Spiritual Assessment
Two roads diverged in a wood, and I -- I took the one less traveled by, and that has made all of the  difference. -- Robert Frost

Chapter 1 - Introduction

This spiritual assessment manual was developed for understanding and administering the spiritual assessment program that can be accessed by clicking on SpiritualityApp above and downloading the program on your computer (available on PCs only). It is to be used to diagnose, treat and research mental and physical illness from the perspective of spiritual values, beliefs and practices. Its intention is to better understand the role of religious faith in the maintenance of health, the healing of diseases, and the coping with chronic illness and losses in peoples' lives. The  computerized version of this assessment program is available for use at no monetary cost. In other words, it is freeware and may be used without payment but may not be modified, re-distributed or reverse-engineered without the author's permission.1

The importance of assessing religious beliefs or personal problems from a pastoral perspective was given renewed attention by Paul Pruyser in his book, The Minister As Diagnostician.2 Not only did Pruyser emphasize the unique perspective ministers and chaplains bring to understanding human personality and problems, but he also contended that many problems were spiritual and required intervention and treatment that was religious in nature. But before treatment could begin, it was necessary that an accurate religious diagnosis be made in order for therapy to be given that was appropriate and responded to the unique problem brought to the pastor's or chaplain's attention.

While Paul Pruyser brought the critical and discerning eye of the clinician into pastoral care, Lawrence Seidl of the Catholic Health Association of the United States has introduced pastoral care to the language and process of quality assurance.3 Seidl argues that "all departments within the hospital, in the very near future, will be required to show that their services provide a measurable, significant outcome."4 This includes pastoral care. The means by which this will be accomplished include the collection of quantitative data the assessment of spiritual needs, and planned interventions or treatments targeted to meet these needs.

While Lawrence Seidl challenges pastoral caregivers to use the tools of quality assurance to document the value of spiritual care, Larry VandeCreek invites us to use the instruments of empirical science and research to provide measurable, significant outcomes resulting from the provision of quality pastoral care. VandeCreek writes that pastoral counselors and chaplains "have been too ready to make a living on existing, borrowed insights and practice patterns, and not ready enough to test our own insights. Consequently, we can legitimately be seen in the scientific world as a ‘do nothing' profession which has failed to make a contribution to knowledge in a scientific age."5 In an article entitled "Religious commitment and Health: Valuing the Relationship," David B. Larson and Susan S. Larson echo VandeCreek's concern that pastoral counselors have not yet "documented ways in which their care has made a difference."6   In reviewing 1,045 articles in the Journal of Pastoral Care, Journal of Pastoral Counseling, Journal of Religion and Health, and Pastoral Psychology, the authors report that only about 5 percent of the pastoral counseling articles contained quantitative information of any kind which qualifies it as being "scientific." "This percentage was drastically lower than the percentage in psychiatric literature, which had 66 percent."7

The failure to produce quality research has been an internal blight on the pastoral counseling profession; it has been a self-inflicted wound. Presently there are external dangers that are equally menacing and that must be faced up to. The two authors quoted above cite well-known psychologist Albert Ellis who states:

"Religious commitment, therefore, is in many respects equivalent to irrational thinking and emotional disturbance…the elegant therapeutic      solution to emotional problems is to be quite unreligious…the less religious they are, the more emotionally healthy they will be."8

In speaking of his medical education, David Larson states that "during psychiatric training if one proposed that religion might not be harmful—in fact might even be beneficial--one was laughed at as a relic of the Dark Ages or condemned as a religious incompetent."9 During a period of cost constraints and efficiency, external attacks on religion's legitimacy as represented by Ellis, and the internal failure to present clinical chaplaincy as a verifiable science, have both resulted in efforts to eliminate spiritual care programs from the health care arena.

This manual and the spiritual assessment program it explains, is intended to address four concerns. It provides chaplains with a tool for "the deliberate assessment of the patient's spiritual needs."10 It provides chaplains and healthcare professionals with a process for documenting the spiritual needs of clients and patients. It can be used to establish a database upon which empirical research can be conducted by pastoral care. This is accomplished by using the computerized version of the assessment which creates a database. Two examples of how this can be done are illustrated in articles published by The journal of Pastoral Care & Counseling.10, 11 These articles illustrate how pastoral caregivers can document the value of including spiritual values and beliefs in the assessment and treatment of physical and mental illness. If a hard copy or printed version of this assessment is utilized, then quantitative values captured in the printed version can be manually transferred onto a spreadsheet or database for statistical analysis. Finally, this assessment instrument provides chaplains and healthcare professionals with a process for developing a quality assurance program.

Notes

1 Living Water Computer Assessment Program copyrighted © 1992 by Gary E. Berg. This software program is presently available as FREEWARE from LIVING WATER SOFTWARE at no monetary cost. This is no guarantee that the assessment instrument will not be sold for a reasonable price in the future. Further inquiry can be made by writing Gary Berg, 260 Park Ave S, St. Cloud, MN 56301.

2 Paul W. Pruyser, The Minister As Diagnostician, Philadelphia: The Westminster Press, 1976.

3 Lawrence G. Seidl, Quality Assurance & Pastoral Care: A Development and Implementation Guide, (St. Louis: The Catholic Health Association of the United States , 1990).

4 Ibid., ix.

5 Larry VandeCreek, A Research Primer for Pastoral Care and Counseling (Journal of Pastoral Care Publications, Inc. 1988) p. 3.

6 David B. Larson and Susan S. Larson, "Religious Commitment and Health: Valuing the Relationship," Second Opinion (July, 1991) pp. 26-40.

7 Ibid., p.38.

8 Ibid., p.34.

9 Ibid., p.28.

10 Larry VandeCreek and Damain Smith, "Measuring the Spiritual Needs of Hospital Patients and Their Families," The Journal of Pastoral Care, Vol. 46, No. 1 (Spring, 1992), p. 46.

11 Gary Berg, Norman Fonss, Arthur Ree, & Larry VandeCreek, "The Impact of Religious Faith and Practice on Patients Suffering From a Major Affective Disorder: A Cost Analysis", The Journal of Pastoral Care, Vol. 49, No.4 (1995), pp. 359-363.

12 Gary Berg, "The Relationship between Spiritual Distress, PTSD and Depression In Vietnam Combat Veterans", The Journal of Pastoral Care, Vol. 65, No.1 ( 2011), 6:1-11.

Chapter 2 - The Need for Spiritual Care and Intervention

The treatment provided by chaplains in a hospital is often generic. Because of a lack of resources and minimal coverage, chaplains visit newly admitted patients, provide worship opportunities in the hospital, call on patients before and after surgery, make routine visits, and are available to those who take the initiative to seek them out. But as Larry VandeCreek has pointed out, persons with the fewest religious resources have the greatest religious needs.13 People who acknowledge the greatest spiritual distress in their lives as evidenced by significant spiritual injuries are also people who possess the fewest spiritual or religious resources in their lives.14, 15, 16, 17 The are not plugged into a faith community. There is the feeling that God has abandoned them or a traumatic event or significant loss has alienated them from a faith they once possessed. This means that people most in need of spiritual care are often those least likely to seek out the chaplain. An assessment process is needed which will identify these needs, and that will then allow the chaplain or spiritual care giver to target those needs with an appropriate response.

Many pastoral care departments are struggling to make the transition from inpatient to outpatient care. Generic pastoral care described in the paragraph above, a ministry of "presence," or non-directive counseling does not lend itself to the outpatient care model. This may be why pastoral care programs have difficulty adjusting to an ambulatory care model. A future role for pastoral care in the outpatient arena may be administering an annual spiritual assessment, identifying specific problems, targeting intervention, and providing patient education on the role of religion and spirituality in prevention and wellness. The assessment process described in this manual lends itself to this model. As the chapter on clinical pathways or guidelines in pastoral care will illustrate, critical events or points of entry into a patient's spiritual life calling for intervention are identifiable and need to be addressed.

In addition to individualizing treatment, this assessment process also allows us to "see things whole." Chaplains and pastoral counselors are skilled—as are physicians, nurses, psychologists and most health care professionals—at providing individual treatment to an individual patient. We are not so accustomed to looking at aggregates, at the larger picture, at relationships between religious behavior and health care, at patient profiles that signal danger or well being. We have had no means at our disposal, until now, to see things whole. Mental and physical well-being or spiritual health is greater than the sum of its parts. A holistic spiritual assessment that includes core values and beliefs gives us information we have too often ignored or have not heretofore possessed. With the ongoing research now being conducted into the interface between religion and spirituality and healthcare outcomes, this information can now be translated into knowledge. The gathering of quantitative data through the spiritual assessment process now makes it possible to assign risks, to consider preventative care, to prioritize treatment programs and focus our attention on the spiritual well-being of clients who can benefit from pastoral counseling and spiritual guidance. When a spiritual assessment is computerized, as has been done with the model here described,18 immediate feedback is provided to the chaplain or spiritual counselor that compares a person's religious resources, a stress index indicating the risk of future illness and re-hospitalization, or spiritual injury scores in comparison to group norms. The pastoral counselor has an advantage when she or he can look at the patient's religious profile and say, "tell me about your unresolved guilt," or "I see that the absence of meaning in your life is a concern you have," or "how have the many losses you have experienced in the last two years changed your life?" And knowing that a high stress score carries with it risks of future illness is important in prescribing pastoral counseling and what issues need to be addressed.

In addition to opening avenues into clinical care, an assessment process that provides quantitative data provides unlimited opportunity for research. Larry VandeCreek puts it bluntly: "My point is this: doing research requires you to move back toward the perspectives of the sciences and mathematics."24 The computerized version of this assessment process is good at math. It is also good a collecting unlimited amounts of data to be mined. All that is needed is an instrument for collecting the data, a paradigm or hypothesis for interpreting it, and the patience and program for analyzing it. The future pastoral care depends on it.

This spiritual assessment manual is written to encourage chaplains, pastoral caregivers and spiritual department programs to consider spiritual care as not only an art and a tradition, but also a science. A number of years ago, Paul Pruyser chastised chaplains and pastoral counselors for their reluctance to become more involved in the diagnosis and the assessment of patients. This he attributed largely to the influence of Carl Rogers on the pastoral care movement.20Rogers' focus on the here and now, his association of diagnosis with authoritarian models of medicine, and his humanistic approach to therapy rejected a conceptual framework required of diagnosis. His focus on feelings and the client's frame of reference did not lend itself to asking the questions needed for making a thorough diagnosis of the patient's condition. For pastoral caregivers in many federal, state and community hospitals, this bias against asking questions is compounded by the nature of the clientele ministered to. The frequency of church attendance, for example, is often significantly below the general population in chemical dependency centers, mental hospitals and medical centers, which serve the homeless, indigent and mentally ill. When chaplains begin asking questions about church attendance, prayer, and the importance of God in a person's life, a barrier to communication is often created. The patient may feel judged and the chaplain may feel self-conscious about asking questions that elicit a defensive answer. It is instructive that many of the assessment tools being developed and the research being done in pastoral assessment is being done not by chaplains and pastoral counselors, but is being done by physicians and those traditionally trained in diagnostic practices. Paul Pruyser,21 Elisabeth McSherry,22 Harold Koenig,23 and David and Susan Larson24 are all examples of persons from other professions taking the initiative in writing about the significance of religious faith in personal well being and health care.

Many pastoral care departments are struggling to make the transition from inpatient to outpatient care. Generic pastoral care already described in this manual as a ministry of "presence," or non-directive counseling does not lend itself to the outpatient care model. This may be why pastoral care programs have difficulty adjusting to an ambulatory care model. A future role for pastoral care in the outpatient arena may be administering an annual spiritual assessment, identifying specific problems, targeting intervention, and providing patient education on the role of religion and spirituality in prevention and wellness. The assessment process described in this manual lends itself to this model. As the chapter on clinical pathways or guidelines in pastoral care will illustrate, critical events or points of entry into a patient's spiritual life calling for intervention are identifiable and need to be addressed.

One additional note is here added for a special category of pastoral and spiritual care. The model here described with special emphasis on spiritual injury and distress was developed in ministering to veterans in a Veterans Administration Medical Center. Soldiers now being deployed overseas are increasingly assigned to a briefing with a chaplain both before and after deployment. Numerous studies indicate that military service in times of war have an impact on the spiritual values and practices of soldiers returning from war.25, 26, 27, 28, 29 A spiritual assessment conducted both before deployment and following a return from military service would provide significant knowledge regarding military service and combat on the spiritual well-being of our nation's soldiers and veterans as a result of war.

Notes

13 Larry VandeCreek, "The Spiritual Well-being of Homeless Persons and a Comparison to Those Who Help," The Caregiver Journal, Vol. 8, No. 1 (Schaumburg, IL: The College of Chaplains) pp. 22-30.

14 Berg, et al. (1995) pp. 362-363.

15 Berg, Ibid. (2011) 6:3-6:6.

16 Alan Fontana & Robert Rosenheck, "Trauma, Change in Strength of Religious Faith, and Mental Health Service Use Among Veterans Treated for PTSD," The Journal of Nervous and Mental Disease, Vol. 192, No. 9, September 2004, pp. 579-580.

17 Julio F. P.Peres, Alexander Moreira-Almeida, Antonia Gladys Nasello & Harold G. Koenig, "Spirituality and Resilience in Trauma Victims," Journal Religion & Health (2007) 46:343-350.

18 Living Water Spiritual Assessment Program copyrighted © 1992 by Gary E. Berg. This software program can be purchased by ordering from LIVING WATER SOFTWARE, 260 Park Avenue S, St. Cloud, MN 56301.

19 Larry VandeCreek, A Research Primer for Pastoral Care and Counseling p. 9.

20 Pruyser, The Minister As Diagnostician, pp. 38-41.

21 Pruyser, The Minister As Diagnostician.

22 Elisabeth McSherry, Daniel Kratz, and William A. Nelson, "Pastoral Care Departments: More Necessary in the DRG Era?" HCM Review 11 (1) (1986: Aspen Publishers, Inc.) pp. 47-59.

23 Harold Koenig, James N. Kvale, and Carolyn Ferrel, "Religion and Well-Being in Later Life," The Gerontologist, Vol. 28, No. 1 (February, 1988) pp. 18-28.

24 David B. Larson and Susan S. Larson, Ibid.

25 Berg, Ibid. (2011).

26 Berg, et al. (1995).

27 Fontana and Rosenheck, Ibid.

28 Peres, et al., Ibid.

29 Gary E. Berg, Charles G. Watson, Butch Nugent, Lee Gearhart and Mark Juba, "A Comparison of Combat's Effects on PTSD Scores in Veterans With High and Low Moral Development," Journal of Clinical Psychology, Vol. 50, No. 5 (1994) pp. 669-676.

Chapter 3 - Spiritual Assessments

George Fitchett documents the place of assessment in pastoral care in his book, Assessing Spiritual Needs.30 He identifies nine approaches to pastoral assessment. They are implicit assessment, inspired, intuitive, idiosyncratic, assessments based on traditional pastoral acts, normative, global, psychological, and explicit.31 With the exception of psychological and explicit assessments, these approaches to pastoral assessment do not lend themselves to objective, measurable markers that are the hallmark of scientific medicine. This puts chaplains and pastoral counselors at a decided disadvantage when operating in a modern medical center or clinic. Psychological models, which have much to teach the discipline of pastoral care, operate out of a domain that by definition has been claimed by a different discipline. At best, when chaplains "piggy-back" on the instruments and models of another profession, we are recognized as "step-children" and borrowers of other peoples' insights and efforts. At worst, such models may be contrary and at odds with the best that is in our theological and religious traditions and practices.

