On Loss and Grief and Dreams - and God

My newest piece is up at the Episcopal Café. It's about the relationship between loss and grief - and between grief and the holy. I've addressed this before, but this is the result of further reflection.

Some New Video Resources

Recently I had the opportunity to particiapte in a webcast presentation from the recent National Funeral Director’s Association (NFDA) Annual Conference. The title was "End-of-Life Care: From One Set of Caring Arms to Another," and the presenting panel included Robert Friedman MD, FAAHPM, the Chief Medical Officer at Hospice Austin in Austin, TX; Dr. Thomas G. Long, the Bandy Professor of Preaching at Candler School of Theology at Emory University in Atlanta, GA; Thomas Lynch, a writer and funeral director from Milford, MI; and Dr. Alan Wolfelt, an author, educator and grief counselor. This was an interesting conversation among the presenters. While initially intended to discuss the interactions when a person in hospice or palliative care dies between the care provider and the funeral home, it became a wider discussion on current styles in our culture of expressing, and perhaps repressing, grief. 

At the time the NFDA web site stated that the presentation would eventually be available for viewing on line. I shared that at the time, and now have the link. This and other presentations from the NFDA Annual Conference are now available on YouTube. If you link to this page you will find links to this and other presentations. Note, too, that NFDA has a YouTube channel, and there may be other videos of interest there. A note for Board Certified Chaplains: if you haven’t fulfilled the 50 contact hours required for continuing education, I think at least some of these presentations would apply. 

 I hope readers find these links and these presentations helpful.

A Good Discussion on Grief and Depression

Some readers may be aware that the Diagnostic and Statistical Manual of Mental Disorders (known more generally as the DSM, with the next edition to be DSM V) is in the process of revision. One controversy in that process has to do with the diagnosis of major depression, and what is known as “the bereavement exclusion.” That is, symptoms that might indicate clinical depression might, for a person who has suffered a significant loss, might only indicate normal grief.

With that in mind, when I heard that there would be a segment on NPR’s Talk of the Nation discussing this issue, I was wary. However, when I listened I was pleased. Jennifer Ludden interviewed a clinical social worker and a psychiatrist. Both were able to discuss their own experiences of grief. Both were able to speak to the normalcy of grief. Both focused less on specific symptoms, and more on function: how well is the person moving over time past the initial grief and reengaging the world. Moreover, both were respectful of the support of clergy and chaplains for those grieving, both in general and in response to a chaplain who called in to the show.

It was an interesting and informative discussion. You can go here to read the transcript or listen to the recorded conversation. Take the half hour or so to listen. It will be well worth your time. 

Worth Reading: A Doctor on a Hard Conversation

I appreciate my readers.  One of my readers, Mark Preece, pointed me to a post at the blog dotCommonweal.  That post was a recommendation and brief comment about an article online at the website of the New Yorker.  The article, titled “Letting Go,” was written by Atul Gawande, a surgeon.  It’s an in depth article, the sort of thing the New Yorker is known for, and it’s worth the time to read.

The subject of the article is, really, the difficulty that physicians have being honest with patients when the patient faces a terminal diagnosis.  As much as anything else, the cause is that the physicians have difficulty being honest with themselves.  Having been educated to think that disease and death are enemies, many physicians are reluctant to stop therapeutic treatment even when there’s no reason to think further therapy will benefit the patient.  They’re also inclined to see a patient’s death as a defeat, and both a personal and professional failure.  But, as Dr. Gawande notes, “Death is the enemy. But the enemy has superior forces. Eventually, it wins.”  Or, as I often say, the mortality rate of being human is 100%

Dr. Gawande does speak well of specialists in palliative care, even as he raises another hindrance.  To really understand a patient’s values and to help the patient understand what is and isn’t possible or statistically reasonable takes a great deal of time.  It certainly doesn’t help that physicians are paid to apply treatments and not to really sit down and talk to a patient.  At the same time, I don’t think lack of reimbursement is the most serious reason that physicians don’t have these conversations, nor does Dr. Gawande.  Rather, it is that most physicians aren’t trained to address the personal, and certainly non-clinical issues that really shape how patients hear information and make decisions.

Dr. Gawande is honest about his own difficulties, and clear, too, in his critique of his profession.  He offers a worthwhile reflection on what makes it hard for doctors to be clear with themselves and their patients when therapeutic medicine has nothing more to offer.     

What a Chaplain Has Learned About Grief, Part 2

I wrote this several years ago to present to an adult Sunday School class. I have used it since to share with a parish visitation group and a parish that lost its church to arson. I have recently revised it and thought I would share it here. This is the second installment.  The first is here.

5. So, what can one expect?

First, you can certainly expect to feel shock and denial. Understand for yourself and for others that a certain initial denial is normal and even desirable. Denial is literally the emotional shock absorber. You don't want to live there, but you can't help but go there at first. Again, this is important for us to know who want to help someone grieving. That initial reaction that appears to be disbelief is, if you will, cushioning for the soul.

It is rarely necessary to confront this, at least in the initial minutes, hours, and days after the loss. Most of the time those who seem to express disbelief and denial are not really trying to deny facts. They’re trying to express the intensity of feelings they can’t yet sort out.

Second, you will realize that the world is not the same, and you are not the same. I remember when the dean of my seminary died, about a year after I graduated. He was a great scholar, but he and I had knocked heads almost from the time I arrived, probably because we were so much alike. I spent most of my seminary career angry with him, and was still expressing that when I learned of his death.

But when I learned of his death I realized a sudden, painful absence. I had lost the person I had loved to hate, and suddenly, even a year out of school and a thousand miles away, my world was not the same.

Obviously, this is one of those times where the sense of change is proportional to the importance of the person or thing lost. Minor losses do change our world, but it doesn’t take too much grieving or too much time to adapt. For a major loss, the magnitude of the change in reality makes adaptation much harder.

It might be easier to imagine if you think of your loss if your house burns down. How long would it take to replace just those things that you can replace? Home? Belongings? Clothing? Even to replace the replaceable takes a lot of time and energy. And what about those things that can’t be replaced, like family photographs? If it took you years to accumulate the lost set of photographs, it will take you years to accumulate a new set.

Now, move from that to the loss of an important person. That person can’t be replaced. Another person may take on the roles and activities in your life that the lost person took. A widow may marry again, and a child may find other older persons who can provide love and support and mentoring. But the new person can never be the old person, and the lost person is not replaced.

By the same token, if the world is not the same, then I am not the same – not the same in the world, and not the same in myself. If my parents die, what does it mean to be their son? Certainly, not what it did while they lived. When my first wife divorced me, and my children moved to live with her, what did it mean for me to be a husband and father? Granted, I hadn’t lost everything of who I am; but what I had lost was absolutely enough to change who I am.

It’s out of these experiences that we feel the anxiety and anger. Yes, this is frustrating and frightening and out of our control; and being frustrated and frightened and out of control, we feel anxiety and anger.

Again, that’s important: when we feel that anger, or we see someone express that anger, we need to appreciate it as normal. It may not be comfortable. It may not even make sense at the time. However, it is reasonable, inasmuch as it makes sense in light of the loss.

In fact the broad spectrum, and the apparent chaos, of our feelings in grief are a reflection of this. All of these feelings are a part of doing the work of grief, which is initially to mourn and let go the person or thing or situation we have lost.

This leads to the third point: the world has changed, and I have changed, and we don’t get the old world, the “old me,” back. It is normal to hear someone say, “I just want things to get back to normal,” or, “I just want things to go back to the say they were.” But the person lost, the situation lost, simply isn’t replaceable.

I have used the word “adaptation,” because we don’t back get the old normal. Instead, we build a new normal, a new way for things to be. That will be enough; indeed, it can be good and joyful. But it will be new; it won’t be the same.

