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. 

General Convention 2012: Reactions to the Denominational Health Plan

Things come full circle. One of the reasons I started blogging six years ago was to comment on legislation and issues at the 2006 General Convention. Now we’re coming to the 2012 Convention.

So, I’ve started watching the legislation being posted for this summer’s Convention. As a reminder (and especially for those for whom details of General Convention are new territory), resolutions to General Convention come in four categories. “A” resolutions come from commissions, committees, agencies, and boards (CCAB’s) of the Episcopal Church. “B” resolutions come from bishops. “D” resolutions come from deputies.

And then there are “C” resolutions. C resolutions come because a diocesan convention or a provincial meeting (in Episcopal parlance a province is a regional gathering of dioceses) have passed a resolution on a subject that included instructions to “memorialize” the General Convention on the subject. That is, a diocesan convention or a provincial meeting passes a resolution to express an opinion and to put that opinion before General Convention as a resolution.

So far, C resolutions are the only ones that have been posted on line. You can already see on line those that have been posted (and I’m sure there will be more).

Right now, the significant majority of C resolutions posted are on the subject of Structural Reform, and most of those have almost identical language. However, there are a few outliers, and two have my attention. That’s because their subject is the Denominational Health Plan, an effort of the Church Medical Trust based on Resolution A177 in 2009. The resolution specified that the plan should be implemented no later than the end of this year. It specified that the Church Medical Trust would offer a plan (or, really a selection of plans), and that within those dioceses had a number of choices. However, one choice it didn’t include (and a choice that is available under canons before this change) was whether or not to participate. That is, dioceses of the Episcopal Church in the United States, their congregations, and any agencies they would designate as “Episcopal” have to participate in the plan. Now, individuals can opt out if they have other provision for health insurance; but institutions can’t opt out. The point of that is to have as many lives as possible covered in the insurance plan; because the more folks you have covered in the plan, the lower the premium (at last in general). (I wrote more about 2009-A177 at the time.)

So far, two dioceses have submitted C resolutions on the Denominational Health Plan, both asking that it’s implementation be delayed. However, they really say two very different things. One is resolution C22 from the Diocese of West Missouri. It calls on General Convention suspend implementation of the Denominational Health Plan “pending consideration of a more equitable and unified Denominational Health Plan that eliminates unfair regional differences and dramatic cost disparities between dioceses…” The point of this is

That the 77th General Convention instruct the Church Medical Trust to formulate a plan that creates a single, unified national plan for the entire Episcopal Church with no variance in premium costs from diocese to diocese, thereby eliminating dramatic cost differences for similar health insurance coverage between dioceses and regions of The Episcopal Church; and be it further

Resolved, That the suspension of implementation of the Denominational Health

Plan is lifted only when the Church Medical Trust presents a revised, unified

national plan consistent with the intent of this resolution to the Executive Council….

The result of this would be, if you will, truly a single plan for the Episcopal Church in which all would still be required to participate. It would be, essentially, an ecclesial form of a single payer plan covering a single, all encompassing risk pool. The suspension is in place until this is done which could take a while; and this resolution calls for things to stay as they are until that can be offered.

This is different from resolution C27 from the Diocese of Central New York. That resolution calls for the Denominational Health Plan to be delayed another three years. It also maintains that all Episcopal diocese, parishes, and institutions would be required to offer health insurance to clergy and lay employees. However, “each diocese or other ecclesiastical organization or body subject to the authority of the church has the right to make decisions as to whether the Episcopal Church Medical Trust or another plan sponsor shall provide health insurance;…”

This is a different result. While it does require all dioceses, congregations, and institutions to provide health care, and requires it within a limited period of time, it specifically rejects a single denominational plan, or having a choice of plans but only from those offered through the Church Medical Trust. This might improve things for some clergy and for many lay professionals, but it resists a church-wide mandate in favor of a multiplicity of health plans – essentially, an incremental change within the same health insurance market that we already have. It would not result in a single risk pool.

Now, full disclosure: for those who didn’t already know, West Missouri is my diocese. Although I voted on the resolution that resulted in C22, I did not participate in preparing it (and I’m not saying how I voted). My only point in this post is to note how different would be the results of these two resolutions. It could raise the question of what problem proposers of each wish to address. C22 is about equity for institutions across the Church accomplished by universal participation. C27 is about freedom of choice for institutions within the Church, albeit with a requirement that all provide something – essentially an individual mandate.

It does seem to reflect the same sort of arguments about providing health care that we’re hearing in the wider American society. Granted, both proposals are progressive enough to require some coverage (after all, we are Episcopalians); but the means, the choices, and (presumably) the costs would be very different.

Even with delay and suspension both of these plans will be overtaken by events if the Affordable Care Act is fully implemented. In that case, passing C27 could result in some dioceses, congregations, and/or institutions could find their coverage through state insurance exchanges. In addition, I will be surprised if there are not additional resolutions from bishops and/or deputies, which may offer other, different models.