The explicit approach to pastoral assessment may or may not provide information that meets the standards of scientific inquiry and clinical objectivity. A semi-structured interview technique focuses on explicit areas of clinical concern, but it also depends on the clinical skills and experience of the caregiver doing the interview. Larry VandeCreek cautions against using semi-structured interview techniques because the "results are easily contaminated by the interviewer's point of view or interpretations. Validation and reliability of the results require interviewer training and continuing supervision."32 Paul Pruyser's model for pastoral assessment,33 and George Fitchett's 7 x 7 model34 are examples of explicit models that are thoroughly grounded in theological and pastoral fundamentals. Both models overcome the limitations of a purely objective or scientific model in that they allow for flexibility and clinical judgement, but they provide no empirical data or criteria for measuring their effectiveness. These explicit models rely on considerable expertise in the fields of behavioral science and theology—skills many chaplains and pastors do not possess. They are only as good as the clinician administering them and do not provide inter-rater reliability or validity.

Fitchett's Assessing Spiritual Needs35 outlines four models of spiritual assessment. In addition to his own 7 x 7 model and Pruyser's model, he reviews Elisabeth McSherry's Spiritual Profile Assessment (SPA) and the model developed by the North American Nursing Diagnosis Association.36 All four are explicit models, but only McSherry's SPA provides the kind of empirical data and objective information called for by VandeCreek37 and Larson and Larson.38

The spiritual assessment program described in this manual relies on and is heavily influenced by the work of Elisabeth McSherry.39, 40, 41 Her Spiritual Profile Assessment uses Kasl's Religiousity Index,42 Rokeach's Ultimate Values Test,43 and Holmes' Personal Health Inventory,44 which has been modified by Westberg's Spiritual Stressor Tally. Because religious faith and spirituality were not given adequate attention in the Holmes/Raye Scale, Granger Westberg added 5 additional questions dealing with religion and the spiritual dimension in a person's life.

The first modification made to McSherry's SPA is the contribution made by Harold Koenig.45 In assessing the spiritual resources of older persons, Koenig has added to Kasl's index non-organized religious activity, including the frequency of prayer, Bible reading, and religious programming on TV or radio. He refers to Kasl's frequency of church attendance scale as Organized Religious Activity (ORA). Prayer, Bible reading, and TV/radio religious programming he refers to as Non-organized Religious Activity (NORA). A final modification to McSherry's SPA includes an item from Hoge's Intrinsic Religious Motivation Scale46 that asks for agreement or disagreement with the statement that "my faith involves all of my life." The Total Religious Index Score then includes the ORA scale, the NORA scale, two questions from the Kasl index that measures a person's subjective attitude towards religion, and Hoge's statement regarding the inclusive nature of religious faith. The two questions from the Kasl index ask how religious a person is and how much strength or comfort one receives from one's religion. A total of these seven questions give information about a person's religious faith and practice.

This spiritual assessment also uses the Holmes/Westberg Personal Health Inventory as it is published in McSherry's SPA. One additional item added to this inventory is a question addressing the issue of sexual and/or physical abuse. A question asks if sexual or physical abuse has ever been experienced. If this question is answered positively, then three additional questions ask about military sexual trauma, if the abuse has happened in the past two years, and if the person is currently in an abusive relationship. The issue of abuse is an item pastoral counselors and chaplains cannot afford to ignore.

With several modifications, the final scale included from McSherry's SPA is Rokeach's Ultimate Values Test. Church and faith are separated as individual values because organized religion and faith do not automatically go together. "Knowing and Loving God" has been modified to "knowing God's love," and "meaningful life" is also added as a value.

Two other indexes are included in this assessment model that are not included in the SPA. The first is a Spiritual Injury Scale (SIS) or Index. This scale includes the following eight items: 1) guilt, 2) anger or resentment, 3) grief or sadness, 4) lack of meaning or purpose, 5) despair or hopelessness, 6) feeling that God/life has been unfair, 7) religious doubt or disbelief, and 8) fear of death. These eight items are rated on a 4-point Likert scale measuring never, sometimes, often, and very often. These spiritual injuries will be explained in greater detail in chapter 6.

The final concern for chaplains covered in the first version of this model asked five questions related to advance directives. With the Patient Self-Determination Act now in place in all hospitals, an opportunity was afforded chaplains to become involved in counseling patients regarding health care decisions and in providing information and education as to what a person's rights and responsibilities are. These questions have now been eliminated from this spiritual assessment because each State has its own unique forms for filling out advance directives and this important issue is now addressed by other disciplines in the healthcare field. Chaplains do, however, need to be versed in the Patient Self-Determination Act so they can provide spiritual support and guidance to patients and their families as they make health decisions for themselves.

Notes

30 George Fitchett, Assessing Spiritual Needs (Minneapolis: Augsburg Fortress, 1993).

31 Ibid., pp. 12-14.

32 Larry VandeCreek, "Measuring the Spiritual Needs of Hospital Patients and Their Families," The Journal of Pastoral Care 46 (1), pp. 46-52.

33 Pruyser,Ibid.

34 Fitchett,Ibid., pp. 39-51.

35 Ibid.

36 Fitchett,Ibid., pp. 105-129.

37 Larry VandeCreek, A Research Primer for Pastoral Care and Counseling (Journal of Pastoral Care Publications, Inc. 1988) pp. 7-8.

38 Larson & Larson, Ibid., pp. 37-38.

39 Elisabeth McSherry, Daniel Kratz, and William A. Nelson, "Pastoral Care Departments: More Necessary in the DRG Era?", HMR Review, Vol. 11, No. 1 (1986: Aspen Publishers, Inc.) pp. 47-59.

40 Elisabeth McSherry, "The Need and Appropriateness of Measurement and Research in Chaplaincy: Its Criticalness for Patient Care and Chaplain Department Survival Post 1987," Journal of Health Care Chaplaincy, Vol. 1, No. 1 (Fall/Winter 1987: Haworth Press, Inc.) pp. 3-41.

41 Elisabeth McSherry, "Modernizatgion of the Clinical Science of Chaplaincy," "The Chaplain As Educator to Modernized Theological Schools," and "Economic Impact of Chaplaincy on the Hospital Environment," The CareGiver Journal: College of Chaplains, Vol. 4, No. 1 (August, 1987).

42 Dianna M. Zckerman, S. Kasl, and A. Ostfeld, "Psychological Predictors of Mortality Amoung Elderly Poor: The Role of Religion, Well-Being and Social Contracts," American Journalof Epidemiology 119 (1984) pp. 410-423.

43 Milton Rokeach, The Nature of Human Values (New York: The Free Press, 1973).

44 Thomas H. Holmes and Richard H. Raye, "The Social Re-adjustment Rating Scale," Journal of Psychosomatic Research 11 (1967) pp. 213-218.

45 Koenig, et al., Ibid.

46 D. R. Hoge, "A Validated Intrinsic Religious Motivation Scale," Journal for the Scientific Study of Religion 11 (1972) pp. 369-376.

Chapter 4 - A Targeted Assessment Program Addressing Spiritual Needs

The first step in the spiritual assessment process is to gather specific demographic information. Such information is helpful in developing profiles related to age, ethnicity, military status and to keep from confusing persons when data is gathered on a large cohort of individuals in a database or in a clinic or medical center setting.

After gathering demographic information that includes gender, race, marital status, and educational level and military status, the first spiritual assessment question asked is How often do you attend religious services? Possible choices are never, major holidays only, more than four times a year, weekly, and more than once a week. The answer given to this question corresponds to the Organized Religious Acitivity (ORA) Score on the patient's printout. A score of 1 means the patient never attends church, synagogue, or religious ceremonies. A score of 5 indicates ORA is high.

Follow-up questions pertaining to religious practices and its importance include:

  • Aside from how often you attend regular religious services, do you consider yourself to be:
    • Against religion
    • Not at all religious
    • Only slightly religious
    • Fairly religious
    • Deeply religious

The next question asked is:

  • How much is religion (and/or God) a source of strength and comfort to you?
    • Not at all
    • Slightly
    • Quite a bit
    • A great deal

The assessment then asks for a response to the following statement:

  • My faith involves all of my life
    • Strongly Agree
    • Agree
    • Disagree
    • Strongly Disagree

These three questions make up the Subjective Religious Score. Combining these three scores gives a low score of 3 with a possible high score of 13.

The next three questions score the patient's Non-organized Religious Activity (NORA). They ask:

  • How often do you privately pray?
    • Never
    • Occasionally (at least once a week)
    • Regularly (once a day)
    • Frequently (twice a day or more)
  • How often do you read the Bible or other religious literature?
    • Never
    • Occasionally (at least once a week)
    • Regularly (once a day)
    • Frequently (twice a day or more)
  • How often do you listen to religious programs on the radio or TV?
    • Never
    • Monthly
    • Weekly
    • Once a day
    • Twice a day or more

These three indexes make up the NORA Score. The minimum score possible is 3. The maximum score is 13.

These three indexes, the ORA, the NORA, and the Subjective Religious Score, make up the Total Religious Index or Score. The range of possibilities is a low score of 7 and a high score of 31. This score is automatically computed by the program and is listed on the View screen and printouts as the Total Religious Score. This number gives a summary of religious resources the patient has at his or her disposal.

The next question asked assesses the patient's ultimate values. It is Rokeach's Ultimate Values Test42 as already modified by McSherry. Four additional changes have been made. McSherry lists "Faith and Church" as a single category. (A 1990 Gallup survey revealed "Faith" as the number one value listed by Americans; 40% placed it at the top of their list.) Faith cannot, however, be equated with organized religion. While church attendance and faith in God are highly correlated, many respondents to the assessment rely upon God for support in their lives and rank high on non-organized religious activity without ever going to church or participating in religious services. For this reason faith and church have been separated.

A second change has to do with the value "knowing and loving God." The value carries with it the imperative "should" or connotes "oughtness." This has been changed to "knowing God's love." The difference is declarative. God is the initiator; I am the recipient of God's grace. God comes to me. A Quality Assurance study that has been repeated several times on a chemical dependency program by a significant number of patients ranks "knowing that God loves and is concerned for the patient" as being the most important task the chaplain has to communicate and demonstrate to the hospitalized patient. From the Christian perspective, Karl Barth has said that the essence of Christianity is contained in the children's song, "Jesus loves me, this I know; for the Bible tells me so." "God is love"43 is a more profound concept and ultimate value than my love for God, which at best is often partial, frequently fickle, and sometimes absent.

The third change is the addition of "meaningful life" as an ultimate value. Douglas John Hall44 identifies the anxiety of meaninglessness as the "regnant anxiety" of our age, that it expresses itself in both an overt and covert nihilism that is the result of a massive loss of meaning.45 Hall further states that "to profess Christian faith today is to confess the meaningfulness of existence."46 Because a meaningful life is an ultimate value provided by religious faith, it has been added to Rokeach's list of values in this assessment.

The fourth change add the category of "sexual fulfillment." This value was added because of the pervasive emphasis and importance placed on sexuality in marketing and in our culture.

The Ultimate Values Test lists the following values and asks the person completing the assessment to rank these values in terms of their importance. It asks for a person's top three values. The choices are as follows:

  • Church
  • Comfortable Life
  • Equality
  • Exciting Life
  • Faith in God
  • Family Harmony
  • Financial Security/Wealth
  • Freedom
  • Friendship
  • Good Health
  • Happiness
  • Inner Harmony
  • Knowing God's Love
  • Marital Relationship
  • Meaningful Life
  • Personal Salvation
  • Religious Community or Tradition
  • Self Respect
  • Sense of Accomplishment
  • Sexual Fulfillment
  • Social Recognition
  • Wisdom
  • World at Peace
  • World of Beauty

After selecting one's ultimate value from the list above, the patient is then asked to select his or her second and third highest values from the same list. The three values appear on the printout as:

  • The patient's highest value is __________
  • The patient's second highest value is __________
  • The patient's third highest value is __________

The next section of the spiritual assessment is a scale developed by the author of this manual entitled Spiritual Injury Scale47 or SIS. It may be referred to as a religious pathology index. It focuses on the disfigurements of the soul that often cause hurting individuals to seek help, either from the church, from pastoral counselors, or from mental health professionals. It is an area that chaplains and pastoral counselors need to claim as their area of expertise and need to develop skills and sensitivity in providing treatment. These are areas that are often poorly handled by mental health professionals with no background or training in theology or spiritual direction. They are areas with a long and rich tradition in the history of spiritual care and religious healing.

A Spiritual Injury is our response to an event caused by self, or an event beyond our control, that damages our relationship with God, self and other, and alienates us from that which gives meaning to our lives. The word injury is intentionally used. Other words such as spiritual distress, wound or hurt could have been chosen. As in an accident where bodily injury is sustained, the injury can be self-inflicted or caused by self intentionally or carelessly, or the injury can be caused by no fault of our own. Such events beyond our control are often fatalistically labeled acts of God. An automobile accident caused by someone else's mistake also falls under the category of an event beyond our control. And just as physical injury tears at or destroys bodily tissue, so spiritual injury destroys or weakens spiritual tissue. Our connectedness to God, other or self is weakened, damaged or destroyed. The word injury carries with it a moral or ethical dimension, as in injury to one's reputation. It is a word that is also used interpersonally, as in an injury to his or her pride. The concept of spiritual injury therefore connotes a personal, interpersonal, moral and sacred dimension missing in bio-psycho-social explanations of human behavior.

Since this manual was first published in 1992, and initial research was conducted on spiritual injuries, the category of moral injury has evolved. Johnathan Shay says that three things must be present for moral injury to occur: 1) a betrayal of what is right, 2) by someone who holds legitimate authority, 3) in a high stakes situation.48  Shira Maguen and Brett Litz follow up on Shay's understanding of moral injury, only instead of betrayal by someone who holds legitimate authority, they define it as self-betrayal. They define it as "an act of serious transgression that leds to serious inner conflict because the experience is at odds with core ethical and moral beliefs."49 It is "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations."50 My definitions of spiritual injury is congruent with this last definition (see Figure 2a in Chapter 6 of this manual), only I understand spirituality as an umbrella that includes morality, but is broader in scope. Spirituality embraces morality which relates to our relationship with sentient and non-sentient life, while spirituality includes our connectedness to the divine or what Tillich refers to as the Ground of our Being.

As noted in Chapter 3, the 8 spiritual injuries are 1) guilt, 2) anger or resentment, 3) grief or sadness, 4) lack of meaning or purpose, 5) despair or hopelessness, 6) feeling that God/life has been unfair, 7) religious doubt or disbelief, and 8) fear of death. These items will be described in greater detail in Chapter 6.

The next section of the assessment focuses on these 8 spiritual injuries. The first spiritual injury is guilt. Its significance as a problem is measured with the 4-point Likert scale. The person taking the assessment is asked, How often do you feel guilty over past behaviors? Possible answers include never, sometimes, often, and very often. This question is illustrated on the following screen.

