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January 2023 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


Klitzman, R., Di Sapia Natarelli, G., Sinnappan, S., Garbuzova, E. and Al-Hashimi, J. "Exiting patients' rooms and ending relationships: questions and challenges faced by hospital chaplains." Journal of Pastoral Care & Counseling (2023): online ahead of print, 1/3/23.

[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]

SUMMARY and COMMENT: This is the third article to be featured on our site over the past year that draws upon data from interviews with a sample of chaplains from around the US [--see Related Items of Interest, §I, below]. Robert Klitzman and colleagues at Columbia University have focused on eminently practical aspects of chaplaincy, to contribute to the "mapping" of our profession [--see MS p. 2], and these articles show how qualitative study can yield a rich well of information for multiple analyses. The topic of exiting patients' rooms and ending relationships is one that is certainly understudied, in spite of its likely pertinence to clinical chaplains many times every day. This research, "the first to explore challenges that chaplains face in ending visits and relationships with patients and families" [MS p. 8], should help CPE students think about the task and spur more experienced chaplains to reexamine professional habits.

The participating 23 chaplains were between 42-75 years old, with a mean of 63, and had been practicing between 3-30 years, with a mean of 18.8. A table [MS p. 3] indicates that the group skews geographically toward the Northeast, with only a single chaplain coming from the West, but overall their comments may resonate with readers generally. A sample of the semi-structured interview questions is given in a table [--see MS p. 2]. The methodology, which "adapted key elements from 'grounded theory'" [MS p. 3], is nicely outlined [--see MS pp. 2-3], and the results are well organized and illustrated with primary quotes.

The authors compare and contrast the position of chaplains to that of other healthcare professionals, especially psychotherapists, for whom patient interactions are usually more structured (e.g., set visit time lengths and with limits set by insurance companies), making boundary issues potentially more manageable. Yet, even for other professionals, boundaries can be a challenge to negotiate, leading to such strategies as "detached concern -- remaining detached but also concerned" [MS p. 2] and intentionally "anticipating and addressing eventual endings of relationships" [MS p. 7], which may be instructive for chaplaincy practice [--see MS p. 7] and the subject of further research [--see MS p. 8].

In brief...chaplains struggle with how to end visits and interactions -- both individual conversations and longer, ongoing relationships with patients and families. These professionals confront questions and uncertainties, and rely on both verbal and non-verbal cues to gauge how long to stay with each patient and family and how to navigate each relationship, at times unsure or troubled by the limits imposed by institutional structures. [MS pp. 3-4]
When patients and families leave the hospital, chaplains can confront related questions about whether, when, and how to end relationships with patients and families that have sometimes extended over intense months or even years. ...Boundaries can therefore be difficult to draw and maintain, and severing these close bonds, often built up over extended periods of time, can be hard for patients as well as chaplains. [MS p. 5]

A summary figure [MS p. 5] lists "Challenges in ending meetings" and "Challenges in ending ongoing relationships," plus "Implications." Key points elaborated in the text include:


  •   "Chaplains felt that few, if any, specific concrete rules or guidelines existed concerning the exact lengths of visits. Chaplains thus often made these decisions based on their perceptions of dynamic interactions." [MS p. 4]

  •   "Patients and families can differ widely in what they want and require, and chaplains thus vary in what they offer. ...Patients and families may...hesitate to state their preferences or needs. Cues may be absent, subtle, minimal, indirect, or implicit rather than explicit. Chaplains must determine how to respond to such cues and are at times uncertain." [MS p. 4]

  •   "Given the inherent murkiness, chaplains commonly self-reflect on their prior decision[s]. " ...[However, chaplains] "tend to get little, if any, direct feedback from patients and families concerning whether the length of time spent was too little, too much, or the right amount." [MS p. 4]

  •   "Chaplains can also provide a silent presence that can be helpful, but its use and appropriate length in any particular encounter can similarly be difficult to gauge." [MS p. 4, and also see Related Items of Interest, §IV, below]


  •   "In part, 'closure' can be elusive since the stresses that patients and families face do not necessarily disappear, but can rather continue post-discharge. ...In varied ways, after hospital discharge, patients and families may therefore want to continue interactions with a particular chaplain.... Such continued interactions can range from very brief to relatively more involved and from symbolic to concrete." [MS pp. 5-6].