Which brings us to this question: what sort of employer do we want the Episcopal Church to be. That’s not simply a matter of whether we think it important to offer health insurance. Not only do both these resolutions require it, but existing canons require it (albeit for a more limited collection of employees). Rather, this might be seen as another expression of the question whether the Episcopal Church is a single body made up of its dependent dioceses; or whether we are an association made up of dioceses which are themselves  associations of congregations and institutions. Both these opinions are being expressed within the Episcopal Church today, and perhaps we shouldn’t be surprised that they might be expressed in a variety ways, including this.

And perhaps that ought to be an aspect of any General Convention, and of any resolution to General Convention. Every day we have the opportunity to ask the question of what kind of church the Episcopal Church wants to be. Moreover, I can’t think of a better forum in which to ask the question than General Convention. It is, really, the same vocational question each of us faces, writ large: what is God calling us to do now? These resolutions raise the specific issue of health insurance for Church professionals. Other resolutions will raise other issues. However, the larger context remains the same: in each issue, to what is God calling the Episcopal Church now? Or, to put it more personally, as it were: before God what sort of institution do we want the Episcopal Church to be?

Chaplaincy Care: A Human Right?

This week the leadership of the Church of England met in General Synod.  While most folks were watching other issues (notably, progress toward ordination of women to the Episcopate in the Church of England), they did address other issues. Notably, they passed this motion:

That this Synod, mindful of Our Lord’s ministry of healing and his charge to his disciples to heal the sick in his name:

    (a) affirm the ministry of all who promote health and wholeness in body, mind and spirit, and, recognising in particular the role of chaplains in the NHS as an expression of the Church of England’s commitment to minister to all in the community, whether as patients or healthcare workers, call upon Her Majesty’s Government to ensure that chaplaincy provision remains part of the core structure of a National Health Service committed to physical, mental and spiritual health;

    (b) call upon Her Majesty’s Government to apply as the test to any proposed changes to the NHS whether they are best calculated to secure the provision throughout the country of effective and efficient healthcare services provided free at the point of delivery and according to clinical need;

    (c) commend the work of mission agencies and the networks of the Anglican Communion in embodying the churches’ contribution to health and wholeness and promoting fairer sharing of health resources worldwide.

This resolution was based on the background paper, “Health Care and the Church’s Mission: Report from the Mission and Public Affairs Council.”  (You can find the motion and the link to the report as a part of this  report at Thinking Anglicans.)The reason for the paper is provided in the Introduction:

The NHS is currently undergoing the most thorough revision and reconstruction in its sixty year-old history. The NHS that emerges from this process will shape the delivery of healthcare in England for decades to come. It is, therefore, appropriate for the Church to look at the current and prospective state of healthcare delivery in England, focusing on particular areas of interest and concern that are pertinent to the Church’s healing ministry and mission.

This paper is worth the time of any of us in chaplaincy, and especially for those of us who are Episcopalians and Anglicans. For one thing, it provides a discussion of spiritual care and its importance in health care generally, and in the National Health Service in particular. It includes this remarkable statement: “Delivery of spiritual care is the responsibility of all professionals in a multi-disciplinary healthcare team, but on the grounds of care, efficiency and human rights, it is essential that chaplains continue to play a central frontline role in ensuring that appropriate spiritual and religious care are extended to all patients, clients and staff.”

The reference to human rights is one that perhaps many of us might not have addressed. The paper makes reference both to the European Convention on HumanRights, and to “The Declaration on the Rights and Responsibility ofIndividuals, Groups and Organs of Society to Promote and Protect UniversallyRecognized Human Rights and Fundamental Freedoms” of the United Nations. The conclusion reached by the Mission and Public Affairs Council based on human rights is similar to that many in the United States have reached based on civil rights: that patients in the hospital are functionally not free, and that to protect their rights to religious expression it is necessary to make a positive provision for spiritual care.  As the report states,

This requires the NHS not only to allow freedom of religious belief and practice, but also to take all reasonable steps to promote such freedoms, enabling patients, clients and staff to express and to practise their beliefs. While these rights have to be set alongside other rights, such as those associated with privacy, the NHS has, nonetheless, an obligation to promote rights associated with religious belief and practice.

In this light, they review information from a survey of National Health System patients admitted in 2009 and 2010.

In 2009/10, there were 14,537,712 hospital admissions in England. An analysis of the ‘Picker Inpatients surveys’ between 2007 and 2009, indicates that, on average, 22% of hospital patients identified belief as being ‘an issue’, with 17.7% of patients wishing to practise their religion while in hospital. 2.1% of patients, however, reported that their beliefs were not fully respected and 2.9% were not able to practise their religion as they had wished. Using the 2009/10 NHS statistics, this translates into absolute figures of 3,198,297 patients for whom belief was ‘an issue’. 2,573,175 patients wished to practise their religion while in hospital, but 305,291 patients did not have their beliefs fully respected and 421,594 patients were not able to practise their religion as they had wished.