The next seven questions are:

  • Does anger or resentment block your peace of mind?
    • Never
    • Sometimes
    • Often
    • Very often
  • How often do you feel sad or experience grief?
    • Never
    • Sometimes
    • Often
    • Very often
  • Do you feel that life has no meaning or purpose?
    • Never
    • Sometimes
    • Often
    • Very often
  • How often do you feel despair or hopeless?
    • Never
    • Sometimes
    • Often
    • Very often
  • Do you feel that God/life has treated you unfairly?
    • Never
    • Sometimes
    • Often
    • Very often
  • Do you worry about your doubts/disbelief in God?
    • Never
    • Sometimes
    • Often
    • Very often
  • How often do you think about death?
    • Never
    • Sometimes
    • Often
    • Very often

The possible range of scores that a person can realize is a low score of 8 and a high score of 32. This score appears on the printout along with the individual spiritual injuries that are often or very often problematic for the person completing the assessment.

The reason for including these pastoral concerns grows out of two experiences. First, these are the kinds of issues that are often addressed in 5th Step counseling. Guilt, fear, resentment, hope, faith, and purpose in life are issues that often become the focus of attention during the 5th Step process. Spiritual assessments and inventories in treatment programs often address these issues, but usually respond to them using narrative statements or check-off blanks that do not lend themselves to quantitative analysis. These are the issues often burdensome to patients seeking treatment in mental health centers and treatment programs. They are also topics that persons with chronic illness, pain and critical illness struggle. Seemingly these are some of the issues that bring patients into the hospital outpatient clinic and need to be addressed as part of treatment.

A second reason for including spiritual injury issues as part of an assessment grows out of the hypothesis that high SIS scores correlate with high medical costs. Data gathered by this assessment can be used to determine if lengths of stay in the hospital, for example, will be positively correlated with high SIS scores. A hypothesis that is now being studied is that health care resources consumed, i.e., length of stay, recidivism, cost of drugs, and other medical care costs are positively correlated with higher SIS scores. Anything that can reduce SIS scores will therefore have a positive contribution to make in containing health care costs and to promote healing. One study focusing on costs found that spiritual injuries were significantly correlated to length of stay in an in-patient mental health setting and therefore were associated with additional healthcare expenditures.51

An additional hypothesis in need of research that can also be measured by this spiritual assessment model is that good health is correlated with low SIS scores. A study using a control group of non-hospitalized persons living in the community will be needed to conduct this research. These and additional research issues are waiting to be addressed by pastoral counselors. The outcome of such studies will determine the role chaplains and pastoral care givers play in the evolving health care system in the United States. The impact of these studies will play a much larger role in the survival and growth of spiritual care programs than all of the political advocacy efforts that have received widespread attention in recent years.

The next 57 questions ask about losses or changes in a person's life pertaining to significant issues people face. Each question relates to the Holmes/Westberg Personal Health Inventory Scale. These questions are as follows requiring a yes or no response:

The first question asked is in the past two years have you experience the Death of a close friend or family member? The following 19 questions asked relate to personal events or change:

  • Personal injury, illness or hospitalization?
  • Pregnancy (or pregnancy of spouse or significant other)?
  • Loss of self-confidence?
  • Outstanding achievement (graduation, promotion, etc.)?
  • Change in eating habits?
  • Change in sexual activity?
  • Change in sleeping patterns?
  • Change in energy level?
  • Considered suicide?
  • Change in religious belief or practice?
  • Stress related to vacation?
  • Change in relations with parents?
  • Change in recreational time or activity?
  • Trouble with the law?
  • Change in time schedule?
  • Change in drinking behavior?
  • Change in smoking behavior?
  • Change in drug use?
  • Have you ever been physically or sexually abused?

The last question addressing the issue of physical and sexual abuse is not contained in the Holmes/Westberg Inventory. It has been added with a score assigned to it of 75 points. The weight assigned to this issue is second to the death of a spouse (100), equivalent to death of a close friend or family member and just above divorce (73). This item has been added to this loss/live change inventory because it is an issue pastoral counselors and chaplains need to assess for and address.

If the person taking the assessment answers yes to the question of physical or sexual abuse, three additional questions are asked. The first additional question states: If you were in the military, did the abuse happen during military service? The third question about abuse asks, Did the abuse happen during the past two years? This question coincides with the other questions in the inventory, which also ask if individual stressful events happened in the past two years. If the person completing the assessment answers yes to this question, then a follow-up question asks, Are you currently in a physically or sexually abusive relationship? The intent of these questions is to make counseling a part of the pastoral care plan if abuse was historical. If abuse is current it needs to be addressed in terms of intervention for the safety of the person involved. Male chaplains, pastors and pastoral counselors who work with female victims of abuse need to refer or closely collaborate with female colleagues and therapists in treating this sensitive issue.

The second section of the Holmes/Westberg inventory pertains to the marital relationship. Questions asked in this section are:

  • In the past two years have you married?
  • Divorced?
  • Separated?
  • Become widowed?
  • Started or ended living together?
  • Disagreements over money management?
  • Increased emotional distance?
  • Trouble with in-laws?
  • Spouse beginning or stopping work or school?

The third section of the Holmes/Westberg inventory asks questions about household events:

  • Family member left home?
  • Gain a new member (birth, parents moving in, etc.)?
  • Spouse at home more than before?
  • Problems with children at home?
  • Change in residence?
  • Remodeling or building?
  • Change in health, behavior, or attitude of a member of the household?
  • Change in neighbors or neighborhood?

The fourth part of the Holmes/Westberg inventory focuses on vocational events:

  • New job, or new line of work?
  • Quit job?
  • Retired from job?
  • Fired from job?
  • Laid off?
  • Promotion?
  • Demotion?
  • Disabled?
  • Less job security?
  • Trouble with work associates?
  • Change in hours, conditions, travel, etc.?

The fifth section asks questions regarding financial change:

  • Changes in financial state (better or worse)
  • Major mortgage or loan taken out?
  • Foreclosure of mortgage or loan?
  • Significant credit card debt?

The last question addressing credit card debt was not in the Holmes/Westberg inventory. It has been added because of the commonality of the problem and is something that needs to be addressed in a holistic approach to meeting human needs.

The final section is the result of Granger Westberg's contribution to the more familiar work of Holmes. It contains the following 5 questions under the heading spiritual dimension:

  • Change in relationship with God?
  • Change in church activity or prayer life?
  • Significant spiritual experience?
  • Spiritual emptiness?
  • Constant feeling of guilt or anxiety?

The weight given to each item in the Holmes/Westberg Inventory is listed in the appendix to this program. When scores are added up they are attached to the assessment summary. If the computerized version of this assessment is utilized this summary is contained in the individual Spiritual Assessment Printouts for each section of the Holmes/Westberg Inventory. An example of such a printout summary follows:

  • Personal events score is 273
  • Marital relations score is 60
  • Household events score is 32
  • Vocational events score is 0
  • Financial events score is 38
  • Spiritual dimension score is 89
  • Total loss/life change or stress score is 492

Again, if the computerized version of the assessment is being used, these scores are automatically computed and are readily available to the chaplain or clinician immediately after the patient has completed the Spiritual Assessment Program. Appendix B at the end of the manual summarizes the scores assigned each individual item on the Holmes/Westberg Personal Health Inventory scale.

Notes

42 Rokeach, Ibid.

43 1 John 4:9.

44 Douglas John Hall, Thinking the Faith: Christian Theology in a North American Context (Minneapolis: Augsburg, 1989) p. 92.

45 Hall, Professing the Faith: Christian Theology in a North American Context (Minneapolis: Augsburg, 1993) pp. 290-295.

46 Ibid., p. 290.

47 Ron Lawson, Charles Drebing, Gary Berg, Scot Jones & Walter Penk, The Spiritual Injury Scale: Validity and Reliability (Edith Nourse Rogers VA Medical Center, Bedford, MA: Unpublished Research).

48 Johnathon Shay (March 9, 2012) Moral Injury [video] Retrieved from https://www.youtube.com/watch?v=XBkCg6_ISpQ

49 Shira Maguen & Brett Litz, (2012) Moral Injury in Veterans of War. PTSD Research Quarterly, 23 (1) 1-3.

 50 Brett Litz, et al., (2009) Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706.

51 Berg, et al., Ibid., (1995).

Chapter 5 - Spiritual Injury 

Spiritual injury was defined in Chapter 4. That definition stated that a Spiritual Injury is our response to an event caused by self, or an event beyond our control, that damages our relationship with God, self and other, and alienates us from that which gives meaning to our lives. Because of their importance for pastoral care and counseling, spiritual injuries or disfigurements of the soul warrant further attention and comment. And no one is better equipped than the pastoral or spiritual counselor to address these needs. This chapter describes each individual injury and will suggest resources by which they can be addressed.

Guilt

In addressing the issue of guilt, I will use as a case study the guilt suffered by many veterans, particularly those who faced combat in Vietnam. There are two reasons for this choice. First, much of the background for the development of the SIS originated in work done in a VA Medical Center with many veterans who served in Vietnam. Nearly 4,000 veterans who have completed this inventory identify guilt as the number one spiritual injury they struggle with. Secondly, if guilt can be addressed at the level experienced in the chaotic evilness of war, lesser expressions of its existence can more easily be faced. In tackling a worst case scenario, then the more ordinary examples we experience in daily life will not be so bewildering. The difficulty in this approach is that we can too easily distance ourselves from war if we have not experienced it, and fail to identify with the spiritual pain felt by those who understand how persistent and destructive guilt caused by war can be.

Arthur Egendorf, in writing about healing the trauma of war, defines guilt as "a catch-all term for the feeling that emerges from our belief that by virtue of something we've seen, done, or lent support to, we are unworthy or unclean."49 William Mahedy, a chaplain in Vietnam and authority on PTSD and its treatment, writes as follows concerning guilt:

Among the painful legacies of Vietnam--loss of religious faith, rage directed against God, fundamental moral questions unresolved, pervasive cynicism--one in particular is found in almost all the stories: guilt.

Guilt has a bad name in our society. It is usually associated with unwanted and unpleasant feelings, anxieties arising from our inability to cope with our own drives and ambitions. We deal with guilt by assuring ourselves--often through some form of therapy--that guilt is an inappropriate feeling, a harmful by-product of a "punitive superego." To deal with guilt, we simply convince ourselves that we're "okay" people and then go about the business of living. But guilt reaches more deeply into the human soul than our society is willing to admit. Guilt sometimes arises from our awareness that we have, in fact, participated in evil, that we have violated conscience and acted against moral standards we had previously accepted as valid.52

Peter Marin, writing in Psychology Today, states that "the unacknowledged source of much of the vets' pain and anger: profound moral distress, arising from the realization that one has committed acts with real and terrible consequences. And the second is the inadequacy of the prevailing cultural wisdom, models of human nature, and modes of therapy to explain moral pain or provide ways of dealing with it."53 In the same article Marin quotes Shad Meshad, on of the initiators along with William Mahedy of the Vietnam Veterans Outreach Program, who puts it this way:"We aren't just counselors; we're almost priests. They come to us for absolution as well as help."54 Again, quoting from Marin: "We seem as a society to have few useful ways to approach moral pain or guilt; it remains for us a form of neurosis or a pathological symptom, something to escape rather than something to learn from, a disease rather than—as it may well be for the vets—an appropriate if painful response to the past. As if he were reading my thoughts, a VA psychologist told me that he and his colleagues never dealt with problems of guilt. Nor did thy raise the question of what the vets did in the war: ‘We treat the vets' difficulties as problems in adjustment.'"55

A feeling closely related to that of guilt is shame. Shame is often associated with just being as opposed to what one has done. In this sense it is judged negatively, as false guilt, as blame that is undeserved; it is associated with low self-esteem, embarrassment, and self-consciousness. It is in this sense that Aldous Huxley defines it. "Shame isn't spontaneous…it's artificial, it's acquired. You can make people ashamed of anything. Agonizingly ashamed of wearing brown boots with a black coat, or speaking with the wrong sort of accent….The Christians invented it, just as the tailors in Savile Row invented the shame of wearing brown boots with a black coat."56 In contrast to Huxley's rather superficial understanding of shame, Dietrich Bonhoeffer's analysis interprets it as alienation, as estrangement, as humans perceiving themselves as being in disunion with God and with other human beings. As in the Garden of Eden story, we perceive ourselves as standing naked before God and perhaps as intuited by other human beings. Others can see through us. "For noting is covered up that will not be uncovered, and nothing secret that will not become known." "57 Man (sic) is ashamed because he has lost something which is essential to his original character, to himself as a whole; he is ashamed of his nakedness…ashamed of his loss of his unity with God and with other men…. Man feels remorse (guilt) when he has been at fault: and he feels shame because he lacks something,"58 because he has lost something. An example of this existential alienation is the experience of combat veterans. What has been lost is innocence. As one combat veteran explained it, as a senior in high school he had read William Golding's Lord of the Flies.59 When he first read it, it had little impact on him and was divorced from his own experience. When he returned from war, he read the same book again, only through different eyes. He had come to understand the truth about human evil in a more penetrating and prophetic way. Using Bonhoeffer's analysis of shame and guilt, combat veterans found themselves in a double bind. If they refused to follow orders or avoided being a participant in war, they felt guilty for betraying the law of the land or the military code of conduct. But to follow such orders put them in conflict or disunion with a more fundamental principle of Divine will. Their choice was between guilt and shame. "Shame is man's (sic) ineffaceable recollection of his estrangement from the origin; it is grief for this estrangement, and the powerless longing to return to unity with the origin." 60

While the initial research that encouraged the development of the Spiritual Injury Scale was done with combat veterans, their experience with guilt and the double bind they find themselves in is also experienced by others. It is most certainly experienced by those spiritually sensitive souls who can read the signs of the times. More than in words spoken in sermons or books written by behavioral scientists (this last group often participate in the denial process by teaching us how to detach, to feel good about ourselves as though it were possible when others suffer, often because of our own way of life), the pervasive sense of shame and guilt are often most powerfully depicted in literature and the arts. Human estrangement and alienation are the themes of such authors as Tennessee Williams, Eugene O'Neill, John Updike, John Hassler and William Golding, who has already been mentioned. We are caught between shame and guilt; if we don't pursue the symbols of success and accomplishment that our culture portrays as desirable, we feel guilty for not "being what we can be" or not giving to self and family those possessions that symbolize "the good life." When the heavy hand of guilt is avoided and we have arrived by achieving success, we somehow sense estrangement and disharmony with our Creator and spiritual life at its most fundamental level, resulting in conscious or unconscious shame, for success is often purchased at someone else's expense. This is most evident at the materialistic and environmental level. The excesses, the by-products, and waste from an affluent and powerful society have global consequences. Death to children and innocent civilians do not only happen in war at the barrel of a gun; it happens, for example, in the cold and frequent open war between the sexes in which unwanted and disposable children are the end result. It happens environmentally and economically. This theme of interdependence and of suffering and poverty in some parts of the globe being the consequence of exploitation and success elsewhere is a dominant motif in liberation and contextual theology. "The underdevelopment of the poor countries, as an overall social fact, appears in its true light: as the historical by-product of the development of other countries."61 Douglas John Hall echoes the same theme, only in a First World context:

To do theology anywhere in the first World today means to suffer. Precisely in those parts of the world where humanity still regularly congratulates itself on its high achievements, Christians are required to suffer--to permit--dark thoughts to enter their consciousness. They are called to this cruciform vocation, not out of any fascination with the negative, but because the rhetorical positive lauded by the image makers of the First World is sustained at an inestimable cost to millions of God's beloved creatures, human and extrahuman, and threatens the future of the planet itself. In the midst of societies that are "First," someone has to remind the human species that the first may well be last.62

Spiritually, self-accusation may be a more legitimate stance than self-justification; a guilt-free or shame-less existence may no longer be a possibility for the spiritually sensitive.