  •   "...[T]he strength of these ongoing bonds can astonish chaplains -- how meaningful these connections are to patients and families." [MS p. 6]

  •   "Terminating these bonds can be hard for chaplains as well [as patients]. Countless patients with serious diseases survive the hospital but then die at home; and emotionally, for both families and chaplains, these deaths can be hard. A chaplain can feel poignant grief over such a loss of patients." [MS p. 6]

  •   "After discharge, chaplains...may initiate interactions and reach out to certain patients or families. ...[C]haplains can therefore also vary through the course of their careers in whether they continue to visit, call or stay in touch with patients or families post-hospitalization, doing so more initially in their careers, and less over time." [MS p. 6]

  •   "Chaplains and patients also stay in touch through social media." [MS p. 6]

  •   "...[C]haplains may at times choose to convey their feelings of closeness to patients and families. ...[For example:] 'You may be leaving our hospital, but you're never going to leave our hearts.'" [MS p. 6]

  •   "On their own, chaplains have developed, too, ways of continuing these connections [to patients] symbolically by creating memorial objects. One chaplain, for example, makes posters for patients and families who may want to feel an ongoing, supportive bond with him." [MS pp. 6-7]

  •   "The present data suggest that chaplains can have strong positive countertransference feelings towards patients (i.e., feelings of closeness and attachment), and want to spend time with patients. Yet, many chaplaincy departments have limited resources and numbers of chaplains, and need to carefully consider which patients require the most attention." [MS p. 7]

The authors note the difficulty of negotiating the "inherent murkiness" [MS p. 4] of the interactive context of the chaplaincy encounter, the need for chaplains to "read non-verbal cues," and how patients and families are themselves in a developing process, "gauging and evaluating the benefits and impacts of interactions over time" --characterizing all of this as a "complex, dynamic choreography" [MS p. 7]. In addition, there are chaplains' own issues around personal investment in patients and feelings of loss and sadness when hospital patients are discharged or die, sometimes unexpectedly. Moreover, chaplains must contend with their own tendencies in managing transference and countertransference [--see MS p. 7 and Related Items of Interest, §II, below].

Klitzman and colleagues connect the issue of boundaries to "chaplains' understandings of the nature of their work, and [how they] raise ethical questions -- for example, regarding what responsibilities these providers have toward patients, how far these responsibilities extend, and whether these duties and relationships should terminate completely and abruptly at hospital discharge" [MS p. 8]. And, while there may be a need to set limits on interaction with patients, there may also be reason for chaplaincy departments to consider offering support post-discharge as well, if such ongoing engagement is thought to be "uniquely helpful, as opposed to a referral of the patient or family to local clergy" [MS p. 8]. Such an assessment, though, must "be balanced against the fact that chaplains may have limited time and should not be overworked or burdened" [MS p. 8].

The findings come from a sample of only 23 hospital chaplains, which may be a sufficient number for a good qualitative study, but they point toward ample possibilities for future research:

...for example, to assess more fully, with larger samples, how often chaplains encounter challenges with these issues (including, for instance, countertransference issues and chaplains' perceptions of the nature, extent, and boundaries of their responsibilities toward patients and families), when, in what ways, and how they address these challenges and whether any factors might predict which patients or families may require more interactions. Studies should also examine patients' and families' perspectives and preferences concerning the lengths of chaplaincy visits and relationships. Future research should examine these issues, too, among chaplains in other settings (e.g., schools and the military). [MS p. 8]

A subtheme of this article seems to be a concern for the care of chaplains themselves and a need for "[i]ncreased awareness of ways of drawing boundaries, and of the tensions involved..." [MS p. 8]. "Hospital chaplains are at risk of burnout, which overwhelming caseloads and feeling bogged down by the system predicts..." [MS p. 7]. The authors suggest that other professionals, like psychotherapists, may be helpful to chaplains' thinking about handling the practical demands of work with a sense of self-care. With this in mind, the article might be a means to open productive discussions between chaplains and psychotherapists, drawing upon the resources within a particular institution or perhaps the broad professional representation within the ACPE. On-line meeting technology, developed in recent years, should circumvent many logistical impediments for chaplains to meet with psychotherapists and others to think about similarities and differences in how interpersonal and intrapersonal dynamics, especially around boundary issues, play into practice and self-care.

