Abstract:
This
essay discusses how the person-centred approach informs a chaplain’s response
to mental health issues in hospital patients. “Person-centred” is a broad term,
but the essence of the person-centred approach is to look at people
holistically as a dignified human being and identify
the contextual factors affecting the person. Therefore, it is vital that
chaplains have a good background knowledge about the types of mental health
issues hospital patients face. When providing person-centred care, the visit is
“to the patient, for the patient” and “it’s not about me.” Interestingly, to
practice the person-centred approach, one needs a high degree of self-awareness
and good self-care. A person-centred chaplain do not impose his/her theology
onto others but instead tries to learn about who God is for the person. Meanwhile,
chaplains must remain God-centred because it is not possible to continue in
crisis chaplaincy if one do not regularly stop to revive spiritually.
This
essay discusses how the person-centred approach informs a chaplain’s response
to mental health issues in hospital patients. Firstly, I will discuss the
various definitions people have given to the term “person-centred.” Secondly, the
types of mental health issues hospital patients face. Thirdly, some ways of
providing person-centred care to hospital patients. Fourthly, the importance of
self-awareness and self-care when providing person-centred care to others. Finally,
I will discuss theological issues that arise in providing person-centred care
to hospital patients.
“Person-centred”
is a very broad term. In the hospital setting, the term “patient-centred” is
commonly used to mean a similar thing, even though some people find the term
too medical and narrow in scope. Other commonly adopted terms describing person-centredness
include: patient-and-family-centred, relationship-centred, user-centred,
client-centred, personalised, and individualised.[1]
Regardless of the term used, person-centred care in the hospital setting has
been an evolving concept.[2]
In 1969, Edith Balint originally described person-centred care as
“understanding the patient as a unique human being.”[3]
Since then, there have been many other conceptualisations of person-centred
care.[4]
[5][6][7][8][9] Rather than providing “one size fits all”
solutions, being person-centred involves meeting people’s needs in a manner
that is best for them.[10]
This means that a person-centred chaplain looks at all the contextual factors
affecting the person.[11]
This includes internal personal factors such as the individual’s gender, age,
values preferences, desires, lifestyle, spirituality, and external
environmental factors such as the person’s family situation, social
circumstances, and culture.[12]
Therefore,
it is important for a person-centred chaplain to have a good background
understanding on the types of mental health issues hospital patients face. In
terms of the mental health status of the Australian population, the Australian
National Survey of Mental Health and Wellbeing (NSMHW) 2007 data tells us that
45.5% of the total population experienced a mental health disorder at some
point in their life, and 20% of Australian aged between 16-85 years experienced
mental disorders in the last year, with 14.4% having had anxiety disorders,
6.2% mood disorders and 5.1% substance use disorders. The prevalence of mental
disorders declines with age from 26.4% in the 16-24 years age group to around
5.9% in the 75-85 years age group.[13]
While we can keep at the back of our minds that a portion of patients in the
hospital may have anxiety disorders, mood disorders and substance use
disorders, the mental health issues encountered in the hospital setting is very
different from the general population.