In writing about justification and healing the wound of guilt, Bonhoeffer states that first guilt must be confessed. He speaks not of guilt for individual acts or deeds, but in terms of being estranged and alienated from the Ground of Being, using Tillich's terminology, and from one another. Bonhoeffer also does not individualize reconciliation and forgiveness, but understands it as a communal endeavor by the community of faith to restore humankind's essential nature. It is accomplished not by rationalizing and justifying guilty behavior, as though that were possible, and not by restitution--who among us can restore life, for that is what has been destroyed--but by confession, and then throwing one's life "on the mercy of the bench." Only in this instance the bench is not human with all of the limitations and imperfections that implies, but a willingness to stand naked before the One who has created us, and can create of us anew. Unconditional love and acceptance, i.e., forgiveness, is the answer implied in the human question of estrangement, alienation, and guilt. It is the only power that can overcome the experience of shame as understood by Bonhoeffer, as separation, estrangement, alienation and a distancing from the Ground of our Being who is commonly known by the name God. Bonhoeffer speaks of healing as a "cicatrization of guilt,"61 which means to heal with the formation of a scar. This word image from medicine is suggestive. A wound can heal only after the foreign object is removed, only after that which has caused the injury is eliminated, the sore is bathed, the infection is destroyed, the sore is cleansed, purified, disinfected. "This forgiveness within history can come only when the wound of guilt is healed, when violence has become justice, lawlessness has become order, and war has become peace."64

Arthur Egendorf says much the same thing when he writes that "nothing in the repertoire of psychological techniques and philosophical arguments I knew came close to the power of forgiveness. Only ‘I forgive you' has the potency to put an end to the recriminations and self-recriminations once and for all."65 But then, writing as a combat veteran, he offers up the profound insight: "but what in us has the right to forgive? What in us has the power to shift so profoundly our relationship with the facts of what we've lived through? I couldn't answer. The question pointed to impossibility: Only a saint or a megalomaniac could forgive the kind of horrors I knew."66 He then offers a suggested way out by indicating that atonement can be found in service,67 that we need a mission in life, and that the warriors mission to kill and destroy must be transformed into the mission to heal. Humankind is called to a vocation greater than the individual self. This is a theme that echoes Paul Pruyser's pastoral diagnostic category of vocation.68 "Forgiving others, taking vows to uplift ourselves, or giving our lives to service, to God, or to some other cosmic passion, are all ways to draw on a power that emerges as we pursue healing."69 This theme of being a warrior and having a mission is a motif that increasingly runs through the literature of what is known as the "men's movement."

The means by which guilt is addressed by religious faith and its institutions include not only counseling and the acceptance by the pastoral counselor, but also the rituals of healing that are central to religious worship. Corporate worship, which includes confession, absolution, baptism, Holy Communion or The Eucharist, hymnody, Creeds, prayers of intercession, and blessings all focus on reconciliation, restoration, cleansing, forgiveness, and healing. The corporate nature of these rituals have symbolic power that transcends a one-dimensional understanding of their efficacy. Church attendance and regular participation in corporate worship has a healing effect on those who participate in it as is being demonstrated by data gathered from this assessment process.70

The healing nature of religious rituals extends beyond the dominant forms of worship known to the majority culture. The rituals of Native American Traditional Religion focus on healing. The Pipe Ceremony, the Sweat Lodge, the Making of Relatives, the Sun Dance, and the Spirit-Calling Ceremony all center on healing, renewal, and restoration. Looking at one tradition and its rituals from a different perspective or culture often brings with it a sense of appreciation and new understanding of the importance of both traditions and their similarities.

In addition to pastoral counseling and worship as resources for forgiveness in addressing guilt, several other resources come to mind. The authors who have already been named are one source of help. They include Bonhoeffer, Mahedy and Egendorf, who have already been cited; these last two writers specifically address issues related to war and its consequences. AA literature, especially books and pamphlets that focus on the 4th and 5th Steps, also address guilt issues. Books by Paul Tournier,71 O. Hobart Mowrer,72 and Karl Menninger73 address guilt from the perspective of psychiatry and psychology. In addition, Paul Pruyser's pastoral diagnosis category of repentance give pastoral counselors and chaplains ample insight into addressing the issue of guilt with clients and people they counsel.74 A book that includes exercises for addressing guilt is To Forgive Is Human: How to Put Your Past in the Past.75 An increasingly popular pastoral care tool are pamphlets such as Abbey Press's CareNotes.76 CareNotes that focus on guilt and forgiveness include Overcoming Guilt—With Faith and Love, Feeling Like a Sinner, Growing Through Failure, and Learning to Forgive Yourself.

When addressing the issue of guilt in counseling, the chaplain, pastoral care giver or spiritual director needs to ask what it is that the counselee feels guilty about. Specificity is important. Ask who, what, where, and when the behavior or event happened that is the focus of a person's guilt and remorse. Context is important. Guilt is not just or only a feeling; it is real and needs to be respected and not minimized nor discounted. While guilt can be distorted, exaggerated or based on a false sense of reality, it can also be reality based where harm is done to self or others. Counselees may avoid talking about the specific actions leading to guilt, especially when associated with shame. This increased the need to be specific and to explore the origins of what leads to guilt. Its basis can be moral injury, which will be further discussed later in this chapter.

Anger and Resentment

The second Spiritual Injury issue on the assessment is anger. It is also related to the issue of guilt and is highly correlated with it, perhaps because its expression may lead to behaviors that later cause guilt and remorse.

Spiritually anger expresses itself as anger towards God, perhaps as turning one's back on God or breaking off relations with a faith community or church. Of the 8 spiritual injury issues listed on the SIS, initial findings indicate that anger is most highly correlated with the Holmes/Westberg Loss/Life Change Index. This may mean that either anger burns bridges and leads to loss and relationships being broken off, or that anger, as was the case with Job, is an individual's response to circumstances beyond one's control. Significant disruptions and losses in a person's life bring about resentment and anger. This includes rage and bitterness towards God that needs to be addressed by the pastoral counselor.

Just as anger is correlated with guilt, it is also highly correlated with depression. I will leave it up to clinical psychologists to judge whether depression is anger turned inward or not; regardless of the relationship, both depression and anger are serious pastoral care issues that need to be addressed. Significant relief is achieved by allowing a counselee to tell their story and pour out the hurts and spiritual trauma that may have led to the anger. Anger can and needs to be expressed in the safety of a therapeutic relationship. The Psalms give ample evidence of anger being poured out within the context of religious faith. But the invitation to be angry without addressing the injuries that give it birth may only escalate it rather than defuse it.

The religious answer to anger is forgiveness towards those who have hurt us. This spiritual response to injustice and hurt has been marvelously expressed in our time by Nelson Mandela, Martin Luther King, and Terry Anderson after his release from being held captive for four years in Lebanon. For Christians, the paradigm of this spiritual maturity and behavior is Jesus. It is also evident in the life of Dietrich Bonhoeffer and Eli Wiesel. The cross is the paramount symbol for Christians of transforming anger into a redemptive act of forgiveness and love; it is a reminder of the cruciform nature of life and the role suffering plays in redemption.

Resources available to chaplains include the Al-anon program and literature, particularly as it applies to resentment. AA's slogan, "Let Go and Let God" also addresses the issue of anger. While the spiritual challenge of guilt is to receive forgiveness, the challenge of anger is to give forgiveness. McCullough addresses both aspects of forgiveness in To Forgive Is Human: How to Put Your Past in the Past. 77 A CareNote that addresses anger is "Dealing With Anger."

In addressing anger, it is again important that the counselor ask that the focus of a person's anger be specific and made concrete. Has the expression of anger in the past led to either trouble with the law or in injury to another? Or is it future oriented? Does the counselee fear or plan on acting out angry impulses and might the anger put someone else at risk of being harmed? In such instances an intervention may be warranted. And is the counselee presently in an abusive relationship, either towards another adult or a child? In some instances mandatory reporting may be required if physical or sexual abuse includes a child.   

Grief and Sadness

An article by James Pierce in The Caregiver Journal78 of the College of Chaplains indicates that people whose "score was above 300 were found to have illness or injury in 90% of the cases. Of the individuals that scored 350 to 400 points, 90% reported significant changes in their health status... (and) 85% of those scoring 500 or higher will within a year experience significant physical illness ranging from mild chronic conditions to heart attacks, onset of cancer, etc." The computerized version of this assessment gives the pastoral counselor immediate feedback as to the losses patients have experienced. A significant number of losses on the Holmes/Westberg Inventory as well as grief and sadness being identified by the person taking the assessment provide the chaplain with an avenue for providing grief counseling and support. These are issues chaplains and pastoral counselors are equipped to face with the patient. It is to be expected that any stress that can be reduced in this area will support healing and serve as a preventative measure in relapse and re-hospitalization. Significant losses do result in sadness and grief.

Resources available to chaplains include Elizabeth Kubler-Ross's book, Death and Dying,79 Granger Westberg's Good Grief,80 C.S. Lewis' A Grief Observed,81 and numerous Care Notes that can be given out to patients. This last resource includes "Finding Your Way After the Death of a Spouse," "Finding Peace With God After Losing a Child," "Losing Someone Close," "Walking With God Through Grief and Loss," and "When Grief Won't Go Away." Grief Therapy groups are also an important resource in the chaplain's toolbox.

When the immediate cause of grief is the death of a family member or close friend, the counselee needs ample time and support to talk about the loss and how one's life will now be changed. Often pastors and chaplains are the primary caregivers at the time of death. A primary resource for healing following a death of a loved one is the religious community itself, especially if the individual is significantly connected to a congregation, temple or mosque.

It is also important that the caregiver differentiate a grief reaction from depression. Grief is targeted to a specific event or loss. Depression is more generalized, may be long-standing and related to a multiplicity of life events. Depression may also have a biological component and need a medical response. In such incidences the chaplain, pastoral counselor or spiritual director needs to consult or refer the person she or he is cocunselling to a psychologist, psychiatrist or medical doctor.

Lack of Meaning and Purpose in Life

The importance of meaning and purpose in a person's life and the destruction it causes when it is missing has become apparent in research conducted with Vietnam veterans. This research is the basis for including this item on the SIS. The all too familiar phrase of many veterans returning from combat that "it don't mean nothin'" should have been a give-away that indeed it had meant everything. This sense of meaning was captured in the title of Al Santoli's oral history of the Vietnam War, Everything We Had.82 The "don't mean nothin'" became part of the denial system and psychological numbing characteristic of PTSD. The correlation that exists between PTSD and lack of meaning and purpose in life is .718.83 Research conducted by Alan Fontana and Robert Rosenheck indicates that veterans seeking help in a Veterans Administration Medical Center is driven by their guilt and their search for meaning and purpose to their traumatic experiences.84

Another barometer of the signs of the times having to do with lack of meaning and purpose is contemporary literature. Willie Loman in Arthur Miller's Death of a Salesman, Harry Angstrom in John Updike's Run, Rabbit, Run series, or T.S. Elliot's The Wasteland and The Hollow Men are classical expressions of people and culture adrift. Douglas John Hall writes that the dominant anxiety of modernity is meaninglessness and despair, and not guilt and condemnation. "A theology which offers tried and true remedies for the human anxiety of guilt and condemnation when the regnant anxiety is the anxiety of meaninglessness and despair is not theology."85

Undoubtedly, guilt and fear are still aspects of contemporary life in North America, for they seem to belong to the human condition; but they are certainly not our primary anxiety. None of the "signs of the times," whether our art, our social sciences, or our popular pastimes, betrays a people consumed by their guilt before God and the prospect of eternal damnation. Everything points to a different anxiety-type and, however it may be terminologically designated, it is certainly closer to what Tillich called "the anxiety of meaninglessness and despair" than to existential guilt before the eternal. We are not so much afraid that we do not measure up to a transcendent canon of human righteousness as that there are no transcendent standards of goodness, beauty, or truth beyond our own lingering desire that such standards might exist.86

A classical resource for dealing with meaninglessness, both from a diagnostic and therapeutic perspective, is the penetrating analysis offered by Victor Frankl.87, 88, 89 His Logotherapy understands human nature holistically and focuses its attention upon humankind's groping for a higher meaning in life. Meaning is also addressed in Pruyser's diagnostic category of vocation. He uses it not as a reference to job or career but more closely associated with its original meaning as calling. "I do not mean career choice or study goals, but a person's willingness to be a cheerful participant in the scheme of creation and providence, so that a sense of purpose is attached to his doings which validates his existence under his Creator."90 The conviction that life has meaning and purpose is ultimately a matter of faith, a topic religious counselors should not shy away from. Yet another resource for dealing with meaninglessness and spiritual emptiness is Helmut Thielicke's Nihilism91. Thielicke brought pastoral and theological care to a generation of the German people following World War II, who, like their American counterparts a generation later, also felt that "it don't mean nothin'" and who had despaired of life and its meaning. A CareNote the deals with meaning and purpose in life is "Trying To Live A Life That Matters."

The extent to which religious faith and regular participation in worship services do make a difference will increasingly become apparent as research is conducted using a quantifiable spiritual assessment instrument. Pastoral counselors and chaplains do have resources for addressing issues of meaninglessness and spiritual emptiness; a primary one being meaningful worship services attended by people seemingly adrift, but who are looking for direction and purpose in their lives.

Further resources for helping people clarify meaning and purpose in life is the writings of Stephen Covey. In both The 7 Habits of Highly Effective People92 and First Things First93 he provides practical resources for reflecting on and writing down a personal mission statement. Mission statements identify and help individuals articulate core values and beliefs and what purpose they serve. Rokeach's Ultimate Values Inventory, that is the basis for the values inventory contained within this assessment instrument also gives the pastoral counselor and chaplain a framework for addressing meaning and purpose in life with the counselee. When significant conflict exists between life experience and core values and beliefs, this tension will be apparent and manifest itself in heightened spiritual injury scores. This conflict will be obvious in reviewing the printout and observing the discrepancy between a person's three highest values in life and items identified on the Holmes/Westberg Personal Health Inventory. This dynamic will further be explained in Chapter 8 in addressing the issue of clinical pathways.

If the assessment instrument reveals that the counselee often or very often feels that life has no meaning or purpose, the caregiver needs to follow up on the nature of this spiritual injury. Can the counselee identify the origin or genesis of this malaise? Did he or she always feel that life has no purpose or meaning, or was there an event associated with such a paradigm shift in the person's life. It can be associated with a significant life change or adjustment such as the death of a child or significant other, a disability or a sense of failure in achieving a life goal or one's sense of mission in life. Life changing events such as war can easily shake the foundations of one's life. Veterans of the war in Vietnam, after experiencing the death of fellow soldiers or causing the death of others, often returned saying "it don't mean nothing." Nihilism, as well as anger, became their response to a war they found unjust, unnecessary and futile. The numbing of feelings symptomatic of PTSD often expresses itself as a loss of meaning and purpose in life. Sexual and physical trauma likewise can lead to this spiritual injury. The loss of religious belief and faith can also result in such a response to life and its events.