This building of the new normal is the other half of the work of grieving. We can’t get the old normal back, and we can’t simply stop, simply stay where we are. We have almost not choice but to begin working on the new world, and we won’t feel anything terribly brave about it.

This is, in fact, hard work. It takes time and effort, and on any given day we may not feel capable. However, we really have no choice: we continue to live in the world, and the world continues to go on. We will do, over time, what it takes to come to terms with the new way things are.

This is why I talk about good days and bad days – even good hours and bad hours – as the measure of our progress. In the initial days of shock and anxiety and anger, there will seem to be many more bad times, bad days, than good. There will be times when we are truly dysfunctional, unable to get out of bed or take on the tasks of the day. More often, we will be able to do what we need to, but with a continuing sense of sadness and heaviness.

And gradually that changes. We discover that, while we are not the same, neither are we altogether different. While we don’t get the old normal back, some parts of it continue. With time and effort the balance shifts. We reach a point where there are more good times than bad times, more good days than bad. It’s not that there are no bad times; they are just less frequent, and less debilitating. There will still be sad times. They will simply come to be outnumbered by good times.

This is the hope in grieving. When you embrace the work, when you work through your grief, you have the promise of a new normal that is once again good. No, it will not be the same, but it can be good and joyful and filled with hope.


6. You can’t do it alone.

Notwithstanding my comment that we must each grieve in our own way, none of us grieves effectively alone. We are no more created to be alone in our grief than we are in our love. Being in relationships is part of the nature of being human, and in the stress and work of grieving we need people.

Now, we may meet that need in a number of ways. Most of us will rely to some extent – usually to a great extent – on family support. At first this may seem like the blind leading the blind: if we are grieving, it’s likely that other members of the family are grieving. However, the companionship of another that has experienced the same events is as helpful in grief as it is in any other experience. And since none us is ever in exactly the same place emotionally, we do have something to give one another, even when both of us are grieving.

This is also where the Church community can be most supportive. Our Christian siblings will not necessarily share with us the same experience or the same feelings, but they will share with us the same hope, both for us and for the person we lose.

We clergy are certainly a part of the support the Church has to offer, but we are hardly the whole community available. I do hope you will call on and depend on your clergy. In addition to the Christian hope we all share, we clergy do have some additional experience and training in addressing grief and providing support. Sure, some of us will be better than others; but all of us will, I believe, acknowledge the need and do our best to meet it.

In some cases, there is also a need for other persons for support. For many, grief support groups and education groups can provide strength and information and encouragement as we adapt to the new normal. Good groups are professionally led, and provide both a place to unload our own pain and for us to provide help to others. Both are good for us.

And for some people there is a real need for professional counseling. We may seek that from clergy in formal pastoral counseling, or from a clinically trained psychologist, psychiatrist, or social worker. For the person whose grief continues to leave them unable to function, to re-engage in life, counseling and therapy can be really helpful. For some of us, it’s just easier to share the feelings and the struggle with someone who is independent of and outside our normal circle.

If we get to that place, it’s important to remember that we’re not somehow “sick” or “crazy.” We simply need that additional help to continue and complete the work that grief requires.

So, that’s what a Chaplain has learned about grief. I imagine I was correct at the beginning: it’s not really new.

But, then, grief isn’t new, either. We all will lose, and we all will grieve. And when we grieve, if we will do the work grief requires, allowing those who love us to help us through, there is beyond grief the promise of new life, a new normal, that is indeed good and joyful and filled with hope.

What a Chaplain Has Learned About Grief, Part 1

I wrote this several years ago to present to an adult Sunday School class.  I have used it since to share with a parish visitation group and a parish that lost its church to arson.  I have recently revised it and thought I would share it here.  This is the first installment.

I'm going to share with you my thoughts out of almost thirty years as a chaplain.  Much of what I tell you will seem trivially true: you've heard it before. However, it is also my experience that these things are worth hearing again. When the times come that we need them, it's worthwhile to have these things well reinforced.

1.  You are going to grieve.

It's not a matter of "if" but of "when." Grief is the natural emotional and intellectual response to loss, and all of us will lose something or someone some time.

This also means that there is no escaping the process: once the loss occurs you are going to grieve, whether you want to or not. Not all losses will be equal, and so grief will not be the same every time. But in some way appropriate to each loss you will grieve.

2.  Every person has to grieve in his or her own way.

This is important for us to remember. When we're grieving it's very freeing that we can do what we need to do, whether it suits anyone else or not. 

Of course, even this blanket permission has its limits. It is very important not to deliberately injure yourself or another when you grieve. It is also possible for grief to make you dysfunctional, emotionally and intellectually "stuck." 

I will say more about that. However, in general you have permission grieve as you need to.

This is also important to us as we care for someone who is grieving. We can't expect a person to somehow "grieve right," to meet our set of expectations of how that grief should be. 

Folks in health care are as bad about this as anyone. We've read the articles, we know the studies, and we think we know what "normal" or "healthy" or "appropriate" grief is.  In fact, "normal' is a pretty broad range. As long as the person isn't doing harm to self or to another, or isn't so stuck they can't function, things are probably all right.

3.  Important grief will not happen fast.

           

More than a decade ago I was in conversation with a medical resident about a patient. The patient, according to the resident, was demonstrating unhealthy grief. The patient was still grieving a death after six months! I had to teach the resident what we knew then: that for an important loss it was within the range of normal to still be grieving actively a year later. 

I say "what we knew then," because in fact we know now that for a significant loss - death of a spouse or a child –active grieving may continue for three years.  And some losses – divorce when there are children is the best example - can raise feelings of grief for much longer, as new losses resurface old losses.  As I’ve said, the time and process of grieving will be appropriate for each person, and appropriate for the loss suffered.  Time is not the best measure. 

A better measure is some sense of "healthy," and the best measure of healthy is "functional." And this is the best guide to "functional:” as time passes, is the person becoming more able to do, first, what he or she has to do, and then what he or she wants to do? Again, this is not what we think the person needs or wants to do, but what that person needs and chooses to do.

4.  Forget stages.

           

Years ago now Dr. Elizabeth Kubler-Ross published her famous book, On Death and Dying.  Over the years it's become something of a standard, and it's easy to see why. Its five stages of grieving are clear, handy, and easy to remember. It's something all of us have learned.

Sadly, it's wrong; or if not wrong, it's usefulness is not nearly as universal as has been portrayed. It's wrong in large part because it only considered one group of grieving people and one sort of loss. For most people in most circumstances her scheme is too cut and dry.

Now, to her credit let me say that she does say some things helpful in what we call "anticipatory grief." That is, the grieving we can do when we know a loss is coming, but it hasn't happened yet. She was working with patients who had a terminal diagnosis. Knowing they were going to die, they did grieve, and they did experience the feelings she describe: shock and denial, anger, bargaining, depression, and, at least in most cases, acceptance.

However, I think there's a lot more to be said.  First, while they all felt those feelings, the list too limited. In fact persons in grief, whether it's ahead of the loss or after the loss, feel a wide range of emotions that includes those, but also includes sadness and frustration and fear and sometimes even happiness and relief. I would suggest a better book is Good Grief by the late Granger Westberg, in which he describes a wider variety of feelings and experiences for the grieving person.

Second, it's too pat to think of these as stages.  Grief is not a clean, step-by-step process in which one experience is left behind when you enter the next stage. Rather, on any given day when you're grieving you may experience any of these feelings. The process of grieving doesn't fit into a pattern, and you may well feel some acceptance or stability one day, and raging anger the next. 

What I think one can say is that early on there will be more bad days than good, when there are good days at all.  But over time the balance will shift, and good days will come to outnumber bad.

Let me say one other thing about anticipatory grief.  There is only so much grief work you can do ahead of time.  You will certainly begin grieving once you know the loss is coming, and you may well reach some level of stability.  You will still feel again the shock, if not the denial, and a lot of sadness when the loss actually arrives.