The most common times people go into
the hospital are: before and after surgery, when a child is born, during a
medical illness, when death is imminent, during and after an emergency, and
when mental health treatment is needed.[14]
From my observations at Sydney Adventist Hospital (SAN), the patients tend to
be very elderly. A staff in the medical ward told me it is very unusual to see
patients younger than 70y.o. in their ward. Furthermore, different wards have
different atmospheres. The cancer wards tend to have very distressed patients
and families, the ICU tend to have highly distressed families with an
unconscious or semi-conscious patient, and the birthing unit is usually a
joyful place which can turn extremely horrible when something goes wrong. Most people die in healthcare settings and many of these
deaths will occur as a result of diseases of the cardiorespiratory system and
cancers. Therefore, a significant proportion of people whom the hospital
chaplain works with are patients who are facing death, or bereaving families of
patients who had just passed away.[15]
Some
patients may appear sick, depressed, irritable, exhausted, and unsociable.[16]
It is important for the chaplain to understand the emotions of patients and
their families. Patients may feel exposed, as medical staff frequently comes in
to examine them. They may feel useless, as they cannot do what they normally
do.[17]
As there is nothing keeping them busy, they may think a lot, eg. worrying about
the hospital bills, dying, etc.[18]
They may feel they are a burden on others.[19]
They may feel separated from their identity, their autonomy and their
community.[20]
They may also see their existence threatened as many people associate hospitals
with death.[21]
Grieving families may experience a wide range of feelings, ranging from the
negative feelings of shock, sadness, anger guilt, anxiety, helplessness,
despair, and loneliness to the more positive feelings of relief, hope and
acceptance.[22]
A person-centred chaplain resists the
temptation to coerce the person, “take control” and “fix-it-all.”[23]
Rather, being person-centred involves effective communication, where the chaplain
practices active listening, views the person holistically, addresses the
person’s emotions and expresses empathy. That way, the chaplain can provide
respectful and compassionate care.[24]
There are some things that can be learnt from Carl Rogers, the psychologist who
developed the client-centred therapy. Based on his experience as a
psychotherapist, he believes “it is the client who knows what hurts, what
directions to go, what problems are crucial, what experiences have been deeply
buried.” Rogers relies upon the client for the direction of movement in the
process.[25]
He proposes that humans have a natural tendency to move in a positive
direction,[26]
“to expand, extend, become autonomous, develop,” and “mature.”[27]
Rogers believes it is important to
clarify the client statement empathetically and understandingly.[28]
In his interview clips with clients, I see him frequently echoing and
paraphrasing back to his clients on what they have just said.[29]
Rogers warns against making declarative statements to a client, as that would
become an evaluation and judgment.[30]
The therapist does not ask himself/herself “How do I see this?” but continually
asks “How does the client see this?”[31]
Rogers theorised that if a therapist can “provide a relationship based on the
three core conditions of acceptance, empathetic understanding and congruence,”
then positive personality change would follow.[32]
Chaplains can learn from Rogers the skills of deep listening and nonjudgmental
communication. However, some people believe Rogers is overly nondirective in
his approach and made up a joke about how a person who is being counselled by
Rogers said he wanted to commit suicide and Rogers simply echoes everything he
said until that person jumps out the window and dies.[33]
However,
the chaplain is not a counsellor or a psychotherapist, and patient encounters can
be brief. In a routine chaplain ward round, I see the chaplain checking in on
each patient in the ward he/she is covering one by one. First, the chaplain
looks at the patient list and remembers the person’s name. Then the chaplain
looks in from outside of the patient’s room to get some clues about the person,
eg. flowers and cards. The chaplain greets the patient by the surname,
introduces himself/herself, and pick up on clues as to whether the patient is
keen for a longer conversation or not. It is up to the patient whether he/she
wants to talk to the chaplain, and when the patient is not keen, the visit ends
with the chaplain making a friendly closing statement. One of the chaplains I
shadowed gave the advice to always remember, “it’s not about me,” and not to
feel bad if the patient does not want to talk. After all, the visit is “to the
patient, for the patient”.[34]
Many times, the patients just want their heath and dignity restored, to feel
cared for, and to be reassured.[35]
For some patients, a short conversation with some words of encouragement is
more helpful than a long conversation.
Being
person-centred does not just involve focusing on one person, but the whole
family, and sometimes the chaplain can only interact with the families because
the patient cannot be helped, ie. unconscious or deceased. In addition to
routine ward rounds, chaplains also attend to calls made by the wards. For
example, a chaplain I was shadowing got called out to attend to the highly
distressed family of a patient who had a sudden reduction in his consciousness.
She still tried to talk to him, and he opened his eyes briefly at one point. She
spoke to the family members present with the patient, mapped out the whole genogram
and worked out the family dynamics. She also communicated with the medical
staff caring for this patient. In this case, the chaplain was not interacting
with the individual patient, but all the people related to the patient in the
hospital. Kirkindoll believes that the chaplain should try talking to the
“unresponsive” patient, because he/she may still be able to hear you,[36]
so I think it is good that the chaplain talked to the patient in this case.
Interestingly, many experts believe
that the person-centred helper needs a high degree of self-awareness and good
self-care. Rogers contends that the attitudes and beliefs held by the
counsellor determines whether or not he/she is able to work with a
person-centred approach.[37]
Kirkindoll suggests that you can only be of help to another person in a
visitation if you are known as a caring person, trustworthy in your motives,
and make yourself physically and emotionally available to others. He coined
three terms to describe the good helper: Firstly, having “accurate empathy,”[38] where you focus your attention on the person so
he/she senses that you accurately understand their situation and care for them.