No one is as well equipped to deal with this spiritual injury as the spiritual counselor or chaplain who is well grounded in his or her own sense of
of meaning and purpose in life. It is the deep water that needs to be plumbed in our post-modern age that denies that life has any purpose or aim other than what we individually assign to it.

Despair

A spiritual injury issue closely related to lack of meaning and purpose is despair. John Douglas Hall94 and Paul Tillich95 both seemingly use the terms interchangeably. Classical expressions of despair are contained in the writings of St. John of the Cross in contemplating The Dark Night of the Soul96 and Soren Kierkegaard's The Sickness Unto Death.97 Mary Louise Bringle98 writes a contemporary expose' which contains a useful historical summary of how Christianity has responded and treated despair. William Mahedy addresses the issue from the vantage point of Vietnam veterans. In speaking of these young men and women whose average age was slightly over nineteen, he writes: "their religious and moral experience amounted to an unprecedented and totally unexpected deadening of the soul. The spirit went numb....A terrible bleakness had overwhelmed the soul....For great numbers of veterans, duty in Vietnam was a journey into spiritual darkness--the very darkest night of the soul."99 Martin Marty's A Cry of Absence100 addresses despair from the perspective of the Psalms.

Contemporary literature and the arts are equally rich resources for understanding despair in contemporary life. Mary Louise Bringle singles out Isabel in Mary Gordon's novel Final Payments, and Celie from Alice Walker's The Color Purple as two examples of women who are in despair.101 Libby, in Jon Hassler's novel, North of Hope,102 also gives us an anguished expression of despair.

Douglas John Hall, in a section to his theology titled, God lives, life goes on!, quotes at length from Samuel Beckett's The Unnameable. He states that the street metaphor going on —speaks to the contemporary forms of human anxiety and alienation.

In distinction from our 19th-century forebears, whose attitude towards life and the future enabled them to lace their rhetoric with terms like "challenge" and "adventure" and to name little towns on the western frontier of this great continent "Onward" and "Success" and the like, late 20th-century Homo sapiens asks whether it is possible to…"go on." Samuel Beckett's concluding lines in The Unnameable capture the mood of our epoch with characteristic sensitivity:

You must go on, I can't go on, you must go on, I'll go on…." It is this form of human experience with which, in the first World at least, Christian theology today must wrestle. The gospel must be expressed in such a way as to speak to this sense of psychic impasse, which today is as fully public as it is private.103

Certainly many of the patients pastoral counselors and chaplains meet up with, especially those chaplains ministering to the mentally ill and chemically dependent, are asking the question as to whether or not they can go on. Father Frank Healy, the priest in Jon Hassler's novel, North of Hope,104 is a believable character who does struggle spiritually to "go on." Paul Tillich describes this "going on" as the "courage to be."105 John Douglas Hall also speaks of courage as both a necessity and as a gift. "Whether we are speaking of the courage to love, or the courage to believe, or the courage to think and to confess our faith, it is the same thing. It is never effortless. Beginners in theology frequently expect to read works of Christian thought as if they were reading Agatha Christie. It may require wit to read Ms. Christie, but it does not require courage. Theology requires courage."106

Mary Bringle interprets healing as taking place within the context of confessionalism, courage, and community.107 The witness of AA gives evidence of confessionalism, courage in terms of surrender, and community as a resource for healing and recovery from alcoholism. This is the pattern all 12-Step programs follow. A CareNote that addresses despair is "When Your Spiritual Life Seems Empty."

Guilt, anger, grief and loss of meaning or purpose in life focus on the past or events that have already transpired. Despair is more future orient or the belief that what is ahead will turn out bad. There is no hope. It globalizes negativity and is pessimistic that anything good is going to happen. Rather than tackling all of life's problems at once and looking into the distant future, the counselor need to help the client focus on the near future and what can be done, sometimes one small step at a time. The serenity prayer is an reflection of this approach, God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference. Setting limited goals that are achievable, one day at a time, and then building on them is a way of "going on". 

The Unfairness of Life

A question that chaplains and pastoral counselors frequently face with the people they counsel or visit in hospital beds is: "Why me? What have I done to deserve this?" Paul Pruyser addresses this issue under the heading of Providence. He quotes psychoanalyst Ernest Jones who states: "What one really wants to know about Divine Purpose is its intention toward oneself".108 Pruyser suggests that pastoral conversation and counseling situations are laced with direct or indirect references to Divine Purpose and Will. Is this a just or an unjust universe, do things happen randomly, fatalistically, intentionally or accidentally? Attitudes of cynicism, hope, despair, fatalism, and gratitude are all reflections of how this question gets answered and worked out in daily life.

Popular attention has been given to this issue by Harold Kuschner in his book, When Bad Things Happen To Good People.109 Theologically the problem of evil is addressed as theodicy; both God's justice and love are challenged in the face of suffering and the enormous evil present from our perspective of the universe. It is a problem that pastoral counselors and chaplains cannot avoid facing with those whom suffer. Numerous resources do exist, however, for the pastoral counselor and the theologian who is willing to go down into the pit with those who personally struggle with this issue in their lives. The list is long of writings on theodicy. The book of Job and the Prophetic tradition in the Hebrew Scriptures wrestle with reconciling Job's or the children of Israel's personal experience of suffering with their status of being either chosen or "good people." Other resources include Douglas John Hall,110 Terence Fretheim,111 Leslie Weatherhead,112 C.S. Lewis,113 and Daniel Simundson.114 Two references which address the issue specifically from the perspective of war and Vietnam veteran issues in particular are Out of the Night: The Spiritual Journey of Vietnam Vets,115 and Uwe Siemon-Netto's The Acquittal of God.116 Pamphlets from CareNotes which address the issue of suffering include "When Someone You Love Is Suffering," "Finding God in Pain or Illness," and "When Your Prayers Go Unanswered."

Doubt and Disbelief

When Douglas John Hall argues that theology or faith takes courage, he is suggesting that it is something worth fighting for. Courage is not an issue when it comes to matters of indifference that are not worthy of our ultimate concern. The fact that belief in God does make a difference in our perception of life, in our struggle to go on, and in the healing process is indicated by the outcome captured by this assessment process.

Theological and pastoral resources include Paul Pruyser's Between Belief and Unbelief.117 It is telling that a clinical psychologist was to write a book on belief during a period when Death of God theologies were being heralded as the wave of the future, a wave that was short-lived and has had a limited lasting influence. While not as widely read or quoted as When Bad Things Happen To Good People,118 Harold Kushner's Who Needs God119 is equally readable and nourishing to the soul. Paul Tillich's Dynamics of Faith120 approaches doubt from the perspective that it is an essential element in faith; faith that is easily arrived at and readily assented to is not worthy of our ultimate concern.

Fear of Death

The final spiritual injury issue addressed by the SIS has to do with the individuals thoughts about death. Death and dying are areas that traditionally have been the domain of religious faith and the clergy. The spiritual assessment process again places chaplaincy at the center of this need for ministry. It does this by asking about the frequency in which death is the focus of a person's attention. Early versions of the SIS asked patients about their fear or worries concerning death. While all seven of the first questions on the SIS were significantly correlated with negative outcomes and indicated co-morbidity with illness, no such association was found with the fear of death. It may be that the reason for this finding is that research to date using this instrument has been largely been administered in a veterans hospital with combat veterans of the Vietnam war. In pastoral counseling sessions, these veterans who were often suffering from posttraumatic stress disorder would say they wish that they had died in war. They might have been suffering from what the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised) list as survivors guilt.121 In one study sixty-four percent of these veterans suffering from PTSD had considered suicide in the previous two years.122 Indeed they were suffering from what Douglas John Hall lists as the struggle of whether or not to go on.123 They feel that they have and are experiencing something worse than death.

Because of this ambivalence towards death the initial question about the degree to which a person fears death was changed to "how often do you think about death?" If the answer given is never then it might be that the individual is in denial or avoiding the subject, especial if age, illness or circumstances in life indicate that as a real possibility. If on the other hand, an individual answers "very often" to this question, it would be wise to explore this response. If the person has also indicated thoughts of suicide in the Holmes/Westberg section of the assessment, it is essential that the pastoral counselor or person administering the assessment ask as to whether the patient or client presently has any thoughts or plans of suicide. Obsessive thoughts about death may also indicate severe depression or fascination with dying or a grief reaction to someone else's death.

Historically, the faith of the religious community has been a resource and support system for individuals facing death. The anointing of the sick, services of commendation for the dying, prayers at the bedside, the reading of psalms and other scriptural passages, and pastoral conversation are all resources for the chaplain to use in supporting individuals who are dying. Faith itself is a resource in facing death.

The impact of death on us, and how our culture has dealt with it is documented in Ernest Becker's book, The Denial of Death.124 The book that heightened popular awareness to death and the way that we respond to it was On Death and Dying by Elisabeth Kubler-Ross.125 The hospice movement and the literature that has emerged out of it has also sensitized us to the importance of facing up to, working through its various stages, and ultimately accepting death as part of life. Growing out of this "death with dignity" movement has been the realization of how important it is to empower the individual, to provide choices, and to recognize the limits of modern medicine. Patients' rights, decision-making at the end of life, and the development of medical ethics as a specialty within both medicine and ethics, in addition to hospice care, has been the medical care community's response to the fear of death. When patients are given options, when they are not treated as the helpless recipients or victims of high technology's mysteries but are given the right to make informed decisions over such interventions as pain control, life-prolonging and life-saving therapies, etc., their fears are reduced and sense of self is enhanced. A book that puts these traditions together, the religious communities' and faith's response to death within a framework for making ethical decisions is Death and Dying: Ethical Choices in a Caring Community.126 Another resource chaplains need to be familiar with, especially chaplains who serve on ethics committees, is a report put out by the Hastings Center titled Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying.127

The advent of the Patient Self-Determination Act of 1991 provides chaplains with an opportunity, as well as with problems, in addressing end-of-life medical care decisions with patients and their families. With the requirement that all medical centers give consumers of health care the opportunity to establish Advance Directives, chaplains have an opportunity to play a leadership role in their hospitals. Larry Holst outlines both the problems and the opportunities afforded patients through the Patient Self-Determination Act in an article published in The Caregiver Journal.128 One medical center using this spiritual assessment instrument that includes questions regarding advance directives provides patients who wish to establish an advance directives affirmatively with a minimum of half an hour of patient education on the medical center's policy, on patient's rights, and on how advance directives can be put into writing during their course of treatment and stay in the hospital. This is an opportunity to improve the quality of care patients receive during their hospitalization.

CareNotes that focus on which focus on issues surrounding death include: "Saying Good-bye to a Loved One Who is Dying," "Planning Now for Tough Medical Choices You May Face in the Future," "When a Child Dies," "Making a Loving Life-Support Decision," "Losing Someone Close," "Hanging on to Hope Through a Serious Illness," "Finding Your Way After the Death of a Spouse," and "Facing Death With Faith and Courage."

Notes

51 Arthur Egendorf, Healing From The War: Trauma and Transformation After Vietnam (Boston: Houghton Mifflin Company, 1985) p. 124.

52 William P. Mahedy, Out of the Night: The Spiritual Journey of Vietnam Vets (New York: Ballantine Books, 1986) p. 9.

53 Peter Marin, "Living in Moral Pain," Psychology Today (November 1981) p. 68.

54 Ibid.

55 Ibid., p. 71.

56 Quoted as a footnote in Dietrich Bonhoeffer, Ethics (New York: Thew Macmillan Company, 1955) p. 21.

57 Matthew 10:26.

58 Bonhoeffer, Ibid., p. 20.

59 William Golding, Lord of the Flies.

60 Bonhoeffer,Ibid.

61 Gustavo Gutierrez, A Theology of Liberation (Maryknoll, New York: Orbis Books, 1973) p. 84.

62 Douglas John Hall, Thinking the Faith: Christian Theology in a North American Context (Minneapolis: Augsburg Fortress, 1989) p. 92.

63 Ibid., p. 117.

64 Ibid., p. 118-119.

65 Arthur Egendorf, Ibid., p. 186.

66 Ibid.

67 Ibid., p. 216.

68 Paul Pruyser, Ibid., p. 76.

69 Arthur Egendorf, Ibid., p. 201.

70 Gary Berg, Ibid., (2011).

71 Paul Tournier, Guilt and Grace (New York: Harper & Row, Puablishers, 1962).

72 O. Hobart Mowrer, The New Group Therapy (Princeton, New Jersey: D. Van Nostrand, Company, Inc. 1964).

73 Karl Menninger, Whatever Become of Sin? (New York: Hawthorn Books, Inc., 1973).

74 Paul Pruyser, Ibid., p. 71-73.

75 Michael E. McCullough, Steven J. Sandage, and Everett L. Worthington, To Forgive Is Human: How to Put Your Past in the Past (Downers Grove, Illinois: InterVarsity Press, 1997).

76 Care Notes, One Caring Place (Abbey Press, St. Meinrad, IN 47577).

77 McCullough, et al, Ibid.

78 James Pierce, "Life Values Assessment Database and Profiles," The Caregiver Journal, Vol. 8, Number 1 (The College of Chaplains, 1701 E. Woodfield Road, Suite 311, Schaumburg, IL 60173) p. 32.

79 Elizabeth Kubler-Ross, On Death and Dying (New York: The MacMillan Company, 1969).

80 Granger Westberg, Good Grief (Philadelphia: Fortress Press, 1977).

81 C.S. Lewis, A Grief Observed (New York: Phoenix Press, Walker and Company, 1961).

82 Al Santoli, Everything We Had (New York: Ballantine Books, 1981).

83 Gary Berg, Ibid.,(2011).

84 Alan Fontana and Robert Rosenheck, Ibid., p. 579.

85 Douglas John Hall, Thinking the Faith: Christian Theology in a North American Context (Minneapolis: Augsburg Fortress, 1989) p.92.

86 Ibid., p. 98.

87 Victor Frankl, Man's Search for Meaning: An Introduction to Logotherapy (New York: Washington Square Press, Inc., 1963).

88 __________, The Doctor and the Soul: From Psychotherapy to Logotherapy (2nd ed.; New York: Alfred A. Knopf, Inc., 1965).

89 __________, Psychotherapy and Existentialism (New York: Simon and Schuster, 1968).

90 Paul Pruyser, Ibid., p. 76.

91 Helmut Thielicke, Nililism (New York: Harper & Row, Publishers, 1961).

92 Stephen R. Covey, The 7 Habits of Highly Effective People (New York: Simon & Schuster, 1989).

93 __________, First Things First (New York: Simon & Schuster, 1994).

94 Douglas John Hall, Ibid., p. 92.

95 Paul Tillich, The Courage To Be (New Haven & London: Yale University Press, 1952) pp. 46ff.

96 Kieran Kavanaugh and Otilio Rodriquez, The Collected Works of St. John of the Cross (Washington, DC: ICS Publications, Institute of Carmelite Studies, 1973).