General Convention 2009: Pet Grief

I continue to look through legislation submitted to General Convention, looking for resolutions on health care or otherwise of interest to chaplains. After all, new resolutions are being submitted every day.

While I haven’t found any new resolutions on health care, I have found some of interest to chaplains. One of those is Resolution C078, submitted by the Diocese of Montana. It is titled, “Liturgy for Loss of Companion Animal,” and reads as follows:

Resolved, the House of _______ concurring, That this 76th General Convention reaffirm that all animals are a part of All Creation, for which we are called to be stewards of God's gifts; and be it further

Resolved, That the Episcopal Church embrace the opportunity for pastoral care for people who grieve the loss of a companion animal; and be it further

Resolved, That this General Convention direct the Standing Commission on Liturgy and Music to develop a rite to observe the loss of a companion animal for inclusion in the next edition of the Book of Occasional Services and that it report its work to the 77th General Convention.

This resolution speaks distinctly to an important change that has taken place in our society. When most Americans were rural and agricultural, the animals around them tended to be either tools or hazards. There were the animals kept to produce meat or fiber. There were animals kept as tools, whether as beasts of burden or herding animals or controllers of vermin. There were animals that were simply hazards, whether to health or to crops. There were some animals that might be either hazards or food sources, depending on how they interacted with human agriculture.

Note, though, that none of these were pets. People might become quite fond of them – note how upset we all became about Old Yeller – but they were rarely confused about how they were to be treated and used. No matter how well tended or loved the bull calf, everyone knew from the beginning that eventually he would be slaughtered or sold. No matter how well loved the dog, she lived in the kennel at the back and not in the bedroom.

While that understanding of how humans and animals relate isn’t gone completely, it’s no longer the most common experience. Most of us have companion animals – pets – and not livestock. There are also service animals that share the lives of many. However, the relationships between service animals and those they serve reflect more often the intimacy of pets than the utility of livestock. For most of us, the animals in our homes are not tools but members of the family. We attribute a certain level of personhood to them. For many they are intimate companions, listeners who don’t interrupt, and providers of unlimited affection. For some they become like children, but children who never grow up and leave, who never move beyond their need of us.

With that in mind, I think it important to take seriously grief at the death of a companion animal. I know from both personal and professional experience that the sense of loss is real and significant in the lives of those who lose the animal. This is often heightened by a greater sense of responsibility; for, all too often, we discern suffering in our companion animals as best we can, and choose to end suffering with euthanasia. We have, as I said, attributed some personhood to these animals. We have taken responsibility for their lives, and frequently for their deaths. The grief that we experience in these relationships and these decisions is meaningful in our lives. We have to go through the same grief processes in these losses that we do in any other.

It is also true that often those around us are not as able to empathize for the loss of a companion animal as they are for the loss of a human companion or family member. It is also common that those grieving loss of a companion animal expect less empathy, and so make it so by being less ready to reach out for support. In either case, there may be a particular experience of isolation in grieving a pet or service animal.

These are all reasons for Episcopalians, both clergy and lay, to take seriously grief at the loss of a companion animal, and to offer compassion and support, as well as to seek support when we grieve ourselves. That said, we can consider as a separable question whether the Church ought to establish an official rite for this circumstance for inclusion in the Book of Occasional Services. The authors of the resolution offer this explanation for the resolution:

Various groups within the Church have shown an interest in developing inclusive liturgies for events that touch people's lives, for which there currently exists no authorized rite. The bond between humans and their animal companions can be strong, causing a deep sense of loss, grief (or even guilt) over the animal's death, especially when dealing with the loss alone, without the presence of their community of faith, or having the preconception that such an event falls outside the interest of their church. Our animal companions provide a unique connection to creation and expand our sense of God's diverse gifts in creation. In many cases they also join us as partners in ministry, in such capacities as assistance animals, i.e., seeing eye dogs, etc. as well as therapy dogs and cats used in health care facilities and for pastoral care. An authorized rite in the Book of Occasional Services would give clergy and others a resource for offering pastoral care at the death of a companion animal.

I would certainly agree with the assertions in this explanation. That said, I don’t know whether we really need an authorized rite for “a resource for offering pastoral care at the death of a companion animal.” First and foremost, as a chaplain I’m conscious that the most important act in pastoral care is quiet, sensitive listening. I am certainly prepared to offer a rite; but it’s not the first step. Moreover, while we understand clearly in our worship tradition that some services require clergy leadership while others decidedly do not, formation of a single “approved” rite would tend to narrow our response and to focus on what liturgical leaders do, instead of what we can all do. Parents have been formulating rites for years for the death of a pet. As we appreciate that the reality of grief at the loss of a companion animal isn’t only the experience of children, we can appreciate the capacity of adults to formulate appropriate prayers to honor the losses in their own situations. As an aside, I am not aware of discussion at this point of a revision of the Book of Occasional Services. Such a rite might be seen more quickly if proposed for trial use as a part of the literature of Enriching Our Worship.

I was a visitor to General Convention in New Orleans in 1982, and was present in the House of Deputies as the Hymnal 1982 was debated and tweaked. When a deputy moved to amend to add “He’s God the Whole World In His Hands” to the Hymnal, a member of the Commission noted that it had been considered and rejected. What was important was the reason it was rejected. That was because that much beloved hymn for children is at its best when those participating were customizing it, adding verses in the moment appropriate to the folks participating. He noted then that for our hymnody we were not restricted to the Hymnal, or to other music specifically approved by the General Convention. I would suggest we are in a similar case here. Burial of the Dead is not a sacramental rite, and we already read the rubrics for that rite with some significant latitude. We have latitude as well to create prayers for situations not addressed in the Prayer Book. I think we can use that latitude creatively to mourn the death of a companion animal, whether alone or in a congregation.

I would be interested to see how this gets through the committee process. I think the occasion for this resolution is real. I don’t know that this makes a specific, approved rite necessary.

Returning to Those Hard Conversations

Some years ago a nurse of my acquaintance asked me the following riddle:

Q: Why to they screw down the casket lids when a patient dies of cancer?
A: To stop the oncologist from saying, “Wait – there’s one more thing that we might try.”

Of course, the joke isn’t fair to oncologists, is it...?

What brought that to mind was this article I found in the “In the News” list on the website of the Center for Practical Bioethics. The story relates to a paper presented at the recent 2008 Annual Meeting of the American Society of Clinical Oncology (ASCO). The paper described results of a research study looking at patients whose physicians had offered end of life (EOL) discussions, with clear information about the patient’s prognosis and all treatment options, including palliative care and hospice. Perhaps we should speak here of two papers, because two papers were presented that, from the abstracts, were clearly related but different results of a single research study. The papers were, “Associations between advanced cancer patients' end-of-life conversations and cost experiences in the final week of life” (B. Zhang et al; abstract here) and “Medical care and emotional distress associated with advanced cancer patients' end-of-life discussions with their physicians” (A. A. Wright et al; abstract here).

According to both abstracts, “Coping with Cancer is an NCI/NIMH-funded, prospective, longitudinal, multi-institutional study of 603 advanced cancer patients. Patients were interviewed at baseline and followed through death…. 188 of 603 patients (31.2%) reported EOL [end-of-life] discussions with physicians at baseline.” At the time the information for these papers was collected 323 had died, including 148 whose doctors had offered EOL conversations. Charts of all 323 were reviewed, and those of patients who had had EOL conversations were compared with the charts of those who hadn’t.