Secondly, having “nonpossessive warmth,”
which is the ability to suspend your own needs when counselling others, ie.
“being able to respond with affection to the other person’s need rather than
using the other person to meet one’s need.”[39]
Thirdly, “inherent genuineness,” where
the helper needs to be comfortable in his/her own personhood if he/she wants to
be of help to others.[40]
Rogers
found that he is more effective when he can listen acceptingly to himself and
be himself, eg. to be able to realise he is angry, or that he feels rejecting
towards a client, and not trying to act well when feeling ill,[41]
and that the more open he is to the realities in himself and in the other
person, the less he finds himself wishing to rush in to “fix things.”[42]
Kirkwood describes how chaplains can do more damage than good if they do not
have a high degree of self-awareness. For example, chaplains dependent on the
ego boosting “highs” of conversions will find it very disappointing when the
patients do not convert, and lose interest in their work. Chaplains who are
highly obsessive and competitive[43]
can be so concentrated on doing things right that they overlook the patients’
needs, feelings and stresses.[44]
These chaplains may have a strong need for complete control over their units,
and they can burn out other colleagues in the unit with their jealousy and
accusations.[45]
Markwick
asserts that “professionals need to bring their hidden motivations to the
surface and confront the potential effects they have on their relationships
with clients.”[46]
Motivations of people in the helping profession vary. Some chaplains knew
clearly they are called by God, while others just wanted to get away from
parish responsibilities.[47]
Some are just performing the duties and expectations of their occupation[48]
while others have a sincere desire to support and comfort an ill patient.[49]
Some people do “people-related activities” out of their own needs, ie. “the
need to be needed.” Yet, the danger of this is that they can leave themselves
open to manipulation.[50]
For instance, they can become so focused on trying to make the patient feel
good that they become out of touch with reality. However, person-centred does
not mean just focusing on trying to cheer up the patient.[51]
It is important to be realistic. As we
identify the patient’s strengths and giving words of encouragement and hope, we
also need to be honest and realistic about the difficulties he/she face.[52] Some
people with low self-esteem and recognition needs may “escape” to chaplaincy
because chaplains are often under minimal denominational supervision, giving
them freedom to make exaggerated reports of the wonderful work they are
accomplishing.[53]
Others became chaplains out of gratefulness. For example, some grateful
ex-patients may return to serve in the hospital because they feel an obligation
to repay the blessings they received from the chaplains.[54]
Worden
encourages counsellors to explore their own histories of loses. Working with
the bereaved may make us aware of our own losses, especially if the loss
experienced by the bereaved is similar to losses that we have sustained in our
own lives. Another area where grief may get
in the way is the counsellor’s own feared losses. Existential anxiety (one’s
own fear of death) is another challenge.[55] Worden believes
counsellors are more effective when they are aware of their own histories of
losses because it can help the counsellor better understand the process of
mourning, and the kinds of resources available to the bereaved. The counsellor
can also identify any unfinished business that is still present from prior
losses.[56]
It also helps the counsellor know his/her limitations with respect to the kinds
of clients and grief situation that he/she is able to deal with, and make
appropriate referrals.[57]
Kirkwood
also believes that knowing one’s own strengths and weaknesses is important
because “a willingness to accept that we cannot minister to all people is a
major criterion for a good pastoral care person.”[58]
During a visit, signs of feeling uncomfortable must be recognised immediately.
If that uneasy feeling cannot be dissipated, then it is unproductive to persist
with the visit.[59]
Worden contends that counsellors need to know their own personal limitations in
terms of the number of patients they can work intimately with at any given time.
