By Donna Foley
One of the first pastoral visits I made in skilled nursing was to a woman religious. After I introduced myself, she responded, “You are very welcome here.” We began talking, and as she reflected on her vocation, she said, “We were told that if we left everything behind for Jesus, we would receive a hundredfold.” Opening her hands, she leaned back a bit in her wheelchair. Over the hum of her oxygen concentrator, she quietly concluded, “This is my hundredfold.” No hint of bitterness or irony was in her expression.
But when I sat down to write a useful chart note to the rest of the medical team, essentially I had to switch languages. And something was lost in translation. When I write for medicine, I am working in a second language. While I would like to imagine my colleagues and I share a common understanding of spirituality, neither of us should assume this.
In linguistics, code-switching is the practice of shifting from one manner of communication to another, depending on the social context or conversational setting. It was originally studied in terms of second-language acquisition. Most of us likely proved quite good at acquiring clinical speech as our second language.
In today’s medical world, the chaplain must show that her spiritual assessment has clinical value, but her colleagues need not show their clinical assessments have spiritual value. We face the challenge of finding common language, even in Catholic medical institutions like the ones where I’ve worked.
But lately I’ve been wondering, have we also adopted a spiritual language from medicine? The healthcare setting itself contains its own operative, but unstated, spiritual values. By “spiritual values,” I am not referring to Catholic social teaching in organizational practice (code-switching at its best), but rather conclusions about spirituality from within Western medicine.
In The Anticipatory Corpse: Medicine, Power, and the Care of the Dying, physician-philosopher Jeffrey Bishop argues that the discourse of psychiatric and medical practitioners emerging in the mid-to-late 1970s subsumed spirituality into the purview of medicine, leaving religion to the representatives of particular communities. He notes it is possible to trace in this discourse how the previous biomedical model was developed into the biopsychosocial one, and further expanded to the biopsychosocialspiritual model in current use.
One problem with this approach, I would suggest, is that it depends on an individualistic, ahistorical definition of spirituality. The resulting categories for spiritual assessment generally treat spirituality as one coping option among many, untethered to communal sources or obligations.
Chaplains explore whether the beliefs of patients or residents provide peace, meaning, or hope. In my experience, this understanding of spirituality is suited to a healthcare setting. But without knowing the flavor and content of particular traditions (even abandoned ones), misunderstandings can occur. This is where a chaplain’s code-switching ability comes in.
And medicine deems some manifestations of spiritual coping healthier than others. For example, in psychologist Kenneth Pargament’s Religious Coping Index (RCOPE), one set of items relates to belief in the devil (e.g., “The devil caused my cancer”). In the RCOPE scheme, this belief is classified as “negative religious coping.” It is “negative” in the sense that it is a harmful belief for the patient to hold, especially in relation to the patient’s health.
However, in “A Theological Assessment of Spiritual Assessments,” Harvard Medical School researcher Michael Balboni relates how in one study of terminally ill cancer patients, a belief that the devil caused cancer was “the only statistically significant question in Pargament’s RCOPE to be associated with better psychological outcomes.” Balboni writes that this finding “suggests that certain patients psychologically benefit by a theodicy which absolves God from blame and focuses on other spiritual sources as cancer’s cause.”
Without coming down on one side or the other in this particular question, it is enough to catch sight of the assumptions in this assessment tool. The researchers who developed the RCOPE seem to have a theological, as opposed to a psychological, position about what constitutes harmful belief.
At one care conference I attended, an elderly resident was asked, “And Frank, what is your goal for yourself?” He responded brightly, “To get to heaven!” The nurse recording notes exclaimed, “Oh no, Frank. You mustn’t say that. We want you here!” Frank was not expressing any harmful ideation, just his life’s real goal. It was in this conference, and in conversation with the nurse afterwards, that I began reflecting on the two different spiritualities operating in this care conference – the nurse’s and Frank’s.
Trained chaplains listen with their hearts’ ears to the people they visit and translate what they hear for interdisciplinary teams. The dominant language of healthcare – however holistic it strives to be – cannot entirely master the multiple, particular dialects of spirituality. So chaplains will need to continue skillfully code-switching.
Donna Foley, DMin, is a pastoral care team member at Saint Joseph Villa in Flourtown, PA.