In important ways there were no significant differences between the 148 and the other patients who had died: they “did not differ in socio-demographic characteristics, psychological measures, treatment preferences, attitudes toward doctors or terminal illness acknowledgement.” (Zhang) At the same time, the costs for the patients who had had EOL discussions were 30% less in the last week of life. This was the result of different decisions. “They were more likely to acknowledge being terminally ill, value comfort care over life extension and complete a DNR order. [Also,] patients reporting EOL conversations were less likely to undergo ventilation or ICU admission and more likely to receive hospice.” (Wright)

So, why would only one third of the patients have an EOL discussion with their physicians? “Physicians are concerned that end-of-life (EOL) discussions may distress terminally ill patients, and may not offer benefit.” (Wright) There is the fear, sometimes articulated, that giving patients bad news, however accurate, might lead the patient to “give up.” However, that isn’t borne out by this study. Patients who had EOL discussions were not in fact more likely to be depressed or anxious. (Wright) Again, they “did not differ in… psychological measures….” (Zhang) They were, however, more informed about their prognoses, and more likely to make decisions that were reasonable in light of those prognoses, and especially “to value comfort care over life extension.”

The news article seemed to me to express surprise that so few of the patients in the study had had end-of-life discussions with their physicians. For me, and I expect for anyone experienced with patients approaching the end of life, the response was, “Well, duh!” It is axiomatic that all too often patients are not informed about hospice services until they’re too debilitated to really benefit from them. The critical criterion for admission to hospice is a medical prognosis that the patient will live less than six months. My colleagues, chaplains in hospice, still speak of how often patients are admitted to hospice so late that they live perhaps six days, because the oncologist waited so long to have the end of life conversation. A document available from the Center for Medicare Services (CMS) notes that

The average length of stay has been steadily increasing. However, the long lengths of stay are becoming longer. For example, in 2005, Mississippi, Alabama, and Oklahoma had an average length of stay of 122, 113 and 108 respectively, while the national average was 67 days.

That is, for patients told they have an expectation of living six months or less (180 days), the average length of stay was only about a third that. But, let’s also note that 67 days is the average. If “long lengths of stay are becoming longer,” we need to recognize just how many patients have much shorter lengths of stay so that the average is not higher.

So, this continues to be a problem. Even as we seek to develop better techniques and programs for palliative care, physicians are still not clear with their patients that a time comes when medicine has nothing more to offer for therapeutic benefit (again, as opposed to palliative benefit) – probably because the physicians are not being clear with themselves. I have certainly encountered physicians for whom their work was a battle with the disease. These physicians are, of course, determined and almost single minded in this battle (and, after all, those are the very characteristics that helped them survive medical school and residency). Unfortunately, they become analogous to the person of faith who “is so heavenly-minded as to be no earthly good.” They focus so completely on the disease that they lose track of the person who’s suffering from it. This is not to say that they don’t care; they care passionately. They simply conflate and confuse doing their worst to the disease with doing their best for the patient; and those goals aren’t always the same.

I commend these abstracts to your attention, as well as a number of other abstracts on similar subjects from the ASCO Annual Conference. It gives me some hope that more physicians will note them; for, if it’s axiomatic for non-physicians that these end-of-life discussions have great value, it’s also axiomatic physicians will take these things more seriously if they hear them from other physicians than if they hear them from the rest of us. With these and other continuing studies, we will eventually help physicians see that these end of life discussions, however difficult, are best for their patients; and what is best for patients is a goal we all share.

Seeing Into Hearts and Minds of Chaplains

PlainViews is an online journal devoted to chaplaincy. I think it's a fine and important journal, valuable enough that it's over on your left, in my permanent links.

And sometimes there's a particular article I think worth calling to everyone's attention. Actually, today there are two. The first is "Bad Death," byRev. Kirk M. Ruehl, a chaplain with Hospice at the Chaplaincy in Kennewick, Washington. He writes, both in poetry and prose, about the idea of the "bad death" (as opposed, as you'll understand, to the "good death"). His article is moving and thought-provoking.

Which brings us to the second article. It's "Bad Death – Responses." A number of chaplains write back in response to Chaplain Ruehl's article with their own thoughts. They are also moving and thought-provoking, and can give you a sense of the breadth, depth, and sensitivity among my colleagues in this ministry.

Take the time to read these two posts at PlainViews. They can give you some glimpses, brief but brilliant, into the hearts and minds of chaplains as they care for those who die and those they leave behind.

More Good Stuff on the Radio

Yesterday was an interesting day for a chaplain’s ears. I heard two interviews that I would like to call to your attention. As will not surprise regular readers, both were from NPR, my most common news source.

The first was on Fresh Air. There host Terry Gross interviewed the Rev. Carroll Pickett. For 13 years Pickett was the death-house chaplain at the Walls prison in Huntsville, Texas, where he ministered to inmates executed by lethal injection. What caught my attention early in the interview was the fact that after each execution he recorded his thoughts and experiences on tape. He did it as a means of self-care, based on his own experience in CPE; and the reference to CPE caught my attention. The interview is about 40 minutes, but it’s well worth the time. (Chaplain Pickett was also interviewed for the 1999 Frontline episode, “The Execution.” You can find a transcript of that interview here.)

Later in the day I caught a portion of All Things Considered in which Melissa Block interviewed Chinese Christians and clergy in the area of the recent earthquake. She asked the clergy how they cared for their parishioners, and how they discussed the earthquake. It was a classic discussion of the problem of suffering; and as one who has to address that problem with some frequency, I was interested in their responses. Take some time, and hear for yourself.

The Chaplain on "The Chaplain"

Updated Tuesday afternoon.

I’ve been caught up in Anglican stuff this past week. However, I wanted to come back to a question I had. In responding to a post last week, I received this comment:

anonymous said...
I apologize for using the comment box for an off-topic inquiry I'd normally do through email, but I didn't see an email address for you and I'm curious to hear your response to a Hollywood depiction of chaplain interacting with a terminal patient that is being touted as "typical" of "liberal" chaplains by a certain self-proclaimed "orthodox Anglican" website.

If you find it beneath commment, I certainly understand, but I thought someone who has actually has some expertise in this area (and is not merely trying to erect a straw man to score political points) might offer some useful insight.

Link to Annoyingly Tendentious Website

Rather than send you back to the “Annoyingly Tendentious Website” (and remember, that was the poster’s comment. not mine), let me send you to this. This is the better YouTube clip, and it provides more information than that to which “anonymous” pointed. Take the time to view it and come back.

I don’t watch “ER” – haven’t in years. I enjoyed it at the beginning, but eventually it failed to hold my interest for the same reason that all medical dramas have failed with me for more nearly thirty years: they just don’t portray real life in hospitals. Fact is, life in hospitals, and especially life in emergency rooms, involve occasional excitement with a lot of daily grind in between. It’s not exactly like that comment from the pilot about “hours of boredom punctuated by moments of sheer terror,” but it’s not too far. Most of us who live in hospitals don’t want as much drama as a TV show would need. At the same time, there’s usually enough drama in our real world to go around. I’ve worked in inner city trauma centers most of my career, even if I now work in a smaller, suburban hospital. People don’t bang doors open, and they don’t come running and screaming. Indeed, these days emergency rooms are secured, and doors wouldn’t bang now matter how hard someone tried.

Most especially, hospital dramas don’t commonly have chaplains or social workers, and so physicians – all too frequently Intern and Resident physicians – and nurses get written as providing a lot of emotional support and social service. That just doesn’t happen. It’s not that they don’t care. It’s that there aren’t enough physicians and nurses around to do what physicians and nurses are trained to do, and they don’t have time to stop and do what chaplains and social workers are trained to do. Doctors and nurses don’t always understand how we do what we do, but they’re absolutely ready to give us room to do it. They generally don’t have a choice: they just have too much else to do.

So, I will say up front that I didn’t see this episode of “ER” broadcast. However, I was able to find more and discover more than the first link provided. That will become important.

When I looked at the link that my anonymous respondent suggested, I noticed how many folks commenting at that site were critical of what they described as “New Age” or “progressive” or “liberal” pastoral care. One or two even blamed CPE. Well, having looked at the selection that I recommend, I don’t like those labels, but I also don’t like the mistakes obviously made in getting to this point.