97 Soren Kierkegaard, Sickness Unto Death (Princeton, NJ: Princeton University Press, 1980).

98 Mary Louise Bringle, Despair: Sickness or Sin? (Nashville: Abingdon Press, 1990).

99 William Mahedy, Ibid., p. 32.

100 Martin E. Marty, A Cry of Absence: Reflections for the Winter of the Heart (San Francisco: Harper & Row, Publishers, 1983).

101 Mary Louise Bringle, Ibid., p. 23.

102 John Hassler, North of Hope (New York: Ballantine Books, 1990).

103 Douglas John Hall, Ibid., p. 103.

104 Ibid., p. 92.

105 Paul Tillich, The Courage To Be (New Haven & London: Yale University Press, 1952).

106 Douglas John Hall, Ibid., p. 242.

107 Mary Louise Bringle, Ibid., pp. 166ff.

108 Paul Pruyser, Ibid., p. 64.

109 Harold Kuschner, When Bad Things Happen To Good People (New York: Avon Books, 1981).

110 Douglas John Hall, God & Human Suffering: An Exercise in the Theology of the Cross (Minneapolis: Augsburg Publishing House, 1986).

111 Terrance E. Fretheim, The Suffering of God (Philadelphia: Fortress Press, 1984).

112 Leslie D. Weatherhead, The Will Of God (Nashville: Abingdon Press, Second Printing, 1978).

113 C.S. Lewis, The Problem of Pain (London: Geoffrey Bles, The Centenary Press, 1940).

114 Daniel J. Simundson, Faith Under Fire (Minneapolis: Augsburg Publishing House, 1980).

115 William Mahedy, Ibid.

116 Uwe Siemon-Netto, The Acquittal of God: A Theology for Vietnam Veterans (New York: The Pilgrim Press, 1990).

117 Paul Pruyser, Between Belief and Unbelief (New York: Harper & Row, Publishers, 1974).

118 Harold Kushner, Ibid.

119 Harold Kushner, Who Needs God (New York: Pocket Books, 1989).

120 Paul Tillich, The Dynamics of Faith (New York: Harper & Row, Publishers, 1957).

121 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised), (Washington, DC).

122 Gary Berg, Ibid., (2011) 6:4.

123 Hall, Ibid.

124 Ernest Becker, The Denial of Death (New York: The Free Press, 1973).

125 Elisabeth Kubler-Ross, On Death and Dying (New York: The Macmillan Company, 1972).

126 Daniel E. Lee, Death and Dyhing: Ethical Choices in a Caring Community (New York: Christian Social Responsibility Series, Division for Mission in North America, Lutheran Church in America, 1983).

127 Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying: A Report by the Hastings Center (The Hastings Center, 255 Elm Road, Braircliff Manor, NY 10510, 1987).

128 Lawrence Holst, "The Patient Self-Determination Act--Problems and Opportunities," The Caregiver Journal, Vol. 8, Number 3 (The College of Chaplains, 1701 E. Woodfield Road, Suite 311, Schaumburg, IL 60173) p. 3.

Chapter 6 - A Clinical Guideline for Spiritual Care

Chaplains in institutional settings are often adept at providing quality generic pastoral care. This means that one size usually fits all. This standardization of pastoral care is brought about by two forces. The primary cause is limited resources. With case loads for chaplains double and triple what it is for disciplines such as social work, psychology and recreational services, chaplains can often do little more than skim the surface. Most patients receive similar care: a brief initial visit introducing pastoral care services and welcoming the patient into the hospital, pre- and post-operative visits, brief prayers when requested or appropriate, and office visits when they are initiated by the patient. In addition to this standard of practice, worship services and committee responsibilities round out the average chaplain's daily routine.

A second force described by Paul Pruyser129 is background and training. For many years the dominant influence in clinical pastoral education was the work of Carl Rogers. This means institutional chaplains' counseling styles are often non-directive, supportive, and flexible. Institutional survival ha pastorals often encouraged such an approach. Chaplains become adept at meeting patients where they are at. If a patient wants to talk sports, most chaplains are well versed in such matters. If other patients come out of a fundamentalistic or pietistic tradition narrowly defined, chaplains can usually hit this ball as well when it is well pitched; and visits do not have to be too long. Institutional chaplains also become well versed in a wide variety of religious traditions, denominations, and no denominations at all. A Rogerian model serves this style of ministry well; it is certainly preferable to an authoritarian, rigidly dogmatic, and narrowly sectarian style of ministry which imposes its will on vulnerable and helpless victims. Ministers who fit this latter mold usually do not last in a complex, secular, and often competitive environment that is health care. Administrators, physicians, highly trained professionals, and patients representing pluralistic backgrounds will not tolerate clergy who are autocratic, judgmental and insensitive to human frailty. Chaplains who display such attitudes and approaches are constantly at the center of conflict, controversy and inevitable run needed chaplaincy programs into oblivion. Healing the wounds inflicted on pastoral care departments by such practitioners is a long and arduous process.

An alternative to the superficial, generic approach, the Rogerian non-directive method of ministry, or the objectionable autocratic style has been the intensive involvement of gifted chaplains and pastoral counselors in specialized programs. All of their energy goes into specialized ministries such as pastoral care with AIDS patients, hospice ministry, family therapy, marriage counseling, homeless programs, chemical dependency ministry, etc. Such ministries are far more satisfying for the caregiver and also do much good. Their limitation, until caseloads are reduced for chaplains and adequate staffing patterns emerge, is that a lot of other patients in the hospital get neglected; they get little or no care from the pastoral care department. Instead, what is needed is targeted, individualized pastoral care directed at a client's most pressing spiritual need. This is also what chaplains have not been able to do in a consistent, skillful way.

Larry Seidl, of the Catholic Health Association, in his book Quality Assurance & Pastoral Care: A Development and Implementation Guide,130 provides chaplains with a well thought out process for providing quality pastoral care. He lists 8 steps by which quality assurance is accomplished. They are 1) assign responsibility to individual/task force, 2) link your service to the institution's mission, 3) define your consumers, 4) define quality and its components, 5) identify the structure (standards/indicators/policies) and measure the department's adherence, 6) initiate a process of treatments, 7) measure the outcomes, 8) identify the problems, and 9) ongoing evaluation of services and personnel. Steps one through five are often well defined in Chaplain Service Manuals and Quality Assurance Plans. We often fall down when it comes to Step Six, initiating a process of treatments designed to meet individual needs. People get attended to who come looking for a chaplain to talk to; often these conversations are significant and helpful. Self referrals bring motivated clients into a chaplain's office. An alternative is to wait for referrals that are initiated by physicians, psychologists, and other health care professionals. If David Larson is accurate about the religious environment existing in physician training programs, and if research is to be trusted that says only 40% of the people trained in the behavioral sciences even believe in God,131 then relying on referrals from other disciplines will not meet the spiritual longings and needs of a majority of the patients admitted to medical care centers. Another process needs to be developed to address the spiritual needs of hospitalized patients.

What is needed is a process by which such patients can be identified and appropriate treatment prescribed. Individualized pastoral care treatment plans need to be formulated based on a comprehensive religious diagnosis or assessment as advocated by Pruyser132 and Fitchett.133 The development of pastoral care guidelines, as described in this chapter, identifies such a process for targeting needed pastoral intervention and treatment for patients and clients who are at spiritual risk. This process will be illustrated visually using the algorithm or flow chart printed on page 70 of this manual.

"A clinical Algorithm or Flow Chart is a graphic format that sets forth a stepwise procedure for making decisions about the diagnosis and treatment of clinical problems."134 The flowchart presented in this chapter explains and follows the Computer Assessment Program presented in this manual. The purpose of this chapter is to provide the reader with a basic understanding of the algorithm. Because this format is clear, concise and graphic, it can be used to write pastoral care treatment plans that are specific and targeted to individual spiritual problems.

Flowchart for Spiritual Care

Medical breakthroughs and progress are evident in the Biological sciences. Infectious diseases are controlled and even eliminated. Where breakthroughs now need to take place is in behavioral medicine. Violence, environmental dangers, chemical dependency, divorce, poor health practices including smoking, obesity, poor nutrition, heart disease and cancer are all related to one degree or another to human behavior. If progress is to be made in these areas, changes in behavior are required. This is an area where religion has had some success. In order to change human behavior, it will be necessary to focus on values, on ultimate concerns, and on that which motivates people to do the things they do. For example, when the connection between smoking and lung disease became apparent, individuals who were concerned about their health and longevity began to stop smoking. Health education became an effective tool for changing behavior and improving health. To change behavior, it will be necessary to co-opt and leverage core values, ultimate concerns and the driving forces in people's lives. A comprehensive health assessment needs to include a person's values system and what motivates individual behavior. A spiritual assessment needs to begin at this point.

After the spiritual assessment is completed (Step 1), the first step in the assessment process is to identify the person's core values, beliefs and practices. This is accomplished by reviewing the person's three highest values from the Rokeach Scale, as well as answers given to the Kasl Index. These answers include frequency of attendance at organized worship services, the importance of religious faith, and religion and or God as a source of strength and comfort.


Figure 1a

This spiritual assessment includes questions about non-organized religious activity including frequency of prayer, devotional reading and use of media for religious purposes. These questions come from the work of Harold Koenig.135 Assessing a person's values and religious behavior provides a filter or screen through which other answers and scores on the assessment can be processed. Beginning with a person's values and religious behavior (Step 2) provides a context in which to view a person's life and those events considered harmful and dangerous to spiritual well being.

After using the Ultimate Values Scale and religious index as a filter or screen, Step 3 begins to look at personal stress as measured by the Holmes/Westberg Inventory. Losses and life changes are often viewed as what happens to us. We are their victims. Personal stress in not only acceptable but it is also reassuring to have people attend to it and ask about it. Change that takes place in our lives is how we tell our story. For this reason it is less threatening to begin an interview with a patient or counselee by commenting on the degree of stress they are experiencing rather than guilt, anger and other spiritual injury issues that require some ownership and a sense of responsibility. Patients will begin to open up and a sense of trust can be established when we ask about stress, losses and events in a person's life they often have no control over. Step 3 begins by asking about personal losses and stress. This includes deaths in the family or among friends, illness and injury, and life style changes. While this element in the stress scale does include suicidal behavior and sexual abuse, because of the nature of these two questions, I come back to them later in the interview after spiritual injuries have been identified. If significant stressors are identified in this first item, they are then channeled into the treatment stream of the algorithm. While the Holmes/Westberg Inventory provides quantitative scores measuring the level of stress, there is no specific number or threshold that determines when treatment is required. As is true throughout this algorithm, the clinician needs to look at the "total picture" or fabric of a person's life. The total is always greater than the sum of its parts. It is how the pieces fit together, i.e., values, life experiences, their meanings, and the accumulated weight of events that determine the nature, the urgency, and the timing of intervention and treatment that is offered.

Step 4 examines the losses, the stressors and changes in one's marital or significant other relationship. Again, the context of individual answers must be considered in relationship to values and goals. If financial security is one's primary goal or value, then conflict over money management may be more damaging than for someone who may be somewhat indifferent to material success. If marital relationship or family harmony are primary values, on the other hand, any significant score in this area of one's life needs to be addressed. The chaplain or pastoral counselor can provide the treatment, or she can use the assessment instrument to refer and make this referral part of the treatment plan.

In similar fashion, Steps 5 through 8, household events, vocational issues, finances, and changes in one's spiritual life are reviewed and discussed with the patient as part of the assessment process, and the primary concerns, problems and changes are noted. Again, changes in these areas need to be filtered through primary goals and values. If "family harmony" is a primary value and stress is evident in the family or problems with a child are identified, they become part of the treatment side of the algorithm. If a sense of accomplishment, or financial security, or social recognition are most important in a person's hierarchy of values, and these are achieved through vocation, then if retirement, problems at work or loss of job are checked off, these things need to be pursued. What meaning do such events have for the person whose life may have centered on work and now has this kingdom threatened? And when one's ultimate values focus on faith in God or knowing God's love, and spiritual stress is identified, this then needs to be included in the focus of attention in developing a treatment plan and in the provision of pastoral counseling.

Spiritual Injury or Distress

The next process that is addressed is the area of spiritual injury or distress (Steps 9 through 16). (Steps 9 through 16). A spiritual injury is our response to an event caused by self, or an event that happens to us and is beyond our control, that damages our relationship with God, self The next process that is addressed is the area of spiritual injury or distress and other, and alienates us from that which gives meaning to our lives. This algorithm identifies eight such injuries. They are guilt (Step 9), anger or resentment (Step 10), sadness or grief (Step 11), lack of meaning and purpose in life (Step 12), despair or hopelessness (Step 13), theodicy or the feeling that life or God has been unfair to us (Step 14), religious doubt (Step 15), and frequent thoughts of death (Step 16). The person who identifies any of these issues as "often" or "very often" being a problem for them on the assessment, needs to have them addressed in treatment. All of these issues are highly correlated with illness and are precursors to future problems. They are also amenable to religious therapies. My hypothesis is that these spiritual injuries are an "early warning system" for illness, broken relationships, and difficulties that are to follow. As such, spiritual injuries are "windows to the soul," waiting to be opened and attended to. No one is better equipped to do this than the chaplain and pastoral or spiritual counselor. As data is gathered and databases are created using this assessment process, we will be able to research this question and indeed determine the adequacy of the Spiritual Injury Scale (SIS) as a reliable instrument for diagnosis, treatment and prevention. Preliminary research conducted at the VA Medical Center in Bedford, Massachusetts indicates that it is a valid and reliable instrument.136 Data gathered at the St. Cloud VA Medical Center indicates that the SIS is a much more sensitive instrument than the Holmes/Westberg Inventory that is much relied upon in the behavioral sciences. Correlations between SIS scores and a variety of illnesses and diagnostic categories are much higher than similar correlations with the Holmes/Westberg instrument.137



Figure 1b

These last few comments are not meant to disparage the Holmes/Westberg scale. Indeed, McSherry's insight into combining the Rokeach
Ultimate Values Scale and the Holmes/Westberg Total Health Inventory gives us a holistic way at looking at values, stress and spirituality that is much more profound and useful than using either instrument by itself. The hypothesis and paradigm I am proposing is that spiritual injury or distress is the outcome of cognitive dissonance or conflict between values and core beliefs on one hand, and behavior or life experiences, on the other hand (Figure 2a). And only be looking at beliefs, values and behavior holistically or collectively can we begin to understand the story and fabric of a person's life including the core of one's spirituality. Pastoral care and spirituality have often been perceived as being ethereal, immaterial, and metaphysical. This algorithm is intended to present a model for pastoral diagnosis and treatment that is clear, concise, graphic and quantifiable. It is also intended to address the challenges that often confront and frustrate behavioral medicine in influencing, motivating, and changing behavior.

