Thursday, 27 August 2009


Every job these days now seems to require some kind of qualificational (is that a word? It is now!) route into and through it, and the more organized these groups get the more some individuals will want to be recognized as ‘professional’. The professional counseling and psychotherapy association I belong to, the BACP, was created when individual counselors and psychotherapists decided that the public was suffering because counselors and psychotherapists had no accrediting body. They set up the BACP and approached the government to demand that only qualified counselors and psychotherapists be recognized as such. Today, people who are not qualified as anything can still offer their services as counselors. The government, who once took no notice of us, have now decided that they will only recognize psychotherapists and not counselors, which leaves a great many highly qualified counselors potentially out in the cold, and the BACP running about trying to catch up.

At the same time, the BACP created an accrediting scheme that can only be a box ticking exercise since it’s unworkable to have someone present during actual sessions to observe and assess. The BACP’s own research discovered that the greatest number of complaints are made against accredited practitioners.

(please cut and paste, my keyboard has no wriggly line!)

Nevertheless, the larger, more prestigious and higher paying employers of counselors and psychotherapists demand that we be BACP Accredited, not because they understand counseling and psychotherapy or because they want the best people for the job but because they believe that qualifications mean they will be getting a better practitioner and because they want people who are content with jumping through hoops in preference to thinking for themselves.

It’s no bad thing to know that a person has completed and qualified from a particular line of study. Pagans want this too, we don’t want someone calling herself Lady BlueBottle, Hereditary Witch Queen of Atlantis to be involved with, well anything really, but particularly not vulnerable people or representing Paganism. We’re all tired of the fantasy-driven pronouncements of too many Pagans and their incredible claims, and we know that this behaviour is not limited to teenagers. In the non-Pagan world we also know highly qualified and experienced professional people who are untrustworthy. Indeed, the more prestigious their status them easier it is for them to be untrustworthy.

What links these things together, from a growing number of US chaplains demanding access to patient notes and counselors and psychotherapists becoming mesmerized and deskilled by professionalism, to the growing number of very honourable and simple jobs becoming dependent on qualifications is status. Pagans are still struggling to have our status as a bona fide religion recognized, and the starting point for many individual Pagan chaplains in hospitals and prisons was the demand that this corporate status was acknowledged. Those Chaplains who overstep meaningful boundaries by demanding access to patients who haven’t requested it and patient notes, are motivated by the desire to have their personal status recognized.

All of which has nothing to do with accountability. We know that human nature is likely to try and get away with what it can, there’s little can be done about that other than the blunt instrument of punishment, and rather than waiting for behaviour to become criminal it’s probably wise to have an agreed standard of behaviour for different professions. Standardised teaching can achieve something like that and yet . . . when teaching establishments have to fulfill quotas in recruitment and pass rates, which all come down to keeping the institution financially above water it all becomes a bit meaningless. But it does keep the money rolling in.

In the US the Association for Clinical Pastoral Education Inc seems to be the largest representative body for hospital chaplains. They talk about people as ‘Living Human Documents’ and have detailed manuals and standards and an accreditation process and bylaws . . . all the stuff that makes an organization look very proper, professional and acceptable – and gives the organization and its officers high status. This is the group that has encouraged chaplains to demand access to patient notes believing chaplains to have the same status as medical professionals. Presumably, therefore, they believe that doctors have the same status as chaplains.

I’d like chaplains to be accountable to their patients and themselves primarily, then the hospital they work in, then their own Pagan community and then the wider world. But I don’t have a Pagan community, I work entirely on my own and so I’m only officially accountable to the chaplaincy office and the hospital which is perhaps good enough. I would really like a chaplaincy supervision group, Pagan or otherwise - almost entirely the same as my psychotherapy supervision group where I could discus in confidence how things are going. But there isn’t one, there aren’t enough Pagan hospital chaplains to create one and UK chaplaincy groups aren’t organized in this manner.

Long manuals and documents and acronyms do little to protect anyone. Libraries filled with complex and weighty tomes of case law and precedent don’t stop people from breaking the law. What does go some way towards curbing the desire to abuse power is mutual respect and support, keeping organizations small and intimate without becoming incestuous. It can be done. And it’s inevitable that such groups will have lower status and less income.

It’s important to know what the law of the land is and what hospital policy is but this doesn’t stop individuals from working – entirely within the letter of their professional standards – in a callous and burned out manner. (Thank you, Mogg) It is infinitely harder to create, maintain and belong to a small group that actually sees you and hears you, is responsible for and to you than it is to hand over your cash to an organization and perform the tricks they require for advancement which gives you a passport to prestige and greater income.

And of course doing things the hard way requires the patience to explain to the people in suits and the people who have been conditioned to trust anyone with a string of letters after their name, that membership of a professional body is no guarantee of a better service.

Wednesday, 26 August 2009

Status and limitations

Have a look at this article by two medical ethicists clearly declaring that hospital chaplains should not have automatic access to every patient or ever to patient notes. I acknowledged the part of my psyche that objected: “Bah! This is just another way of keeping religion in its lowly place.” But it isn’t. We know that there are individual chaplains who feel the need to impose their religion – they’re likely to perceive it as offering a very important service to vulnerable people. Indeed, we probably know of Pagan friends who found a Christian chaplain at the end of their bed offering their services, and how inappropriate that was. That’s an abuse of power.

I remember being fairly pushy myself when it came to having Paganism recognized in hospitals and I’m grateful for the other Pagan individuals and groups who’ve also made it their responsibility. Wherever there are institutions who have a chaplaincy service and who’re likely to have Pagans amongst them then Paganism should be officially represented on the chaplaincy panel, that’s pretty straightforward. That whole debate is about status, primarily the status of Paganism, but also about the status of chaplaincy.