Here is the setting: Chaplain Julia Dupree sits in an ER room with a patient, one Dr. Truman. While injured himself, Dr. Truman is also concerned about another patient in ER, a young boy whose life the doctor saved. However, the Chaplain learns there is more to the story. Dr. Truman is a prison doctor, one who carried out a number of executions by lethal injection. One of the prisoners so executed was in fact the father of the child whose life the doctor saved. Worse, that execution was complicated. The patient’s IV infiltrated – it got backed up and blocked – and the patient didn’t die. Following procedure, Dr. Truman started a new IV, started new drugs, and the patient died. Dr. Truman is terribly aware of all of this, as is the child’s mother. She confronts him during the show, saying, “This doesn’t make up for it. I will never forgive you.” And so by the time he meets the chaplain, Dr. Truman has decided he can’t forgive himself, and he can’t expect God to forgive him.

Let’s be clear: right from the beginning the chaplain made a significant mistake. She fails to assess who and where her patient is, emotionally and spiritually. Right at the beginning of the scenes in the link I prefer, a rosary is quite visible in the patient’s hands. That would suggest the patient is Roman Catholic, and would raise questions about his participation in executions in the first place. Moreover, as he tells his story he makes clear that in hindsight he has interpreted the infiltration of the IV as divine intervention. “God sent me a sign, and I ignored it.”

The chaplain does not believe the patient is beyond forgiveness, and so she jumps to offer words of comfort, and to suggest, without being explicit, that God has already done what the patient only needs to accept and appreciate. But, the patient isn’t there. The chaplain appears unable to wade into the patient’s pain and guilt and be there with him. She isn’t prepared to let him guide her in meeting his needs, even to let him decide what he thinks he needs. She doesn’t consider whether this would be an appropriate referral, if he might benefit from sacramental penance. She doesn’t consider whether to confront him, to ask whether he really believes he is more powerful than God, that his sin is beyond God’s capacity to forgive. She simply asserts that he is forgivable, and even already forgiven, a thought that, true or not, the patient is not prepared to hear. His ability to trust her collapses, and he throws her out. Nor can she see this as something that at least validates and empowers the patient (after all, who else in that setting can the patient actually throw out?). We learn later in the next clip that this is for her a major defeat, one that prevents her from trying again.

It’s in that clip that we realize why she made the mistake. Talking with a supportive physician, she says, “People in crisis want rules, structure, something to lean on, I get that; but it’s not me.” But, it’s not supposed to be about her. It’s supposed to be about the patient. She speaks about her education, and her varied spiritual background and experiences. She says, “I thought an inclusive approach to spirituality would work in a place like this.” She’s right, and the physician affirms it. But in this instance she failed in being inclusive of this patient. As much as she wanted to be there with him, she failed to be there for him.

This highlights a mistake made by the writers. This young chaplain has education and training, but appears to have little foundation of her own. I’ve found it very difficult to find any backstory for this character, but in this instance she seems uncertain of her own foundation, her own tradition. This is something missed by advisors to the writers. The professional organizations that educate and certify for chaplaincy require ecclesiastical recommendations and endorsement: evidence that in fact the chaplain or student come from a specific faith tradition and is conversant with that faith tradition. To be available to someone else, the chaplain needs some clear sense of who she or he is, of where he or she comes from emotionally and spiritually. It helps me as a chaplain to encounter even those most different if I know the tools of my own faith, and my own limitations. There are no “generic” chaplains. Instead, there are chaplains from various traditions prepared to care for and support, to the best of their ability, patients and families across the spectrum of human beliefs. And a long time ago a student taught me profoundly that enthusiasm is no substitute for groundedness, something that education and training in themselves won’t necessarily provide, and certainly won’t replace. In that room this chaplain couldn’t be there for this patient because she couldn’t be there for him instead of for herself. My fear is she couldn’t be there because she wasn’t sure where she was in the first place.

But let me note this: unlike most of the commenters at conservative blogs, I don’t think the problem was the basic technique. This chaplain did not fail because she took a nondirective approach, or because she held a progressive faith. This chaplain failed because she was not prepared to accept this patient where and as he was – something that throughout my career I’ve seen from clergy across the Christian spectrum, conservative and progressive, “left” and “right,” High and Low and Broad. Some of the commenters, so delighted to find fault with her, make exactly the same mistake.

This is just a short reflection. I’d love to see a transcript, to take this to a group of CPE students and see what they do with it. Perhaps folks commenting here can add, as Malcolm+ did in responding to anonymous’ initial comment. The presence of a chaplain is not likely to bring me back as a viewer of “ER.” On the other hand, any presence of a chaplain (or any other clergy, for that matter) in the media who’s trying to help and not to manipulate or control is worth our attention, and perhaps an opportunity to reflect and to learn.

Update:

If you're interested, there are two other web pages reflecting on this character on "ER," one of which refers to this episode. At PlainViews Chaplain Julia Allen Berger comments on "Chaplains in the Media." And she cites the Hastings Center's Bioethics Forum, where Nancy Berlinger, editor of the BioethicsWalk at PlainViews, has posted this interesting article providing some historical context.

Until the Kingdom Comes....

This has been a day for discussing mortality. Actually, it’s been a week for it – and it’s only Tuesday! But in two days I’ve had a week’s worth of such considerations.

I’m not really talking about death here: it hasn’t been that a number of patients have died. Rather, it’s been that a number of patients and family members have been thinking about dying, about that point where either medical science or human will or both reach the point where there is nothing more to do. Some are there, some can only see it in the foreseeable future; but for all it is a firm reality. There’s the patient who no longer seems to care, and the patient who’s announced that it’s time to have last conversations, to say goodbye and then “to sleep, perchance to dream.” There is the spouse who doesn’t want to let go, but who is realizing the beloved will never be quite the same, even if in some sense the body continues to function. There’s the patient newly diagnosed with the same disease that took the lives of all his siblings. All of them are seeing with particular clarity a truth they knew but, like most of us most of the time, shelved, somehow thinking there would always be “another day.”

That truth is that we die. Unless the Kingdom comes first, we can all expect to die. It has long been a soapbox issue for me to rail when I see a new medical study talking about “the mortality rate.” A new study comes out, proclaiming the great leap forward, the new chemical or the new technique that offer such progress. And such progress is often described this way: “with the new medicine the death rate (from x circumstance) was reduced by 15% (or 2% or 20% or whatever number is presented). Brothers and Sisters, the truth is this: the death rate is 100%. Until Christ changes things beyond all recognition, the death rate is 100%, and all of us will fall.

As a chaplain it’s often within in my purview – indeed, it’s sometimes my responsibility – to point out this truth. In general I have always wanted the bare fact to be stated by the physician, because often the bare fact requires illustration, illumination, with biology and chemistry and engineering that the physician is better able to provide, and better heard in providing. But once the bare fact is out there, the human reception, the emotional incorporation, falls under my professional sphere. Often enough it’s simply to hear and encourage the resulting grief. Sometimes it’s to ask the question that no one else can ask: “And what if your loved one is dying? What if this is the end?”

Understand that in general I’m not interested in stripping way denial. Denial as an initial reaction in grief is a buffer, a shock absorber (both literal and metaphorical). It can actually aid the grieving process, allowing the griever to absorb without being overcome. But sometimes there are decisions that must be made. Sometimes when medical science or human will or both reach their limit for the patient, those around the patient must be confronted with that which they’ve most feared, most avoided; for if they do not the patient suffers – suffers what some of them, and certainly some of us in the business, consider literally a fate worse than death.