One last comment: The overall difficulty of "reading" the interests and reactions of patients and families, including sensitivity to non-verbal cues, would seem to be exacerbated by the circumstance of telechaplaincy, where the scope and manner of interpersonal cues is shaped and limited by the medium. The effect of this on the dynamics of exiting a telechaplaincy interaction or ending a relationship virtually would seem to be an area for additional research and could lead to instructive comparisons with chaplaincy interactions that are in-person yet with patients who are physically or verbally constrained from full expression, such as with patients who are on mechanical ventilators.


Suggestions for Use of the Article for Student Discussion: 

This month's article should be very readable for any CPE student, and while its resonance may increase with the amount of a person's clinical experience and might be best suited for discussion later in a program timetable, it could also be used early as part of introducing the topic of leave-taking. Discussion could begin with a general sharing about students' own experience of exiting patients' rooms and ending relationships. Another approach could be to use the 14 major quotes in the text, and ask the group which ones stand out and why. (The ACPE educator might even urge students, prior to reading the article, to pay close attention to the illustrative quotes.) Have the students previously considered the topic of exiting patients' rooms and ending relationships, and do they see this as a bookend to the topic of entering rooms and introducing themselves? What are the circumstances that seem to make leave-taking problematic for them, and does the difficulty appear to be located in the needs of others, in their own needs, or in a basic lack of structures that would assist with boundary setting? Does leave-taking and boundary-setting create conflicts in chaplains' feelings of "calling" or motivation for entering into this line of service? Do feelings or thoughts of anticipation about boundary setting seem to interfere with patient care by distracting the chaplain or interjecting an agenda? Do the students worry about the risks in not setting boundaries (e.g., fostering dependence) versus risks in setting boundaries too rigidly (e.g., impeding a sense of presence)? How do they think patients and families feel about setting boundaries with them? How might patients and families be challenged in picking up on chaplains' indirect and non-verbal cues? When a chaplain allows for silence in the interaction, in the service of "presence," does that heighten attention to non-verbal cues? What may be some of the complications, as well as benefits, that could come from creating "memorial objects" [MS p. 6]? And finally, how much is social media a factor in the process these days? If the group wanders in discussion, Figure 1 [MS p. 5] could help keep the conversation organized.


Related Items of Interest:

I.  We have previously featured the work of Robert Klitzman and colleagues in June 2022 ("Hospital chaplains' communication with patients: characteristics, functions and potential benefits") and September 2022 ("How hospital chaplains develop and use rituals to address medical staff distress"), but see also the following articles that were written out of the same basic data from interviews with a national sample of chaplains:

Klitzman, R., Di Sapia Natarelli, G., Garbuzova, E., Sinnappan, S. and Al-Hashimi, J. "When and why patients and families reject chaplains: challenges, strategies and solutions." Journal of Health Care Chaplaincy (2022): online ahead of print, 11/26/22. [(Abstract:) Hospital chaplains perform important activities, but critical questions arise about the challenges they may face in working with patients, and how these professionals respond. Thirty-three telephone interviews of approximately 1 hour and were conducted with 21 board-certified chaplains. When asked about their biggest challenges and most rewarding interactions, several chaplains described rejections by patients or families. Patients and families at times rejected chaplains, and did so for six broad types of reasons - not wanting to discuss the disease due to conflicted feelings, including anger or frustration at the patient, the cosmos or God; or wanting to minimize it; wanting a chaplain of their own faith; or of a particular gender or other characteristic; being atheist or wary of religion; or misunderstanding what chaplains do. Patients at times also disagreed with family members about whether to reject a chaplain. Chaplains responded variously: feeling transitory hurt (which generally decreases with experience); respecting patients' autonomy and leaving; exploring reasons for rejection; and revisiting later and often then making helpful connections. These data have important implications for future practice, education and research regarding chaplains and other providers - suggesting, for example, how patients' families and the public might benefit from increased understanding about the field.]