They also need to know how to reach out for help and support.[60]
Kirkwood warns that “person-centredness” does not mean becoming so
“others-centred” that the chaplain becomes too available, because this can
easily lead to burnout, and a burnt-out chaplain is not much of a help to
others.[61]
Some theological issues arise when
chaplains provide person-centred care in a pluralistic arena. One is the conflict
between the chaplain’s theology and the patient’s theology. A person-centred
chaplain do not impose his/her theology onto others but instead tries to learn
about who God is for the person and how that person lived his/her theology,[62] and to “tap into it to sustain them through this
crisis in their life.”[63]
Sometimes standardised prayer books do not reflect what was going on for the
patient and the chaplain needs the guidance of the Holy Spirit to pray a more
personalised prayer.[64]
However, the chaplain can affirm the patient’s belief system without denying his/her own theology. In fact, when
the patient invites you to share your faith or wants to get converted, it is
impossible for to remain on a “non-directive” path anymore. Another important
theological issue is the importance of God-centredness even as we take a
person-centred approach. Kirkwood warns that “not enough of God is dangerous as
chaplains go about their tasks”[65]
because “the patience required to handle being regularly called upon to deal
with trauma is only possible by regularly stopping” to “spend time in spiritual
revival and discipline.”[66]
To
conclude, it is important for a hospital chaplain to use the person-centred
approach to ministry. This approach reminds the chaplain to look at the
hospital patients holistically as a dignified human being and identify the contextual factors affecting the
person. However, to be a person-centred chaplain, one needs a high degree of self-awareness,
especially of one’s own motivations and limitations. Being “person-centred”
does not mean being so “others-centred” that the chaplain neglects his/her
self-care. Theologically speaking, a person-centred chaplain do not impose
his/her theology onto others but instead tries to learn about who God was for
the person. The chaplain can still affirm the patient’s belief system without
denying his/her own theology. Meanwhile, chaplains must remain God-centred
because it is not possible to continue in crisis chaplaincy if one do not
regularly stop to revive spiritually.
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[1] Maria J. Santana, “How to
practice person-centred care: A conceptual framework,” Health Expectations 2018 (21): 430; “What is person-centred care
and why is it important?” Health Innovation Network South London, accessed
January 15, 2019,
https://healthinnovationnetwork.com/system/ckeditor_assets/attachments/41/what_is_person-centred_care_and_why_is_it_important.pdf
[2] Santana, “How to practice
person-centred care,” 429.
[3] E. Balint, “The
possibilities of patient-centered medicine,” J R Coll Gen Pract. 1969 (17): 269‐276.
[4] Santana, “How to practice
person-centred care,” 430.
[5] Marie-Eve Poitras, et al.
“What are the effective elements in patient-centered and multimorbidity care? A
scoping review,” BMC Health Services
Research 2018 (18): 2; F. Dwamena, “Interventions for providers to promote
a patient-centred approach in clinical consultations,” Cochrane Database System Review 2012 (12); Simone A. Dulmen, et al.
“Supporting a person-centred approach in clinical guidelines. A position paper
of the Allied Health Community - Guidelines International Network (G-I-N),” Health Expectations 2015 (18): 1543; Junietta
Baker McCall, A Practical Guide to
Hospital Ministry: Healing Ways (New York: The Haworth Pastoral Press,
2002), 16.
[6] Matthew Low, “A novel
clinical framework: The use of dispositions in clinical practice. A person
centred approach,” Journal of Evaluation
in Clinical Practice 2017(23): 1062.
[7] Carl R. Rogers, Client-Centered
Therapy (London: Constable, 2003), 20.
[8] Low, “A novel clinical
framework,” 1062.
[9] Santana, “How to practice
person-centred care,” 433; “What is person-centred care and why is it
important?”
[10] “What is person-centred
care and why is it important?”
[11] McCall, A Practical Guide to Hospital Ministry,
17.
[12] “What is person-centred
care and why is it important?”; Santana, “How to practice person-centred care,”
434; Dulmen, et al. “Supporting a person-centred approach in clinical guidelines,”:
1544.
[13] Tim Slade et al. The Mental Health of Australians 2: Report
on the 2007 National Survey of Mental Health and Wellbeing (Canberra:
Commonwealth of Australia, 2009), xii.
[14] Michael L. Kirkindoll, The Hospital Visit (Nashville: Abingdon Press,
2001), 12.
[15] Mark Cobb, The Hospital Chaplain’s Handbook: A Guide for Good Practice (Norwich:
Canterbury Press, 2005), 65.
[16] Neville A. Kirkwood, Pastoral Care in Hospitals (Harrisburg:
Morehouse, 2005), 19.
[17] Kirkwood, Pastoral Care in Hospitals, 14-15.
[18] Kirkindoll, The Hospital Visit, 25.
