005 by Author House, Bloomington, IN, under the title 24/7 or Dead: A Handbook for Families with a Loved One in the Hospital. Despite the change of title, the author’s adversarial approach to health care is a constant. Her recitation of horror story after horror story in relation to her husband’s hospital experiences is frightening in retrospect. I can only imagine the fear and mistrust reading this book may instill in someone experiencing a medical emergency. While tools from the author’s Web site may be helpful for a patient’s family member or advocate, this is a book to be read when one is well and capable of digesting a vast amount of information and sorting through the horror of the missteps and mistakes in this one patient’s care.

Hospital Stay Handbook: A Guide to Becoming a Patient Advocate for Your Loved Ones reviewed by Linda F. Piotrowski MTS BCC, Pastoral Care Coordinator/Chaplain Palliative Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Faith & Fitness: Diet and Exercise for a Better World Tom P. Hafer (Minneapolis, MN: Augsburg, 2007, 143 pages, softcover)

I am in favor of faith, fitness, diet and exercise. I follow my faith tradition, I am fit, I commit to a reasonable diet, and I exercise regularly. I strive for a better world. I also was looking forward to reading this work. Regrettably, I was disappointed. There is little new in this volume. At best, it is a basic book, which takes a parochial religious approach, in this case inviting Christians to understand that through thoughtful living—judicious food choices, regular exercise, and connection with a community—they may lead healthier lives.

The book is unabashedly aimed at one faith community. Though he features other sources, Hafer laces his chapters with quotations from the Christian Scriptures. This book may find its way to the libraries of church communities in the self-help section; however, it is not a candidate for a chaplain’s essential reading, much less purchase.

Faith & Fitness: Diet And Exercise for a Better World reviewed by David J. Zucker PhD BCC, Rabbi/Chaplain, Director of Spirituality, Shalom Park, Aurora, CO.

Rising from the Dead: Stories of Women’s Spiritual Journeys to Sobriety


Patricia D. Nanoff (New York: The Haworth Press, 2007, 118 pages, softcover)

As chaplains, we may see patients before they acknowledge their alcoholism or before they “hit bottom” and reach that transition point that marks the beginning of recovery. Women alcoholics tend to be more isolated and misunderstood. Reading Patricia Nanoff’s Rising from the Dead may help both to raise our awareness and to improve our ability to minister to them.

Nanoff, an experienced licensed clinical social worker with a DMin, shares and illuminates stories of twelve women, ages forty-six to ninety, who have maintained sobriety for twenty-five to fifty-three years. For recovering alcoholics, telling and retelling their stories reminds them of their own progress in a way that reinforces their recoveries and inspires others. Indeed, recovery has given them new meaning and purpose. They consent to tell their stories so that others may be reassured and healed as they themselves have been.

Nanoff hopes to inform the “helping professional who wants to understand that particular pathway from hell to redemption.” (pp. 5-6) In addition to the narratives, she also succinctly describes the Alcoholics Anonymous twelve-step method of recovery, the Minnesota model for addiction treatment and some theological and psychological perspectives on the value of storytelling and the process of recovery.

Nanoff weaves many themes through her loosely organized book, the title of which is derived from a David Haas song. She and her storytellers speak dramatically and authentically of transforming shame into redemption, of struggling with questions of God’s active agency and of developing a new relationship with God. She also comments on the Christian liturgical year as a metaphor for the healing process.

Inspiring and thought provoking, Rising from the Dead may serve as a basis for a chaplains’ group discussion, particularly regarding the role of the chaplain. It may also serve as a resource for personal reflection and a source of reassurance for women in recovery.

Rising from the Dead: Stories of Women's Spiritual Journeys to Sobriety reviewed by Mardie J. Chapman MS MDiv BCC, Chaplain, St. Anthony’s Hospital, St. Petersburg, FL.

ABCs of Healthy Grieving: A Companion for Everyday Coping Harold Ivan Smith (Notre Dame, IN: Ave Maria Press, 2007, 174 pages, softcover)

Grieving in itself is difficult, emotionally draining and time-consuming. Grieving well is an art that may be learned. This book is an excellent primer for that purpose. Harold Ivan Smith presents a succinct, eminently practical “how to” book. He is masterful at offering advice and doing so with admirable brevity.

There are entries for each letter of the alphabet and multiple entries for some letters: Allow for individual differences in grieving; Anticipate the holiday “blues”; Befriend the silence; Cry; Discourage hasty decisions.

Each entry is limited to two pages that feature a relevant quotation or two followed by Smith’s wisdom. Each concludes with an “I can” statement, which invites the reader to address what s/he has learned.

This is a small book with a very large message. Though it is published by Ave Maria, a religiously affiliated press, it is relevant and inviting to those of all faiths or of no faith.