Klitzman, R., Sinnappan, S., Garbuzova, E., Al-Hashimi, J. and Di Sapia Natarelli, G. "Becoming chaplains: how and why chaplains enter the field, factors involved and implications." Journal of Health Care Chaplaincy (2022): online ahead of print, 12/14/22. [(Abstract:) Many questions arise concerning how and why chaplains enter the field. Interviews of ~1 one hour each were conducted with 23 U.S. chaplains. Chaplains vary widely in professional and personal backgrounds and experiences, which they often draw on in their work. Personal experiences can lead them to enter the field, enhance their empathy and strengthen their commitment. They have frequently faced significant trauma (e.g., parent's death) or helped family and/or friends with end-of-life challenges. Chaplains often entered other fields first (e.g., clergy, business or healthcare), but they often had incomplete or incorrect prior knowledge about the field. Prior experiences can also affect their work (e.g., in recognizing the power of silence). A sense of personal "calling" frequently leads chaplains to find their work deeply rewarding and sustaining. These data, the first to explore how and why chaplains enter the field, have critical implications for future practice, education and research.]


II.  Our authors write: "Literature about chaplaincy does not appear to have examined countertransference issues" [MS p. 7]. Indeed, there has been a lack of focus on this subject in research, but the topic has been addressed in some chaplaincy-oriented sources. The following may be useful to chaplains for thinking about transference and countertransference not only for clinical care but also for the process of research. [Note: the UK Board of Healthcare Chaplaincy's "Spiritual Care Competences for Healthcare Chaplain" (2020) specifically mentions transference and countertransference as psychological concepts relevant to chaplains developing and updating their knowledge and skills for practice (--see Domain 1.1).]

Franzen, D. M. "Transference and countertransference in pastoral care, counseling and supervision." Reflective Practice 38 (2018): 179-199. [The author outlines three cases and uses transference and countertransference to explore clinical relationships. The article is written with emphasis on professional training and in light of the development of understandings of transference and countertransference, but it contains information and perspectives that may be valuable to clinical chaplains generally.] [This article is available online.]

McLean, G. "An integrative professional theory and practice paper: personal reflections from the journey through Clinical Pastoral Education." Journal of Pastoral Care & Counseling 69, no. 4 (2015): 201-214. [This reflection paper includes the author's use of counter-transference as a diagnostic tool to guide his self-awareness in his professional practice.]

Pedhu, Y. "Efforts to overcome countertransference in pastoral counseling relationships." Journal of Pastoral Care & Counseling 73, no. 2 (2019): 74-81. [This article, out of Indonesia, targets pastoral counselors, but its explication of the concepts here may be of interest to pastoral caregivers. (Abstract:) Countertransference is considered as a negative factor that may impede counseling relations but some assume that counter- transference is a normal reaction. The purpose of this article is to explore countertransference in pastoral counseling and efforts to overcome it. The author examines the concepts, approaches, and structure of countertransference. Previous research is also reviewed. Based on this review, the author elaborates some strategies that can help pastoral counselors to overcome countertransference in their counseling practice.]

van Zundert, M. J. "Perceptions of chaplains and patients on working with a narrative method in spiritual care." Master's Thesis, Tilburg School of Catholic Theology, Tilburg University (2021). [This document is of interest for the author's notes about the roles of transference (pp. 24-26) and countertransference (p. 27) in the research.] [The thesis is available online.]

Winfield, T. P. "Vulnerable research: What can chaplains and sociologists learn from each other?" Journal of Contemporary Ethnography 51, no. 2 (April 2022): 135-170. [The author is a spiritual care provider with experience in correctional as well as healthcare settings. In this article, she notes the importance of self-awareness training for field researchers in order to attend to the influence of transference and countertransference in the research process, especially when power dynamics are in play. See p. 144. This article was featured on the Chaplaincy Innovation Lab site (June 18, 2021).]


III.  Burnout among chaplains, from occupational stresses, has been the subject of four past Articles-of-the-Month:

Case, A. D., Keyes, C. L. M., Huffman, K. F., Sittser, K., Wallace, A., Khatiwoda, P., Parnell, H. E. and Proeschold-Bell, R. J. "Attitudes and behaviors that differentiate clergy with positive mental health from those with burnout." Journal of Prevention and Intervention in the Community 48, no. 1 (January-March 2020): 94-112. [(Abstract:) Clergy provide significant support to their congregants, sometimes at a cost to their mental health. Identifying the factors that enable clergy to flourish in the face of such occupational stressors can inform prevention and intervention efforts to support their well-being. In particular, more research is needed on positive mental health and not only mental health problems. We conducted interviews with 52 clergy to understand the behaviors and attitudes associated with positive mental health in this population. Our consensual grounded theory analytic approach yielded five factors that appear to distinguish clergy with better versus worse mental health. They were: (1) being intentional about health; (2) a "participating in God's work" orientation to ministry; (3) boundary-setting; (4) lack of boundaries; and (5) ongoing stressors. These findings point to concrete steps that can be taken by clergy and those who care about them to promote their well-being.] [March 2020 Article-of-the-Month]