[19] Kirkwood, Pastoral Care in Hospitals, 15.
[20] Kirkindoll, The Hospital Visit, 24-25.
[21] Kirkwood, Pastoral Care in Hospitals, 16.
[22] Mal McKissock, and Dianne
McKissock. Coping with Grief (Sydney:
ABC Books, 2012), 12; J. William Worden, Grief
Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner
(London: Routledge, 2009), 91.
[23] P. Kinsella, What Are the Barriers in Relation to
Person-centred Planning? (London: Joseph Rowntree Foundation, 2000).; J. Mansell
and J. Beadle-Brown, “Person-centred planning and person-centred action: a
critical perspective,” in Person-centred
Planning and Care Management with People with Learning Disabilities, ed. P.
Cambridge and S. Carnaby (London: Jessica Kingsley, 2005); J. Thompson, et al. Person-centred Practice for Professionals
(Maidenhead: Open University Press, 2008).
[24] Santana, “How to practice
person-centred care,” 434.
[25] Carl R. Rogers, On Becoming a Person: A therapist’s view of
psychotherapy (Croydon: Robinson, 2016), 11-12.
[26] Rogers, On Becoming a Person, 26.
[27] Ibid., 35.
[28] Rogers, Client-Centered
Therapy, 28.
[29] “Carl Rogers and the
Person-Centered Approach,” Carl Rogers, accessed December 19, 2018,
http://www.psychotherapy.net.proxy1.athensams.net/stream/morling/video?vid=274
[30] Rogers, Client-Centered
Therapy, 28.
[31] Ibid., 42.
[32] Isabel Gibbard, “Brief
person-centred counselling,” Healthcare
Counselling & Psychotherapy Journal 2009 (9): 4-7.
[33] “Carl Rogers and the
Person-Centered Approach”
[34] Kirkwood, Pastoral Care in Hospitals, 8.
[35] Ibid., 17-18.
[36] Kirkindoll, The Hospital Visit, 16-17.
[37] Gibbard, “Brief
person-centred counselling,” 4-7.
[38] Kirkindoll, The Hospital Visit, 40.
[39] Ibid., 41.
[40] Ibid., 44.
[41] Rogers, On Becoming a Person, 16-17.
[42] Ibid., 21.
[43] Kirkwood, Pastoral Care in Hospitals, 5.
[44] Ibid., 272.
[45] Kirkwood, Pastoral Care in Hospitals, 273.
[46] Anne Markwick, “Person-centred
planning and the recovery approach,” Learning
Disability Practice 2013 (16): 34.
[47] Kirkwood, Pastoral Care in Hospitals, 257.
[48] Ibid., 3.
[49] Ibid., xi.
[50] Ibid., 258.
[51] Ibid., 4.
[52] “Person Centred planning
with children and young people: The Tower Hamlets model,” Tower Hamlets, accessed
January 15, 2019,
https://www.towerhamlets.gov.uk/Documents/Children-and-families-services/Early-Years/TH_PCP_Model.pdf
[53] Kirkwood,
Pastoral Care in Hospitals, 259.
[54] Kirkwood, Pastoral Care in Hospitals, 261.
[55] J. William Worden, Grief Counselling and Grief Therapy: A
Handbook for the Mental Health Practitioner (London: Routledge, 2009), 252.
[56] Worden, Grief Counselling and Grief Therapy, 253.
[57] Ibid., 254.
[58] Kirkwood, Pastoral Care in Hospitals, 7-8.
[59] Ibid., 9.
[60] Worden, Grief Counselling and Grief Therapy,
256.
[61] Kirkwood, Pastoral Care in Hospitals, 268.
[62] Martha R. Jacobs,
“Creating Personal Theology to Do Spiritual / Pastoral Care,” in Theology of Spiritual / Pastoral Care, ed.
Rabbi Stephen B. Roberts (Woodstock: SkyLight Paths Publishing, 2013), 7.
As Jacobs puts it, “It is not about me and what I believed; it was about
them and what their belief system was and who God was for them.”
[63] Jacobs, “Creating
Personal Theology to Do Spiritual / Pastoral Care,” 11.
[64] Ibid., 9.
[65] Kirkwood, Pastoral Care in Hospitals, 268.
[66] Ibid., 286.