As a priest it’s also part of my purview. Indeed, the Church instructs me to instruct you that someday you will die. There is this rubric in the Prayer Book:

The Minister of the Congregation is directed to instruct the people, from time to time, about the duty of Christian parents to make prudent provision for the well-being of their families, and of all persons to make wills, while they are in health, arranging for the disposal of their temporal goods, not neglecting, if they are able, to leave bequests for religious and charitable uses.

I cite it regularly, although I fear I may be one of the few priests who does. Many of my Sundays are spent supplying, filling in for colleagues who are traveling or ill. When we get to the announcements I announce my “second sermon.” When they laugh, I say, “You think I’m kidding.” I speak to the rubric, and then expand on it to discuss the importance of Health Care Treatment Directives and Durable Powers of Attorney for Health Care – to say, not only must we expect to die, but we can expect that we might well get sick, and make appropriate provision. (I will offer here, as I do in the congregations, a gold star to the person who knows just where in the 1979 Prayer Book to find this rubric. It is in a place that makes sense, but it’s not where I would have put it.)

So, as a priest and a chaplain it is part of my role, part of my practice, to bring home now and again that we are mortal. It is an important fact of life, for all that we do our best to ignore it or delay it or prevent it. It will confront each of us, and because of each of us those we love, sooner or later. Indeed, it is critical that we appreciate it (by which I do not mean to pursue it, suicidally or homicidally, or ascetically); for our faith is built on our mortality. We believe in Him who became mortal that we might become immortal – in him who died that we might live. We believe Christ took on all that is our human nature, including our mortality, so as to transform it. We participate in his resurrection because we participate in his death; but we participate in his death because he participated in ours. Until the Kingdom comes, we have no way to resurrection except through death.

And so until the Kingdom comes, we must discover and rediscover the truth: the death rate is 100%. And when some have difficulty with that, I will do my best to help them. I will do my best to be with them as they realize and recognize mortality. I’m a priest and a chaplain; it’s what I do.

Caught by a New Word

I’m not exactly how it came across my desk, but come across it did. “It” was the November, 2007, issue of Charisma. Charisma is a magazine that from its content reflects the life of the Pentecostal churches in the United States. I certainly found a number of the articles interesting.

The one that caught my attention, though, was “Hope for the Wounded Soul,” by Elizabeth Moll Stalcup. The article is about an approach to pastoral counseling called Theophostic Prayer Ministry. If I hadn’t been intrigued by another article on pastoral counseling, that word “Theophostic” certainly did.

You can read the article on line to get some sense of the history of this process. You can look at the TPM web site for detailed information, but in the article is a brief description of the process:

Typical TPM sessions begin by discussing the current situation, but the goal is not problem-solving as in traditional therapy, but rather helping the person connect with what he is feeling. After his current emotions are identified, the recipient is asked to let his mind connect with any memory that matches the present emotions.

Not all memories are traumatic. In fact, people often express surprise when they realize how much they have been negatively impacted by lies stemming from old, seemingly minor memories. The TPM facilitator is not to interpret the memory, express his opinion, diagnose the condition or make assumptions about what might have happened.

Instead, he encourages the person seeking healing to search his memories to determine his own beliefs. The facilitator asks questions such as, "What does that little girl believe is causing the pain?" "What do you believe will happen if you let yourself feel that?" to help the person identify what he believes in the memory.

After the core lie is identified, the facilitator asks the person if he is willing to hear what Jesus has to say. If he is, the facilitator will pray and ask Jesus to speak into the situation. Some people get mental pictures or words from God, while others just get a sense of what is true.

Now, when I read the description in the context of the article, I had a feeling I couldn’t shake that this was all somehow familiar. It took me a while, and then the connections began to come.

First, recognizing that feelings about current events may well reflect or be reinforced by similar feelings from past events is well established in counseling practice. A number of therapeutic practices include this sort of review for insight. Exploring the memory to understand the events, and especially the feelings involved, is common in many ways of supporting people.

In this case, the process begins to look a lot like an Ignation spiritual exercise. The counselor isn’t to tell the person how to interpret the event. Instead, the minister asks the person served how he or she remembers and interprets the event, and what feelings are involved. As the person served gets insight into the earlier experience, the minister invites the person to hear what Jesus might say to the person in or about that memory. This is much like the experience of entering into a story from the Gospels, imagining oneself in the story, to experience the feelings of the story and to hear what Jesus says in that story. (I’m not saying it is an Ignation exercise; only that they have some aspects in common.)

The hope is that the person served will hear a message from Jesus (whether in words or feelings) that will bring a new perspective to the memory, something that addresses the “core lie” that has held the person served in bondage to the memory. That sounds an awful lot like “reframing,” providing a new perspective on the situation that has provoked so much emotional energy.

So, I recognized that sense of familiarity. To help a person, a minister supports that person in finding insight on past events, supports that person in reflecting on those events in a manner similar to an Ignation exercise, with the hope that the experience will help the person reframe the past events and so better understand both past and current events. Again, I’m not saying that mine is an accurate description of Theophostic Prayer Ministry; only that those were the similarities or parallels that I saw in reading the articles.

At the same time, I would never suggest that Jesus couldn’t provide individuals with meaningful reframing. I’ve seen this sort of thing happen many times. As a chaplain, I’m quite inclined to see this as an act of God’s grace, whether explicitly labeled or not.

I don’t practice TPM, and I’m not endorsing it. There are certainly a number of web sites and publications arguing that in fact TPM is dangerous (try here or here) - although from my admittedly cursory review, they seem more concerned that it’s theologically dangerous than that it’s therapeutically dangerous. And, on the point of being therapeutically dangerous, it certainly seems as open to abuse as any other counseling modality.

But, how could I look at such a word as “theophostic,” and not want to see what it’s about?

Grief and Adapting to Change

We all know that romantic notion: "I want to save this moment forever. I never want anything to change." We see it literature and in the movies all the time. Of course, in the movies, as soon as we hear someone say that, we know things are about to fall apart. The disaster happens, as it does in every drama. In real life, too, as much as we might want to, we know that we can't hold those moments. Things change,

Life is change. Most of the time we want that. Children grow into adults. We learn new skills, and want to use them. We choose to move from work to retirement.

Sometimes we face changes we don't want, or have mixed feelings about. Those same children grow up and move away. Unwanted job changes happen (including, for some, retirement). Illness comes – and especially chronic illness

Whatever the change, it involves stress. We know there is good stress and bad stress. Good stress is stimulating. Think about that good challenge – the good game when you knew you performed at your best; the time in school when you knew the answer, and you really wanted to be called on; the night before the wedding. Bad stress, on the other hand, is unfulfilling, and literally dis-stressing. I’m sure we all have enough examples in our lives: the time when the results weren’t so good, and after all our excitement we were left weak, sad, tired.

But in either case it affects us in a number of ways. We know many of the physical symptoms of stress (or, is it excitement?) –

• Dizziness or a general feeling of "being out of it" (or, is it ecstasy?)
• General aches and pains
• Grinding teeth, clenched jaw (or, is it determination?)
• Headaches
• Indigestion and upset stomach (or, is it butterflies?)
• Increase in or loss of appetite
• Muscle tension in neck, face or shoulders
• Problems sleeping
• Racing heart
• Cold and sweaty palms
• Tiredness, exhaustion
• Trembling/shaking
• Weight gain or
• loss

And we know emotional symptoms of stress –

• Anxiety
• Relationship problems
• Chronic sadness
• Even depression.
  

More important, change always involves grief. Again, not all change is unwanted or unhopeful. At the same time, all change, whether wanted or unwanted, involves some loss; and with any loss comes some grief.

I think this is one of the most important issues missed when folks adjust to changes. I think we miss it whether we are those making the changes, or those encouraging others to make changes. When we see the change as “positive,” we have those hopeful aspects that counterbalance or distract us from what we lose. When we don’t see the change as “positive, we tend to try to “push through,” to “get on with it.” Only when the change is significant do we actually acknowledge that we might have grief. We’re conscious of grief in proportion to our sense of the importance of the loss. But the truth is all changes involve some loss, and so some grieving is part of the process.