ABCs of Healthy Grieving: A Companion for Everyday Copingmore than meets the expectation of its title. It exceeds it with well-written and wise grace and humor. I recommend it unreservedly. It is a book to read, to share and to offer to anyone who is grieving.

ABC's of Healthy Grieving: A Companion for Everyday Coping reviewed by David J. Zucker PhD BCC, Rabbi/Chaplain, Director of Spirituality, Shalom Park, Aurora, CO.

What Can I Do? Ideas to Help Those Who Have Experienced Loss


Barbara A. Glanz (Minneapolis, MN: Augsburg Books, 2007, 173 pages, softcover)

This book is a compendium of good advice and personal experiences, provided both by the author herself, and by dozens of people who shared their journeys through the grieving process with her. The volume focuses both on people who are going through their own grief processes and on those who would help someone to grieve well.

The sixteen chapter titles indicate well the direction of the book. Several are directed to caregivers: Chose Your Words Carefully; Anticipate the Person’s Needs and Offer Practical Help; Share Your Own Experiences. Others address the mourner: The Blessing of Tears; Share Good Memories; Celebrate the Life of the Person; Create Traditions That Keep the Memory of a Loved One Alive.

Though written for a general audience, there is a Christian religious slant to the book. For example, in the dedication the author mentions “our heavenly Father, who has promised to reunite us all for eternity one glorious day.” In a subsection titled “Remember Holidays and Special Occasions” the author refers to New Year’s Eve, Valentine’s Day, Mother’s/Father’s Days, Halloween, Thanksgiving and Christmas, even including advice for a Christmas cheer box and help with a Christmas tree! In fairness, she does briefly mention Buddhist and Jewish traditions. One difficulty with the latter is that she quotes a source that represents one part of the Jewish spectrum and is not necessarily representative of Jewish practice overall. Further, she writes of “the grieving process proscribed by the Jewish religion.” I am fairly certain that she meant to write, “prescribed by the Jewish religion.” (p. 134)

In short, this is a good book, but readers may need to translate or adjust some of the language or examples to meet their needs.

What Can I Do?: Ideas to Help Those Who Have Experienced Loss reviewed by David J. Zucker PhD BCC, Rabbi/Chaplain, Director of Spirituality, Shalom Park, Aurora, CO.

Any Day with Hair Is a Good Hair Day Michelle Rapkin (New York: Hachette Book Group USA, 2007, 178 pages, softcover)

This is a good “how to” book that I would feel comfortable giving to someone with cancer. On the cover of the book Rapkin states, “How to get through CANCER and get on with your life (trust me, I’ve been there).” While I don’t consider that sentence a subtitle, it is her thesis spelled out in full. The book is chock full of practical ways for one to battle cancer.

Rapkin does not speak directly of her type of cancer, nor does she go into the detail of her personal struggles, though she touches on some of them. Rather, this book is a collection of practical things from a wide audience of cancer survivors—including Rapkin herself—that helped them get through their treatments. To that end, this book is intended for people who have been newly diagnosed with some type of cancer. It is designed to help them navigate through the medical world and to take control of their treatment.

What I especially liked in the first couple of pages was how Rapkin responded to and experienced her diagnosis. She claims the first side effect of cancer is not from treatments that will come later, but from the feeling of powerlessness that accompanies the diagnosis itself. I thought she was very astute. Some people who find out they have cancer stay in this powerlessness mode the rest of their lives, but Rapkin has a practical plan for dealing with this feeling.

She maintains that in the same moment you are diagnosed with cancer, you also become acting president and CEO of a major health concern: yours. The rest of the book outlines practical ways to exercise your power as CEO over your plan of treatment, over well meaning family and friends, and over your mind and spirit as well as your body.

One chapter of the book looks at humor as a way of dealing with cancer. I agree with Rapkin’s view that humor is


not curing power, but healing power. There is a difference, and sometimes healing power is enough.

This book is full of resources—Web sites, nonprofit organizations, retreat centers—and includes a glossary of common cancer related terms. Rapkin fills a chapter titled “top ten” with lists such as the following: things to do while waiting (which there is a lot of), music to have chemo by, movies to entertain and distract, novels to read, helpful cancer books, myths about cancer, Bible passages to comfort and encourage.

The author seems to have approached her cancer as a woman with a good education and financial resources, both of which obviously gave her a sense of power over her circumstances. While the book may help cancer patients with less education and financial means, I’m not sure those folk would reach for this helpful resource in their local bookstores.

Any Day with Hair Is a Good Hair Day: How to Get Through CANCER and Get On with Your Life (Trust Me, I've Been There) reviewed by Mark A. Weiler DMin BCC, Director of Pastoral Care, North Colorado Medical Center, Greeley, CO.