Galek, K., Flannelly, K. J., Greene, P. B. and Kudler, T. "Burnout, secondary traumatic stress, and social support." Pastoral Psychology (2011): 60, no. 5 (October 2011): 633-649. [(Abstract:) The current study examines the extent to which selected work-related variables differentially predict burnout and secondary traumatic stress (STS) and the degree to which social support mitigates both of these occupational stress syndromes. Multiple regression performed on responses from 331 professional chaplains found that: (1) the number of years worked in the same employment position was positively associated with burnout but not STS; (2) STS, but not burnout, was positively associated with the number of hours spent per week counseling patients who had had a traumatic experience; and (3) social support was negatively related to burnout and STS. Only specific sources of social support (supervisory support and family support), however, were negatively associated with burnout. Results highlight the need for counselors to be attuned to not only their clients but also to their own inner dynamics in order to mitigate the possible deleterious effects of their work.] [October 2011 Article-of-the-Month.]

Hotchkiss, J. T. and Lesher, R. "Factors predicting burnout among chaplains: compassion satisfaction, organizational factors, and the mediators of mindful self-care and secondary traumatic stress." Journal of Pastoral Care and Counseling 72, no. 2 (June 2018): 86-98. [This study predicted Burnout from the self-care practices, compassion satisfaction, secondary traumatic stress, and organizational factors among chaplains who participated from all 50 states (N = 534). A hierarchical regression model indicated that the combined effect of compassion satisfaction, secondary traumatic stress, mindful self-care, demographic, and organizational factors explained 83.2% of the variance in Burnout. Chaplains serving in a hospital were slightly more at risk for Burnout than those in hospice or other settings. Organizational factors that most predicted Burnout were feeling bogged down by the "system" (25.7%) and an overwhelming caseload (19.9%). Each self-care category was a statistically significant protective factor against Burnout risk. The strongest protective factors against Burnout in order of strength were self-compassion and purpose, supportive structure, mindful self-awareness, mindful relaxation, supportive relationships, and physical care. For secondary traumatic stress, supportive structure, mindful self-awareness, and self-compassion and purpose were the strongest protective factors. Chaplains who engaged in multiple and frequent self-care strategies experienced higher professional quality of life and low Burnout risk. In the chaplain's journey toward wellness, a reflective practice of feeling good about doing good and mindful self-care are vital. The significance, implications, and limitations of the study were discussed.] [July 2018 Article-of-the-Month.]

Yan, G. W. and Beder, J. "Professional quality of life and associated factors among VHA chaplains." Military Medicine 178, no. 6 (June 2013): 638-645. [(Abstract:) Chaplains play a unique role in the Veterans Affairs (VA) health care systems and have numerous responsibilities. Compassion satisfaction (CS), compassion fatigue (CF), and burnout (BO) are three major phenomenons that have been documented in other helping professions, but little is known about VA Chaplains' professional quality of life. This study examines a national sample of VA Chaplains and their professional quality of life along with associated factors. Two-hundred and seventeen VA Chaplains completed an anonymous Internet survey, and regression analyses were conducted to determine which variables affect professional quality of life. On average, participants report high levels of CS and low levels of CF and BO. Gender, perceived support from VA administration, and mental health (MH) integration were significant predictors for CS. MH integration and perceived support significantly affected CF. Age, MH integration, and perceived support affected BO. Significant interaction effects were found for CF and BO. In summary, younger Chaplains and Chaplains who report low levels of collaboration with MH professionals are most likely to develop CF and BO. This supports continued support from the VA for interdisciplinary initiatives and mentorship of younger Chaplains.] [October 2013 Article-of-the-Month.]


IV.  The article mentions the use of silence in the chaplaincy encounter. For more on silence, see our February 2018 Article-of-the-Month: "Silence as an element of care: a meta-ethnographic review of professional caregivers' experience in clinical and pastoral settings."



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