So, what to do? The answer: we have to address the grief, to recognize that this is a part of adapting to changes in our lives. According to psychologist William Worden, that involves four tasks.

First, accept the reality of the loss. In this case, accept the reality of the change. That might seem straightforward. At the same time, it’s so easy to accept the change intellectually, and resist the importance of the change. How easy is it to say, “Yes, I know things are different; but that’s no reason life can’t go on as before.” In fact things can’t go on as before, because the circumstances, the very facts of “before” are changed.

That brings us to the second task. The second task is to experience the pain of grief – or in our current discussion, to acknowledge the consequences of the change. Because the facts of “before” have changed, things simply can’t go on as before. Grieving families will sometimes say to me, “I just want things to be normal again.” My answer to them is, “You can’t get the old normal back, but you can get a new normal, and it can be joyful and blessed.”

And to get to a new normal we come to the third task. In grief, that task is to adjust to an environment in which the deceased is missing. In addressing change, we’d describe it better as making the adjustments necessary because the old “normal” is gone.

What’s important is that the adjustments, the adaptations we need to make are frequently the life changes that we’re encouraged to make to cope with stress, or to cope with chronic disease. In essence, it’s about making the decisions and taking the steps that improve life and health: the exercise, the healthy diet, the discipline of taking medication, and so on. And especially important is using the support of folks around you to help with the new way of living.

Granted, all this doesn’t come easily or immediately. We expect grief to take a while to live through – longer than most people want to expect. We don’t make these changes perfectly right from the start. But, we keep at it, knowing this is necessary in developing the new “normal.”

Which brings us to the final task. In grief that task is to withdraw emotional energy and reinvest it in another relationship. In adjusting to change. we can say that we need to let go of our wishes for the old “normal” and put our energy into the new “normal.” In that sense, the new “normal” is the new relationship in which we reinvest. We see ourselves as worth investing in, and so the new “normal,” the new relationship, is worth investing in.

We may even discover that some things were not so good in the old “normal,” things that in the new “normal” are better. We deal with chronic disease at our house, and one of the things we realized when it was finally diagnosed, is that it had been taking a toll for a long time. Once it was diagnosed and treatment begun, we were more secure, less afraid that unexpected flare-ups would happen, and less afraid when they did happen. While it took a while to adjust, and, yes, to grieve, we discovered that the new “normal had a lot of good in it, without some of the fears and shocks of the old “normal.”

That won’t always happen, I know; but I do know that the new “normal,” as I said, can be happy and joyful and blessed. We reinvest our energies in the new situation, the new “normal,” because it is how we reinvest in ourselves.

I think that’s why it’s important that we recognize that there will be some grief associated with every important change, and that we need to accept and address that grief as a part of adapting to the change. Changes, and especially important changes, aren’t easy; but I think if we recognize that part of making the changes is addressing the grief that comes with them, we will understand ourselves better in the process, be more forgiving of ourselves in the process, and will know and embrace the new “normal” we discover.

Presented 11/14/07 at our hospital's Munch and Meet Diabetes Support Group

Toward Reconciliation: "Episcopal Visitors"

There was a rumor prior to this meeting of the House of Bishops that Presiding Bishop Katherine Jefferts Schori would offer again a Primatial Vicar plan. Assumptions were that it would be something like that offered by Bishop Jefferts Schori and her predecessor, Bishop Frank Griswold, and rejected as insufficient by several bishops of the Anglican Communion Network.

Now we know what that plan will look like. News stories report that eight bishops have agreed to serve as “episcopal visitors” on her behalf. According to Episcopal Life Online,

Jefferts Schori's invitation to the eight bishops seeks to delegate the first of three primary canonical duties of the Presiding Bishop, that of visiting each of the Episcopal Church's 110 dioceses during each Presiding Bishop's nine-year term. The Presiding Bishop's other two principal canonical roles are to "take order" for ordaining and consecrating bishops, and to oversee certain disciplinary actions as needed.

Presumably, the other two “primary canonical duties” could be delegated on a case by case basis.

These are the bishops who have agreed to this role:

The eight are active diocesan bishops Frank Brookhart of Montana, Dorsey Henderson of Upper South Carolina (based in Columbia, S.C.), John Howe of Central Florida (based in Orlando), Gary Lillibridge of West Texas (based in San Antonio), Michael Smith of North Dakota, James Stanton of Dallas, and Geralyn Wolf of Rhode Island, together with retired Connecticut Bishop Clarence Coleridge.

There will, I’m sure, be intense discussion about these bishops. Two names stand out to me. The first is Bishop Geralyn Wolf of Rhode Island. She has participated in the meetings of the “Windsor Bishops” in Texas, and so would have credentials for some. At the same time, some of those bishops most vocal about a need for alternative oversight are also those who do not believe a woman ought to be ordained in any order.

Second, and perhaps more surprising, is the name of Bishop Stanton of Dallas. He has been a Network bishops from the beginning. At the same time, he has not moved in lockstep with other Network actions. Most critically, he has distanced himself from the requests for “alternative pastoral oversight.” Rather, he requested a “direct pastoral relationship” with Canterbury. In his address to the 2006 diocesan convention, he said,

“"Separation is not a strategy.... Those who are thinking about departing from the church are fulfilling, not Christ's call, but the world's expectations about the church — that we really cannot get along, even with each other."

His agreement to serve as an “episcopal visitor” would seem to bear that out in concrete terms.

Finally, we can note that this is in line with Designated Episcopal Pastoral Oversight (DEPO). DEPO has been approved by the House in the past, and has been recognized – arguably, endorsed – in the Windsor Report. So far it appears to have worked where both parties were willing to accept it. Providing a more formal structure for that might make it more attractive to those with some lingering concerns.

There will be a lot to talk about over the next few days, some things newsworthy, and some not. This is an interesting note on which to start.

The Voice of a Chaplain: Responding to Tragedy

Yesterday, as a part of reporting on the tragic fire in Charleston, South Carolina, in which nine fire fighters died, NPR's Michelle Norris interviewed the Rev. Robert Dewey, founder and Chief Chaplain of Coastal Crisis Chaplaincy. Coastal Crisis Chaplaincy focuses on “first responder” chaplaincy, offering pastoral care to police officers, fire fighters, and other “first responders,” to their families, and to the victims they serve.

Rob is an Episcopal priest and chaplain. In addition to his work in Charleston, he has been very involved since the attacks on September 11, 2001 in the work of Bishop Packard, Suffragan Bishop for Chaplaincies for the Episcopal Church, in developing the Episcopal Church’s strategies for disaster response.

Rob has been a valued colleague since he and I served different congregations in Memphis, many years ago. I know I have appreciated what he has done for the larger Church in the past six years. I encourage you to take a little time and listen to his report of the needs he has found in serving in Charleston in this tragedy, and of the compassionate care he and his chaplains have offered.

Call for the Chaplain

I do sometimes remember that I am a chaplain.

I can’t watch medical dramas on television. It’s not a matter of how well or how poorly they’re written. “ER” and “House” and others are fine shows; and I can’t watch them.

I can’t watch them for any period of time – more than about ten minutes – without grumbling (or yelling), “It wouldn’t happen that way!” There are lots of details that stimulate that. However, the most important one is when someone – patient, family member, staff member – is wracked with grief and the physician, staff or resident, takes the time to offer grief support. I know from years of experience that that doesn’t happen. I don’t mean to imply that physicians don’t care, or that they wouldn’t stay if they could. However, most physicians in my experience don’t have the training to provide the emotional support they might want to. Indeed, most physicians, and especially resident physicians, don’t have the time to offer support, much as they might like to.