The means by which spiritual injuries are addressed is to ask for specifics when the counselee states he or she is often or very often troubled by a specific injury. What happened in a person's life that brought on the guilt, the resentment or the grief? Has the person's life always been without meaning or purpose, or what event triggered a present sense of meaninglessness? These questions will elicit specific and concrete responses. It is at this stage in the assessment process that the counselor needs to address the issue of suicide or sexual abuse if these risks have been identified on the stress assessment. The original Holmes Inventory did not address the issue of sexual or physical abuse. Questions regarding childhood abuse, abuse that may be more recent, and a current relationship that may be physically or sexually abusive have been added. Both the issue of suicide and abuse are highly associated with spiritual injury. Suicidal behavior is highly correlated with absence of meaning and purpose in life, hopelessness or despair, anger and grief. In a study of adult male veterans, childhood sexual, physical and emotional abuse were highly correlated with all spiritual injury items with the exception of fear of death when compared with similarly situated veterans who had not experienced abuse.138 Discussing spiritual injuries as they relate to life events gives the chaplain and pastoral counselor the opportunity to address the impact these events have had on spiritual faith and its development. Spiritual distress and barriers to spiritual growth and development then need to be addressed in the pastoral care treatment plan.

The "Do" Box

The final step to this algorithm is Step 17. It is the development of a treatment plan based on  the information that has been gathered. A great deal is now known about the patient's story or the "living human document"139 that can be assessed in light of core beliefs or clients ultimate concerns. Step 2 in the algorithm is a data box that contains information gained from the patient. The development of a treatment plan in Step 17 needs to take into consideration the information gained in Steps 2 through 16. The counselor can now screen, filter, and make decisions regarding the importance and value to give the changes, life experiences and hurts that have been documented by the patient. This becomes a "do" box contains the elements used in developing the pastoral care treatment plan. This plan can either be written as part of the spiritual care flowchart illustrated as Step 18 in Figure 1, or it can be an element in a multidisciplinary treatment plan. It is preferable that this algorithm be part of a larger multidisciplinary algorithm. Where this is not possible, or until outcome studies and research support the importance of this algorithm, it may be necessary for it to be a standalone flow chart utilized by pastoral care departments for notation in the medical record.

The importance of Step 17 is that it identifies any conflict that may exist between a person's core beliefs and values, and her or his behavior or life experiences. Where this conflict exists cognitive and spiritual dissonance is inevitable. These are the obstacles and impediments that create a sense of blockage in a person's life. This step is where people get stuck in their desire to move ahead with the story of their life.140 My experience tells me that turbulence at this juncture causes spiritual injury or distress. This is a hypothesis that needs to be studied and can be as databases are developed and longitudinal studies are conducted using this assessment process. Step 17 becomes the heart of the pastoral assessment process. Any leverage that caregivers have to change or modify destructive behaviors resides in this box. It provides a toehold into understanding the story behind the story. It will explain the central narrative account of a life that is either moving ahead unimpeded, or a life that is in disarray and conflicted.141 Figure 2a and 2b diagram the dynamics. Any resolution of this conflict will involve either a change in one's value system, which means conversion in the classical religious sense, or a change in behavior. Theologically this behavioral change is understood as repentance, with repentance meaning not only remorse but also a literal "turning around." Historically, this conflict between values and behavior was understood as "sin," or "missing the mark." Spiritual distress is relieved when behavior hits the mark with the bulls-eye being core values, beliefs and goals. The dynamics between values, behavior and spiritual distress become the arena in which spiritual assessment, pastoral planning and religious counseling and education take place. One of the goals of treatment will be to align values with behavior (Figure 2b), thereby reducing and minimizing spiritual injury. The algorithm has now identified 13 potential crisis points that are amenable to assessment and treatment. If the individual items in the Holmes/Westberg Inventory are considered separately, 66 items are identified that have implications for spiritual care, and none of them are "ethereal."  




Treatment Care Plan

The next step in the flowchart (Step 18) is to develop and document a spiritual care treatment plan. Much of this is done electronically by using the computerized version of the assessment. Values are listed, scores are tabulated, flags are raised (suicidal behavior, abuse and advance directive issues in the computerized version), and spiritual injuries are marked. By this time a list of problems will have been identified and placed on the treatment side of the algorithm. Not all problems and changes in a person's life will become treatment items. Instead, they need to be weighted -- which the Holmes/Westberg Total Health Inventory already accomplishes-- prioritized, assigned to the proper caregiver or program, or set aside as interesting but not essential.

The development of the spiritual care treatment plan is the coming together of what has gone before. If much of pastoral care can be faulted it is for assuming that one size fits all, or for being so "client-centered" and non-directive that we bring nothing to the table but "presence." More is needed. Pastoral presence is necessary but not sufficient in today's competitive healthcare environment. The assessment process allows us to target specific spiritual concerns and problems, to understand their genesis, and to weigh their importance. Most chaplains do not have the luxury of unlimited time, and managed care does not provide the pastoral counselor unlimited counseling sessions. Today most therapy is brief and pastoral encounters are restricted. Without a methodology for assessing spiritual needs, what happens is that we may spend much time with those who may need us the least, and ignore those individuals who are most at spiritual risk. The spiritually wounded do not float to the top where they are easily skimmed from the surface. Tragically they sink to the bottom and are ignored or lost in the crunch of limited resources and downsizing. Relying on the referrals of other services and disciplines can also have the effect of screening out the individuals who may need spiritual healing and care the most. Training received by other disciplines does not adequately prepare them for making quality referrals to chaplains and pastoral counselors. Biases identified by David Larson142 in medical training predispose physicians from making such referrals for spiritual care. The treatment plan, based on a focused assessment, is the means by which these shortcomings are overcome.

A criticism of algorithms is that they are too "cookbookish," that they limit the latitude of the practitioner and confine clinical skills. The intent of this algorithm is not to confine but to sharpen pastoral counseling skills. While a thorough assessment is therapeutic by itself, treatment per se only begins at this point. Whatever skills, art, knowledge and talent a clinical chaplain or pastoral counselor brings to the table can freely be exercised at this point. The setting can be individual or group therapy. Whatever "school" one belongs to can be employed to address the identified spiritual needs of the patient. Various approaches such as spiritual, behavioral, cognitive, dynamic, insight, solution-focused, and system-directed therapies can be used by the clinician in providing treatment. Each method or theoretical model employed must be judged on the merits of its own effectiveness, acceptance by the client, and hopefully by measurable outcomes. In no way should the gifted clinician be limited from exercising his or her skills by clinical pathways or guidelines that are becoming the established method for providing clinical care.

Screening for Spiritual Risk

A frequently expressed concern of chaplains is that they do not have time to do a complete assessment. An alternative is to utilize the SIS as a screen for spiritual risk. A complete assessment can then be administered to patients who score high or identify several spiritual injuries. Or having identified a particular injury, the chaplain can focus on that specific issue, including brief conversation at the bedside. To better manage limited resources and to focus attention on patients at greatest spiritual risk, pastoral care departments are also using multilevel assessments.143 A complete assessment is only administered to patients who match a particular profile or surpass an established threshold indicating spiritual need.

Special Cases or Exceptions

For any model or theory to be accepted and considered valid, it must recognize and allow for exceptions when they take place. Based on this model, one of the goals of religious counseling will be to align value and belief systems with behavior. The greater this alignment the less spiritual injury there will be, and vice versa (Figure 2a and 2b). There is a category of patients, however, who seemingly do not suffer spiritual injuries, whose moral development is seemingly underdeveloped or immature. They are the individuals who are diagnosed as suffering from an antisocial personality disorder, adult antisocial behavior or narcissistic personality disorder, people who are "constitutionally incapable of being honest with themselves"144 and therefore cannot be helped. For some individuals in this category, they may be terminally ill spiritually. For example, this may hold true for the chemically dependent person who feels no remorse, no guilt or shame after doing grievous harm to others. In such an instance spiritual injury may be a blessing and indicate a longing for healing. There are other people in our culture who may feel no spiritual distress, such as guilt or remorse, because of an underdeveloped value system and who do quite well by the world's standards. Bright, narcissistic individuals, for example, may succeed as entrepreneurs in the business world by bending the rules or making the system work for them, but the other people in their lives suffer for and because of them. They seemingly have no shame. The narcissistic individual whose behavior does not conform to accepted community standards and is not bright enough to "outwit" the system usually ends up in trouble with the law, in prison, or turns to anger and even violence in displacing their conflict outward.

The point of all this is that the absence of spiritual injuries is not necessarily the goal of treatment nor does it represent spiritual health. The individual who arrives in the clinic or hospital who is spiritually "dead on arrival" (DOA) will not show spiritual distress or injury. The discerning clinical chaplain or pastoral counselor will need to make the determination of spiritual health and wholeness based on what else is going on in the person's life and not solely on the basis of a SIS score. Individuals who report no spiritual injuries may have a belief system and core values that do coincide with their behavior, but the long-term outcome is spiritual death, communal isolation, illnesses such as untreated alcoholism or drug addiction, and eventual physical death. The person whose "Higher Power" is alcohol and whose behavior coincides with abusing alcohol has a value system and behavioral system that are congruent. They may deny spiritual injuries such as guilt, lack of meaning and purpose, or despair and hopelessness, but the eventual outcome for such a life style is that spirituality suffers, family life disintegrates, employment is terminated, health problems develop, and their eventual outcome is premature death. In instances where the behavior is illegal, the consequences are often incarceration or even violent death. Core values and behavior coincide, so such individuals are not troubled by spiritual injuries or a "broken and contrite heart,"145 but because of the nature of their behavior, the consequences are either self-destruction or unlawful and damaging behavior towards others. Figure 3 represents this dynamic.

Summary

When a client completes the assessment the final screen thanks the person for entering the data. The instrument must then be closed so the person doing the assessment does not have access to any records. To obtain the data that has been entered the person administering the assessment must then reopen the program by again entering one's username and password. The entire database is then available. A menu item for the assessment just completed opens a summary page which lists all the data available for each assessment. The following diagram provides an image of a spiritual assessment summary.

  

Clicking on Stress Score boxes creates a drop box that lists all of the items listed in the Holmes/Westberg Personal Health Inventory Scale. If a person completing the assessment acknowledges thoughts of suicide or a history of sexual abuse, these items also appear at the bottom of the summary page.

Conclusion

Clinical pathways will increasingly be used as the way medicine is practiced. Services, events, practice patterns, and products that are included in an algorithm will be supported and maintained. If what is done by a practitioner is not annotated, included in or specified as part of a specific algorithm applicable to the appropriate diagnostic category, it will be perceived as being non-essential and overhead wisely eliminated. This holds true whether what is being done is performed by a doctor, a nurse, or a chaplain. Events that will be included in an algorithm will be supported by outcome data, research and literature reviews. Practice patterns and professional standards that are not data driven and cannot be demonstrated as valuable in the healing process will soon be eliminated. The measurement standard that will be used will be return on investment (ROI). Any ROI that ends up as a negative number measured by a cost analysis will no longer be sustained with medical dollars. While adequate outcome measurements are not yet in place for much of what is done in medicine, decisional support systems being created will soon give us the information needed to make informed decisions about such matters. Services that do not maintain input information and track outcomes will not be able to continue justifying their existence.146 The algorithm presented in this paper is data driven and quantitatively measurable. The assessment it is based on creates an extensive database that demonstrates religious faith's association with positive healthcare outcomes.

Our nation expends a greater amount of our GNP on medical care than any other nation in the world, yet outcomes based on life expectancy, infant mortality and health status do not measure up to some countries that spend much less. This means that some of the things we do are costing us more than their outcomes warrant. Information technology will soon allow us to name what these things are. Let us hope that pastoral care is not one of the casualties. It need not be, and indeed spiritual care will be enhanced and strengthened if we do the groundwork that prepares us for this future. The development of clinical guidelines and pathways is one of the ways by which this will be accomplished.

Notes

129 Ibid., pp. 39-40.

130 Seidl, Ibid.

131 Larson & Larson, Ibid.

132 Pruyser, Ibid.

133 Fitchett, Ibid.

134 C.Z. Margolis, "Uses of clinical algorith," Journal of the American Medical Association 249 (1983): 1042-1045.

135 Harold G. Koenig, James N. Kvale, and Carolyn F, "Religion and Well-Being in Later Life," The Gerontologist 28, No. 1, (1988): 20-21.

136 Ronald Lawson, Charles Drebing, Gary Berg, S. Jones and Walter Penk, "The Spirituial Injury Scale: Validity and Reliability," Paper presented at the annual meeting of the American Psychological Association, San Francisco, CA (August 1998). This paper appears as Appendix A.

137 Gary Berg, Peter Lundholm, Alfred Stangl and Lloyd Haupt. The spiritual database at the Department of Veterans Affairs Medical Center in St. Cloud, Minnesota contains over 3800 records. Unpublished research examining severity of depression, post-traumatic stress disorder, and alcoholism and their correlation with both the SIS and the Holmes/Westberg Total Health Inventory show stronger associations between spiritual injuries and illness than milar associations with stress.

138 Ronald Lawson, Charles Drebing, Gary Berg, Aime Vincellette, and Walter Penk, "The Long Term Impact of Child Abuse on Religious Behavior and Spirituality in Men," Child Abuse & Neglect, Vol. 22, No. 5 (1998):373.

139Charles V. Gerkin, The Living Human Document: Re-Visioning Pastoral Counseling in a Hermeneutical Mode (Nashville: Abingdon Press, 1984).

140 Ibid., p. 121.

141 Ibid., pp. 121-122.

142 David B. Larson and Susan S. Larson, "Religious Commitment and Health: Valuing the Relationship," Second Opinion, Vol. 17, No. 1 (July 1991): 27-40.

143 Garland Vance has developed a multilevel spiritual assessment based on this model at the Department of Veterans Affairs Medical Center, Asheville, North Carolina.

144 Alcololics Anonymous, Third Edition (New York: Alcoholics Anonymous World Services, Inc., 1976) p. 58.

145 Psalm 51:17b, The Holy Bible, New Revised Standard Version, 1989.

146 Will Kinnaird and Elisabeth McSherry, "The Development and Use of Codes for Chaplain Interventions (Procedures and Products) in the Veterans Affairs Healthcare System," Chaplaincy Today, Volume 14, No. 1, 1998, 14-22.

Chapter 7 - Correlation as Methodology

The intent of this chapter is to link the systematic theology of Paul Tillich to the quantitative and measurable procedures presented in this manual. Tillich identifies his methodology as the method of correlation.147 He states "the method of correlation explains the contents of the Christian faith through existential questions and theological answers in mutual interdependence."148 "In using the method of correlation, systematic theology proceeds in the following way: it makes an analysis of the human situation out of which the existential questions arise, and it demonstrates that the symbols used in the Christian message are the answers to these questions."149 "Symbolically speaking, God answers man's (sic) questions."150 "The Christian message provides the answers to the questions implied in human existence....God is the answer to the question implied in human finitude."151

Correlation is also a mathematical term that can precisely be measured through statistical analysis. Tillich acknowledges this when he states that "the term 'correlation'...can designate the correspondence of different series of data, as in statistical charts."152 In describing the rational character of systematic theology, Tillich states that theology must be subjected to the rigors of scientific analysis and rational inquiry the same as any other science;153 whether he anticipated the extent to which this is now possible or not would be mere conjecture. Nevertheless, the capability now exists to do this in ways not available to religion when Tillich presented his systematic theology. The idea that a theology might be "systematic" suggest, as Tillich argued, that we try to push the symbols of religious faith to their limits through analysis, computation, and logical inquiry. Now the human situation can be examined through the eyes of religious faith and practice to discover what correlations do exist. We can precisely ask the question raised by Albert Ellis as to whether the symbols of religious faith contribute to illness and the demise of the human spirit, or whether these symbols heal and make whole. Technology not available to Paul Tillich opens doors to inquiry which have been shut until now. The computerized version of this assessment instrument intentionally gathers data about our common, human existence, places it alongside the practices, values and symbols of religious faith, and asks what the correlations between the two might be. Three possibilities exist: 1) there is a negative correlation between religious faith and practice, and illness--i.e., the symbols of faith contain antibodies against disease, breakdown, and disintegration; 2) there is a positive correlation between these two realms as argued by Ellis, i.e., religion reinforces illness and weakens the human or spiritual immune system; and 3) the relationship is purely random, chaotic, and accidental; in other words, correlations do not exist.