So, in 2009 and 2010 there were more than 14 million admissions. Perhaps 20 per cent would say that belief was “an issue,” and/or that they wished to practice their faith while admitted. Of those more than 14 million, two percent felt their beliefs were not respected; and almost three percent were not able to practice their religion. The report notes that, while the percentages might seem small, they represent more than 400,000, and perhaps more than 700,000 admissions. (I grant that the higher number is unlikely, with an expectation that there is a great deal of overlap between these two groups. It remains that even the smaller number represents a large number of dissatisfied patients, and just within England’s National Health Service.)

The report then notes what provision the National Health Service has made:

This hospital population was served by some five hundred ‘whole-time-equivalent’ chaplains who made approximately one million patient-visits between them. Chaplains also attend to the needs of critically ill patients and neonates who were not surveyed, as well as to families and staff, and many serve on ethical committees or manage bereavement or other services. Given this workload, it is fair to say that the NHS may already be close to failing to fulfil its human rights obligations. Five hundred whole- time-equivalent chaplains is a tiny contingent, compared with the 140,897 doctors, 417,164 nurses and 44,661 managers employed in a National Health Service workforce that totals almost one and a half million. (Emphasis mine)

In the United States, at least, a discussion framed by freedom of religion (and often by freedom from religion) seems to overlook that meeting the spiritual needs of hospital patients (like the military and prisoners and others who are functionally not able to freely exercise their beliefs) requires this positive provision. This report approaches the issue from the other direction, from the perspective specifically of protecting those rights. The Church of England is concerned that the National Health Service may be failing in adequately protecting human rights. One wonders whether in the United States where hospital care is not systematized, much less national, we’re also failing by that measure.

As I said, the paper is worth our time to review. It is of course interesting to hear how the Mission and Public Affairs Council has understood the importance of and provision for chaplaincy within the National Health Service. Beyond that, though, it can provide us with a different perspective from which we might analyze how well we are and aren’t doing in our own context.

A Lesson From the Everglades

I have long quoted a famous bit of t-shirt philosophy: "When you're up to your neck in alligators, it's hard to remember that your original intention was to drain the swamp." (Yeah, I know: the t-shirt didn't say "neck;" but this is mostly a professional blog.)


Now, this seems pretty straightforward. However, I once had someone challenge that. "If your intention was to drain the swamp," he asked, "shouldn't you have prepared for alligators?"  It's a valid point.


So, in a recent conversation, the topic was plans. We were discussing annual reviews, and how the goals one set at the beginning of the year and the accomplishments one could claim at the end of the year, weren't necessarily the same. The goals were important, but so were the actual accomplishments. It was just that the accomplishments came in response to problems and issues that hadn't been apparent when the goals were first set.


It was then that this occurred to me: "When you're up to your neck in Burmese pythons, it's hard to remember that your original intention was to drain the swamp; and it doesn't matter how prepared you were for the alligators."

Remembering Colleagues

Over the years, I have periodically noted a Lesser Feast in the Episcopal Calendar. I have done that most commonly when the person remembered was involved in healthcare ministry in one way or another - the Martyrs of Memphis, or Damien and Marianne of Molokai.

Today is also a day to remember colleagues in specialized ministry. They were not in healthcare, at least not explicitly. However, they were ministering in difficult circumstances, and they gave up their lives for others. They are the four U.S. Army chaplains remembered as "The Dorchester Chaplains." When in World War II the troop ship Dorchester was torpedoed and sank, they were diligent in serving the soldiers under their care. When there weren't enough life preservers, they gave up their own and went down with the ship. Representing different faith traditions, they served together and prayed together and died together. You can read their story in more detail here.

As I said, they were not explicitly in healthcare. However, there is so much in common between what healthcare chaplains and military chaplains do. I have often said that being in the hospital is like travel in a foreign country. The people around you where strange clothing and speak a different language. You're in a different time zone, eating strange food, and experiencing strange customs. Even your money no longer has meaning, and your body isn't your own. The same is true, as near as I can tell, for those serving in the Armed Forces (no, I haven't served, but I've tried to listen well). With that in mind, there seems to me much in common between the ministry of a healthcare chaplain and a military chaplain. We are all there for those whose worlds, and whose health and safety, are no longer under their own control. (And, yes, I realize this is true of other specialized ministries. I don't want to slight anyone; but this is who we remember today.)

So, take the time to remember the Dorchester Chaplains, and to honor the service of all their colleagues who still serve among those in harms way. Pray that God protect them and those they serve; and that in God's time we may know fully that greatest place of safety, the true peace of God.