That got triggered again by an article in the February 21 edition of the Journal of the American Medical Association (JAMA). The article, by physicians Paul Maciejewski, Baohui Zhang, Susan Block, and Holly Prigerson, is titled, “An Empirical Examination of the Stage Theory of Grief.” (You can access the article on line here.) To summarize, they found that the stage theory of Elizabeth Kübler-Ross (at least as it has come to be used in much of health care) doesn’t stand up in their study. That is, people don’t progress through grief in clear and distinct stages, and they may come to some measure of “acceptance” much faster than has been commonly assumed.

Now, this principle doesn’t bother me a bit. I’ve been teaching that for years. Indeed, chaplains have been saying form some time that grief doesn’t happen in stages, and doesn’t happen in sequence. There are a number of concerns to raise about Kübler-Ross, and this is only one of them.

What does bother me is that in their literature review there is no reference to the pastoral literature on grief. Indeed, there is no reference to nursing or social work literature, either; but the literature I know best is the pastoral literature.

It’s not that there’s nothing out there. The authors write, “To date, no study has explicitly tested whether the normal course of adjustment to a natural death progresses through stages of disbelief, yearning, anger, depression, and acceptance.” That may well be true. However, there is a great deal of literature on how people grieve, and it includes both empirical quantitative studies and studies of individual cases. For example, in the Journal of Pastoral Care there are five such studies in the past ten years. I haven’t had time to ask my hospital library to do a literature search to include the nursing and social work literature; but my guess is that there is much more out there in those disciplines. After all, we pastoral folks are late (and sometimes lame) in developing our body of research.

I’m not really surprised. One of my chief complaints over the years is that we professionals in health care don’t read each other’s literature. I fear that’s even worse when physicians are the researchers. We comment in health care that you need to get a doctor to talk to a doctor if you want to be heard. These physicians certainly looked at reputable journals and found relevant articles. However, I don’t see any reference to pastoral, nursing, or social work literature; not in their citations, nor even in an offhand reference in the text.

And that’s a shame. When I was primary investigator for a study of nurses’ attitudes about pastoral care (a long time ago now) I discovered there was a wealth of literature from other disciplines – literature that was certainly relevant to my study. I was delighted to discover those resources from colleagues in other disciplines.

So, I’m sorry that these investigators failed to note those resources, even if they didn’t find them useful. I fear they didn’t find them at all, and perhaps because it never occurred to them to look. While doctors do care about grieving families, most of the time they don’t provide the care. The greatest providers of immediate care are nurses and chaplains; and the most common providers of long term aftercare are clergy. It would have made sense, even if professional respect never occurred to them, to at least acknowledge that. And, you know, the professional respect would have been nice, too.

With the Ears of a Chaplain

I have been listening with interest to the reports of the status of Israeli Prime Minister Ariel Sharon. I am, of course, conscious that there are significant political ramifications to his condition. However, I listen with a different concern, another ear.

I have spent the last 25 years in health care ministry, full or part time. Much of that time has been spent in intensive care in general, and in neurological and neurosurgical services in particular. It is that experience that shapes the way I hear news of Sharon’s condition.

The latest reports are that members of the family are seeing small movements, small signs that give them hope. They play a tape of a grandchild’s voice, and his eyes move. They speak, and he seems to move, to respond.

The doctors are more cautious. They speak of reflex responses, of random motions from random neurons firing in the brain. They know all too well that it takes more than the flutter of an eyelid, the withdrawal of an arm, to demonstrate purpose and intent, to document that in fact there’s someone in there.

I have been with families in that situation too many times. I know too well how much a family can hope. Events that seem inconsequential, even invisible to health care staff are understood by loved ones as incontrovertible evidence: the person they love is not only physically alive but cognitively intact. Somewhere, behind those tubes and lines and wires, behind the blank, often swollen face, there is still a person, the same person they knew and loved before the injury.

These can be difficult times for me as the chaplain. Let me be clear: I believe in miracles, and I’ve seen more than my share. Still, I dread the question that may come next, the question they will ask the chaplain because when the doctor’s there he or she is too focused, too authoritative to ask; or because most of the time the doctor isn’t there at all. “Chaplain, have you ever seen someone this sick, this badly injured recover?”

I have to stop and consider how to address that question. Ever? I’ve been in this business a long time, and I’ve seen a lot of patients. This sick? Much of the time we don’t know just how sick the patient really is; there are too many variables, even with all the technology we can bring to bear. Recover? What would it mean to recover? How able was the patient before this happened? How far could this patient go, even with the best of care and all the time in the world? Are they asking about physical function, or basic activities of daily living, or complete physical and intellectual wholeness? If I am to answer this question with integrity, I have to think this through.

For good or ill – for good and ill – I’ve had years to think this through. So, when the question comes I can review what I’ve learned about this patient and about this family fairly quickly. I will not lie. I do not want to destroy hope, but I dare not give false hope. The families of the Sago Coal Mine disaster have shown the cost of that. There are matters beyond my control, promises I can’t keep; and I must speak carefully. “I have been a chaplain a long time. I believe in miracles, and I have seen some. But, no: I have never personally seen someone this injured recover to be the person they were before.”

This is, of course, not what families want to hear. And I would be pleased to be wrong, and happy to give thanks. But it is the most honest answer I can give. It does not deny what God can do. It also does not deny all the patients I have seen who did not recover. It honors the family’s question with the honesty and integrity it deserves, and with all the love and compassion I can muster.

And so I pray for the Ariel Sharon and for his family, not because of his political position or his international stature, whatever they may be. I pray because I know the road his family is walking, a road I have walked with other families on their way to grief.

Mourning Dreams

I am a member of several news lists and lists servers. Today on one of them a colleague described a person who had asked for his pastoral support. This person had entered into a relationship, one which she thought showed promise of growing and becoming permanent. She even thought that this might be a part of God’s plan for her. Unfortunately, the relationship did not last. My colleague asked for thoughts about supporting her. Her distress brought to my mind the mourning of dreams.

One of the things I find true of human beings, and yet often overlooked, is that we mourn dreams. That is, we imagine our lives in the future, and sometimes we imagine lives that we desire greatly. When those dreams are lost, we mourn greatly as well - perhaps as profoundly as we would have grieved had the events actually taken place and then been lost.

I notice that most with parents who lose a baby during pregnancy or at childbirth. They have hardly had a chance to know this child; but they know all too well the hopes they have had for this child. I knew it in my own divorce. For almost 20 years I have had a wonderful life with my wife; but when the first marriage was lost, so were many plans and dreams. I am proud of my sons. They are good young men: but when they left to live with their mother all those years ago, so did significant dreams about how I had wanted, had planned, to be their father. Indeed, since I do have my sons, and their mother is still alive, I find myself revisiting those dreams, grieving them all over again (albeit with less intensity).

I think we underestimate the importance of grieving for lost dreams. I speak often with persons in grief. They say, “I just want things back the way they were!” We appreciate those concrete losses, those persons, objects, situations that were treasured and how are gone, as a part of the way things were. Even those of us who work with grieving people regularly may not always think beyond that. But we are creatures of fantasy, we human beings. We may speak of living in the moment. We may imagine we are straightforward, pragmatic, feet-on-the-ground people. But in fact we all have our dreams and make our plans. We can hardly live without them. We cannot attend to our current needs without preparing for our future needs. And if we have the latitude, after we’ve thought of our future needs we will think of our future wants. Only a little of that, and we have moved on to hopes, to plans, to projections in which we, too, become invested. And when any of us is invested emotionally, we grieve that which is lost, whether it’s as tangible as a loved one or as ephemeral as a wish.

Cherish your dreams, and the dreams of those you care about. They are as real as they are fragile. If lost, they must be grieved, and grieved in full. Treat your dreams as the treasures they are. Treat with compassion those who have lost theirs.