This Incomplete One: Words Occasioned by the Death of a Young Person Michael D. Bush, Ed., (Grand Rapids, MI: Wm. B. Eerdmans Publishing Company, 2006, softcover)

“There is no purple prose in these sermons, preached in the most painful of circumstances, the death of a young person. Language has been cut to the bone. They are intensely moving. And authentically Christian.” (p. ix) These words from the forward by Nicholas Wolterstorff, himself a grieving father and author, couldn’t be more true. Editor Michael D. Bush has compiled a soul-affirming collection of sermons preached on the tragic occasion of the deaths of young persons who ranged in age from just a few days to mid-life. I see this anthology as providing great comfort for Christian families in the midst of the greatest anguish that may be endured, the untimely death of a child.

This Incomplete One affirms the great love that parents have for their children. As a grieving father whose only son, Mark, 18, died over four years ago, I identify with these messages. Each sermon includes a brief description of the circumstances that occasioned it and the person whose life it acknowledges. Some are written by the pastor who ministered capably to a grieving family; some are written by the grieving parent. “There are…two recurrent themes. Amidst the grief over the brevity of this child’s life, there is gratitude for his or her presence in our midst. The child was a gift. The grief does not smother the gratitude. And death, they all affirm, is not the end. We grieve, but not as those who have no hope. Yet none says that since death is not the end, we should not grieve. Though grief does not smother hope, neither does hope smother grief.” (Forward, p. x)

Of historical interest is a sermon, published for the first time in English, from Karl Barth, whose son Matthias died in a climbing accident in the Swiss Alps. Also of interest is a sermon by Jonathan Edwards at the death of young missionary David Brainerd. Edwards’ own daughter, Jerusha, nursed Brainerd through his illness and death from tuberculosis. She died two weeks later and was buried beside him. There are outstanding messages from William Sloane Coffin, Jr., whose son Alex was killed when his car plunged into Boston harbor from a rain-soaked highway, and from John Claypool whose daughter Laura Lue died of leukemia. Written nearly twenty years later, Claypool’s message, “What Can We Expect of God?” from Isaiah 40:27-31, is a masterpiece. I heartily commend This Incomplete One to pastors, chaplains, grief counselors as they minister to grieving Christian families whose children have died at any age from any cause. These sermons are destined to become classics.

This Incomplete One: Words Occasioned by the Death of a Young Person reviewed by Phil Pinckard MDiv BCC, Chaplaincy Services and Education Director, Medical Center of South Arkansas, El Dorado, AK.

Finding Comfort in God’s Embrace: 31 Meditations for Those Who Grieve


Gwen Waller (Auburn, WA: Main Street Book House, 2005, 142 pages, softcover)

The strength of this book is that it presents a well-written collection of meditations, which would be a valuable resource for helping those who are grieving the loss of a loved one. The most significant limitation is that it is written from a manifestly Christian perspective and may therefore be of limited usefulness to those from other religious traditions or in interfaith contexts.

The author’s premise is succinctly stated through a quotation on the back cover: “Grief’s journey can feel dark, frightening, overwhelming. But you need not walk this path alone. Finding Comfort in God’s Embrace offers support from those who have gone before you and from God, who longs to go with you.” Following the death of the author’s son, Darren, a friend challenged her to “write a devotional book for people who are grieving.” Finding Comfort in God’s Embrace is the result.

This book is organized in eight parts. Each contains three to five chapters and focuses on where the griever may find comfort, e.g., in God’s Nearness, in God’s Compassion, in the God of Peace. Each chapter consists of a Bible passage (primarily NIV), a meditation, a short prayer and an exercise. Taken as a whole, the chapters provide clear illustrative lessons in the comfort to be found in God’s embrace, asking the reader to discover this comfort through the exercises.

As previously mentioned, the book’s limitation is that it presents a Christo-centric worldview and is written in an evangelical tone. The theology expressed also may be problematic: “The purpose of grief is to protect our souls. God designed it to sustain us in times of great loss. It can insulate us and slow us down. Grief is productive depression, which works the loss through our soul.”

Nevertheless, Finding Comfort in God’s Embrace is a dependable source of support for the grieving evangelical Christian. As stated in the last paragraph, “In the midst of our grief, His (God’s) love may seem hard to grasp, but we can pray Paul’s prayer (Ephesians 3:16-19) for ourselves, as well as for others who grieve alongside us. God Himself longs for us to know and to experience His love, and to believe that whether our hearts are filled with joy or seemingly broken beyond repair, He is with us. May we continually find strength in His presence and comfort in His embrace.”

Finding Comfort in God's Embrace reviewed by James H. Wise, MAMS, Diaconal Minister ELCA, Chaplain, M.S. Hershey Medical Center, Hershey, PA

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