This assessment instrument places two dimensions of human experience alongside of each other: it makes an analysis of the human situation out of which existential questions arise. It does this through the spiritual injury scale, the Loss/Life Change scale, and the Ultimate Values Test. Added to this mix are the categories of diagnosis, psychological and physiological testing, length of stay, age, measurements of traumatic experiences, and a host of other categories and experiences that are readily available for assessment in hospitals and clinical settings. Alongside the longings, hurts, hopes and fears expressed in these three scales and categories are placed the symbols of religious faith and practice, and the dimension of intrinsic religious faith. It is now possible to test the theory, faith statements, or hypotheses--for in fact this is what systematic theology or systems of faith are all about: hypotheses--of Paul Tillich or any faith system to determine its validity and value for the human enterprise.

We now come to the place where we can ask if belonging to the community of faith provides us with sustenance, with the symbols, the medium, the sacrament by which we can experience renewal, healing, and divine grace in our own lives. And are we thereby equipped, in turn, to become that community, which like its Lord, is a symbol, a medium, a sacrament of grace to its world. Langdon Gilkey states that "the gospel contains a Christian message to and about human existence; it presents an interpretation of our common existence that is both true about it and healing to it."154 Until now we have had no way of knowing that faith heals other than the fervent witness of religious folk. We have equally had those who have just as fervently claimed that religious faith is an expression of weakness, an unhealthy dependence, even an expression of mental illness, or at best irrelevant in addressing the issues of modernity and the human struggle to survive and to prevail. Gilkey states that religion heals. Is this in fact true? We are now ready to pursue this investigation even further.155

Notes

147 Paul Tillich, Systematic Theology, Vol. 1 (Chicago: The University of Chicago Press, 1951) pp. 59-66.

148 Ibid., p. 60.

149 Ibid., p. 62.

150 Ibid., p. 61.

151 Ibid., p. 64.

152 Ibid., p. 60.

153 Ibid., pp. 53-59.

154 Langdon Gilkey, Through the Tempest: Theological Voyages in a Pluralistic Culture (Minneapolis: Fortress Press, 1991) p. 43.

155 The brief theological excursion contained in this chapter is written from the perspective of the Christian faith. It is not intended to be exclusive. What is written regarding the symbols of Christianity, or more appropriately, the Tradition of Jerusalem, could equally be applied to other traditions as well, i.e., Native American Religion, the Great Religions of the East, and even those faith systems which are in their early developmental stages. The language, symbols, and theologians cited here are done so due to the fact that they are the ones familiar and influential to the author of this manual. The process represented by this Manual is applicable to any tradition. It is suggested that this process and program also has application for other disciplines and traditions outside of the realm of religion. Even scientific schools of thought have their traditions and faith statements!

Chapter 8 - The Importance of Big Data

In an article published in Foreign Affairs,  Keneth Cukier and Viktor Mayer-Schoenberger document how big data is changing our world and how we think. The explosion of big data is a relatively recent phenomena. It is now being used to organize cities, to understand global warming and to influence and determine how medicine is practiced. The authors state that "using great volumes of information...requires three profound changes in how we approach data. The first is to collect and use a lot of data rather than settle for small amounts or samples, as statisticians have done for well over a century, (which is how research has traditionally been done). The second is to shed our preference for highly accurate and pristine data and instead accept messiness:  in an increasing number of situations, a bit of inaccuracy can be tolerated, because the benefits of using vastly more data of variable quality outweigh the costs of using small amounts of very exact data. Third, in many instances, we will need to give up our quest to discover the cause of things, in return for accepting correlations....Big data helps answer what, not why, and often that's good enough." 156

The importance of this change for pastoral care and chaplaincy, and for religious faith in general, is that it necessitates that religious factors that are quantifiable need to be captured along with other data, or else religious faith, pastoral care giving and spiritual counselling in general with be overlooked and absent from the playing field in the practice of medicine. Data needs to be gathered. The instrument described in this ,manual is one way of doing this. Other markers of religious faith may be equally valuable, but if data is not gathered that can be retrieved, computerized and analyzed, a significant resource for healing will have been overlooked and chaplaincy will be perceived as marginal in the health care setting. 

Chaplaincy has long sought evidence that the presence of a chaplain on the health care team has contributed to recovery, healing and well-being because of his or her interaction with clients and patients in the health care setting. As Cukier and Mayer-Schoenberger point out, "knowing the causes behind things is desirable. The problem is that causes are often extremely hard to figure out, and many times, when we think we have identified them, it is nothing more than a self-congratulatory illusion." 157 Of course, chaplaincy is not the only discipline inflicted with this predisposition. But "seeing correlations can be enormously valuable, even when the underlying causes remain obscure."158 Moving from causation to correlation may be a little messy, but it has much to offer in understanding the role of religious faith in healing and getting things done in our contemporary and all-too often fuzzy world.

Notes

156 Kenneth Cukier and Viktor Mayer-Schoenberger, "The Rise of Big Data: How It's Changing the Way We Think About the World," Foreign Affairs, May/June 2013, p. 29.
157 Ibid., p. 32.
158 Ibid., p. 32-33.

Appendix A - The Spiritual Injury Scale: Validity and Reliability

Lawson, R., Drebing, C.E., Berg, G.E., Jones, S., and Penk, W.

The Spiritual Injury Scale is a brief 8-item paper and pencil self-measure of attitudes and affects related to the degree of subjective spiritual discomfort or "injury" people may experience. This would include experiences of alienation from God, anger with God, ongoing guilt, hopelessness, etc. The measure was developed by researchers (Berg, G., et al. 1986) within the Veterans Administration and has been included in the Spiritual Profile Assessment (McSherry, Tappert, King, Shuster, Anderson, Bard, and Phillips, 1986), a large multi-dimensional measure of spirituality. It is being used widely within the VA for both clinical and research purposes (Lawson, Drebing, Berg, Vincellete, & Penk, "The Long Term Impact of Child Abuse on Religious Behavior and Spirituality in Men", Child Abuse & Neglect, Vol. 22, No. 5, 369-380, 1998). Unfortunately, there has not been any careful examination of the psychometric properties of this test, no data regarding validity or reliability.

The Spiritual Injury Scale has been included in only three published research studies ((Lawson, Drebing, Berg, Vincellete, & Penk, Ibid.; Berg, G.E., "The Use of the Computer as a Tool for Assessment and Research in Pastoral Care, Journal of Health Care Chaplaincy, Vol. 6 (1) 1994; and Berg, Fonss, Ree, & VandeCreek, "The Impact of Religious Faith and Practice on Patients Suffering From a Major Affective Disorder: A Cost Analysis", The Journal of Pastoral Care, Vol. 49, No.4, 1995). In a study of 1205 adult male veterans, half of whom were survivors of child abuse, a past history of child abuse was significantly related to Spiritual Injury Scale, with survivors having significantly elevated scores. The type of abuse was also significantly related to scores on the Spiritual Injury Scale, with more "severe" forms of abuse (i.e., sexual and physical abuse) associated with higher scores. While this is somewhat supportive of the validity of the measure, it seems reasonable to ask whether the Spiritual Injury Scale may simply be a measure of depression or distress. The first goal of the current study is to investigate discriminant validity of the Spiritual Injury Scale by examining the relationship between depression, anxiety, and the Spiritual Injury Scale. The second goal is establishing internal reliability and split-half reliability of this new measure and to assess the contribution of each item to the overall reliability.

Method: Data were collected from 101 male veterans who completed the Spiritual Issues Assessment, including the Spiritual Injury Scale and a questionnaire regarding current religious behavior and belief. All veterans were outpatients in a substance abuse program within the Edith Nourse Rogers VAMC in Bedford, Massachusetts. The test was administered by a member of the Chaplains department at the beginning of the treatment process. Subjects were also administered the MMPI-2 by a licensed psychologist.

To examine the concurrent and discriminant validity of the Spiritual Injury Scale, scores were correlated with questionnaire items measuring religious behaviors and beliefs, as well as with scales 2 (depression) and 7 (psychasthenia) from the MMPI-2. Coefficient alpha and split-half correlations were calculated.

Results: Mean age of the sample was 43.7 (s.d. = 9). With respect to religiosity, 68% describe themselves as "fairly" or "deeply" religious, 23% stated that they were "slightly" religious, 8% "were not religious", and 1% were "against religion". Compared to the 1980 national survey of religiosity done by the Princeton Religion Center, the religiosity reported by this sample is comparable to that of the U.S. population at large. The mean score on the Spiritual Injury Scale of the sample was 15.4 (s.d. = 3.5). On the MMPI-2, the mean score on scale 2 (Depression Scale) was 70.7 (s.d. = 14.6) while the mean score of scale 7 (Psychasthenia Scale) was 71.2 (s.d. = 17.4), suggesting high levels of depression and anxiety in this sample. This is not surprising considering that they were testing during enrollment in a substance abuse program.

Coefficient alpha was found to be .79 and standardized alpha was found to be .78. One item was found to actually lower internal consistency, with a coefficient alpha of .81 if that item were deleted. This item focuses on fear of death, which correlates poorly with the remainder of the test (r = .17). Split-half correlation was found to be .81.

The Spiritual Injury Scale showed a moderate correlation with the MMPI-2 Depression Scale (r = .33) and with the Psychasthenia Scale (r = .39). Correlations of the same magnitude were noted with scales 4 (Pshchopathic Deviant) (r = .39), Scale 8 (Schizophrenia) (r = .32), and the F scale (r = .30).

With respect to questionnaire items about religious behaviors, the Spiritual Injury Scale was significantly negatively correlated with self-report of overall religiosity (r = -.23) and with attendance at relgious services (r = -.23). Similarly, significant positive correlations were noted with self-reported frequency of "feeling spiritual emptiness" (r = .32) and "constant feelings of guilt or anxiety" (r = .46). More modest negative correlations were noted with respect to self-reported frequency of prayer (r = -.16) and reliance upon religion and God as a source of strength (r = -.18). No correlation was found with frequency of Bible reading (r = .01) or frequency of viewing religious programs (r = -.09). The Spiritual Injury Scale was found to be significantly higher in those subjects who reported a past history of child abuse (F = 16.3, p < .001).

Discussion: The current data provides clear support for the validity and reliability of the Spiritual Injury Scale. Coefficient alpha is within an acceptable range and would be improved with the deletion of the last item measuring fear of death. Inter-item correlations suggest that the remaining items are valuable and the split-half correlation is also within the acceptable range.

Correlations with self-reported frequency of religious behavior and attitudes are strongly supportive of the concurrent validity of the Spiritual Injury Scale. As would be expected, Spiritual Injury Scale scores were found to be negatively correlated with several key religious behaviors. It was highly correlated with anxiety about the experience of spiritual emptiness and anxiety or guilt.

Correlations with MMPI-2 scales provide support for the discriminant validity of the Spiritual Injury Scale. While it would be reasonable to hypothesize that the Spiritual Injury Scale may simply be a measure of depression or anxiety, the correlations with the MMPI-2 scales measuring depression and anxiety are only moderate in degree. The correlation with the F scale suggests that there may be a tendency for subjects tending to over-report symptoms to also score highly on the Spiritual Injury Scale. This may suggest that when it is being used in research, a validity scale such as the F scale should be included to improve the accuracy of the measure.

The current data suggest that the validity and reliability of the Spiritual Injury Scale would be improved with deletion of 1 item, resulting in a 7-item measure. Even without this change, the current data suggest that the Spiritual Injury Scale is a valid and reliable measure.

Appendix B - Holmes/Westberg Personal Health Inventory Scores

  • Personal Event or Change
    • Death of a Close Friend or Family Member: 75
    • Personal Injury, Illness or Hospitalization: 53
    • Pregnancy (or Pregnancy of Spouse or Significant Other: 40
    • Loss of Self-Confidence: 25
    • Outstanding Achievement (Graduation, Promotion, Etc.): 28
    • Change in Eating Habits: 15
    • Change in Sexual Activity: 39
    • Change in Sleeping Patterns: 16
    • Change in Energy Level: 24
    • Considered Suicide: 58
    • Change in Religious Belief or Practice: 19
    • Stress Related to Vacation: 13
    • Change in Relations with Parents: 19
    • Change in Recreational Time or Activity: 18
    • Trouble with the Law: 29
    • Change in Time Schedule: 15
    • Change in Drinking Behavior: 24
    • Change in Smoking Behavior: 24
    • Change in Drug Use: 24
    • Physical or Sexual Abuse: 75
  • Marital Relationship
    • Got Married: 50
    • Divorced: 73
    • Separated: 65
    • Became Widowed: 100
    • Started or Ended Living Together: 60
    • Disagreements Over Money Management: 35
    • Increased Emotional Distance: 32
    • Trouble with In-Laws: 25
    • Spouse Beginning or Stopping Work or School: 26
  • Household Events
    • Family Member Left Home: 29
    • Gain of a New Member (Birth, Parents Moving In, Etc.): 39
    • Spouse At Home More Than Before: 20
    • Problems with Children At Home: 30
    • Change in Residence: 20
    • Remodeling or Building: 15
    • Change in Health, Behavior, or Attitude of a Member of the Household: 44
    • Change in Neighbors or Neighborhood: 12
  • Vocational Event
    • New Job, or New Line of Work: 36
    • Quit Job: 40
    • Retired From Job: 45
    • Fired From Job: 47
    • Laid Off: 45
    • Promotion: 39
    • Demotion: 39
    • Disabled: 47
    • Less Job Security: 35
    • Trouble with Work Associates: 23
    • Change in Hours, Conditions, Travel, Etc.: 20
  • Financial Change
    • Changes in Financial State (Better or Worse): 38
    • Major Mortgage or Loan Taken Out: 31
    • Foreclosure of Mortgage or Loan: 30
    • Credit Card Debt: 20
  • Spiritual Dimension
    • Change in Relationship with God: 20
    • Change in Church Activity or Prayer Life: 19
    • Significant Spiritual Experience: 20
    • Spiritual Emptiness: 20
    • Constant Feeling of Guilt or Anxiety: 30

The total possible score for each category is as follows:

  • The Personal Events Score: 633
  • Marital Relations Score: 466
  • Household Events Score: 209
  • Vocational Events Score: 416
  • Financial Changes Score: 99
  • Spiritual Dimension Score: 109
  • Total Personal Health Inventory Score: 1932

© 2011 Spiritual Assessment. All rights reserved.

Website Builder