If this is the case then we need to think hard about what chaplaincy is about and what our role is. Chaplaincy seems to me to be about perceiving a person as unique and as part of their own ‘ecosystem’ – relationships, history, hopes and dreams, fears, desires, abilities, the whole kit and caboodle - rather than simply as their diagnosis, and serving individuals and groups so that they can find meaning and purpose for themselves. I really like this quote

Helping, fixing, and serving represent three different ways of seeing life. When you help, you see life as weak. When you fix, you see life as broken. When you serve, you see life as whole. Fixing and helping may be the work of the ego, and service the work of the soul.

Chaplains are not part of the medical team. Although spirituality has a role in wellbeing and health this doesn’t mean that chaplains have the same role as doctors, nurses and radiotherapists. This is no threat to our status: we wouldn’t expect doctors, nurses and radiotherapists to be experts in spiritual care. I know that if I read a patients notes I will form a certain set of beliefs and expectations around those written words, it’s why notes are so confidential and the writing of them always under review. ‘Witty’ shorthand such as ‘FLK’ (Funny Looking Kid) is now recognized as reducing the humanity of the individual and being unethical and unacceptable. So it is that the chaplain – and every other person who isn’t directly concerned with the symptoms and cure of the patient – has no need to know anything about them other than what they see in front of them.

I’d say that the strict adherence to limiting who has access to patient notes is a measure of the quality of care patients receive. I know a very ethical, professional complimentary therapist working in a local mental health hospital who is given access to patient notes. She doesn’t take it but it’s not too surprising that the hospital is well known for the number of patients who abscond.

Certainly, doctors have a godlike status. Nurses are, of course, angels. I’m not sure where in the heavenly hierarchy radiographers might fall but as far as pay and conditions are concerned it’s somewhere above ward cleaners and canteen workers. That’s just the way it is, that’s a matter of society deciding that junior doctors and professional football players should be paid more than experienced nurses and firefighters. Chaplains, well we’re strange altogether, with Deity as our employer and the general public feeling both that they respect us and feel weird around us. For me, that’s just a symptom of our liminality and whilst that’s not always the most comfortable place to be it’s also entirely appropriate. This is not to say that chaplains should be content to creep around being thankful to be allowed into a hospital: that’s to get status and role confused.

Paganism should be given the same status as any other religion. Pagan chaplains should be treated with the same respect that other chaplains are offered, and all chaplains should be treated with the same respect as any other member of the healthcare team. But our role is not to tell people what’s best for them. Neither is it to do things at or to a patient. Although chaplains of all faiths have a responsibility to our gods and the culture of our religions we have a greater responsibility to offer something that other people who work in healthcare cannot: we offer love. We are with patients in a unique manner; we bring the empathy of the professional psychotherapist, the communication skills of mediators, and leadership functions of senior staff. We add a thorough, boundaried and flexible knowledge and understanding of our religion and, on top of it all, the wisdom that whatever a persons religion, spirituality or atheism they are equally worthy of our attention.

High status is lovely but the role of the chaplain is not to compete, it is to Be With people who have requested spiritual input. As long as that is facilitated in a quality manner and chaplains of all faiths are treated respectfully what more do we need, and why?

Monday, 24 August 2009

Note Keeping

Because of audits and keeping track of who is where with whom chaplains have to keep some notes. It’s worth remembering the intent of these notes, what they’re not intended for and how they may be used.

The written word has such enormous authority and at the same time can be so ambiguous as to be used and misused by people with very varying purposes.
There’s an art to note keeping, you need to record the fact that you and a particular patient met at a certain date and time and that’s it. There’s a temptation to go into detail and things can begin to unravel quickly, sometimes years after the event.

“X seemed excited today” can be read as “X was sexually aroused.” “X was agitated:” was that generally or specifically around you? Did that agitation have any connection to his behaviour later in the evening, and who did you inform about his agitation? If X goes on to offend or if a clinician or a barrister wants to make a point about X or about your relationship with X or with your way of practicing you can see how your own words can be used to prove something that you did not intend. If we use words that we don’t really know the full meaning of – like ‘manic’ or ‘depressed’ or ‘labile’ – then those words can come back to bite us, used both to prove something about a patient or to demonstrate our own lack of knowledge. You can imagine in a court being asked: “Can you describe what you understand the meaning of ‘manic’ to be? And can you tell the court what your professional qualifications are?”

I get a bit weary when overly anxious people start making noises about the desperate threat of litigation and how we must protect ourselves by messing everyone else about. Personally, as long as the patient, the ward staff and I are happy for something to happen, like taking a patient off the ward, then off we go. It would be so much more safe if we remained in a glass box with audio and videotaping but there are implications for the quality of our relationship. But. The written word supersedes memory in importance. Notes are, not unreasonably, assumed to be an accurate, contemporaneous record of events.

I write notes as if the patient is going to read them which helps me stay focused on what I’m communicating and how it may be read. It’s easy to forget that whilst we are afforded the same respect as other professionals in a clinical setting we are not serving the hospital but the patient. It’s tempting to try and match specialist language or to demonstrate to a putative professional reader that we function at the same level as they do; a paradoxical temptation since the less confident and settled we feel in the role of chaplain the more likely we may be to fall into this style of writing. In the very unlikely event that you’re asked to write anything more than the fact you met then you really should ask for written guidelines about how to write notes for that hospital, then discuss them in depth with the lead chaplain and write those notes under their guidance at the same time as keeping your highest ideal very clear in your own mind.

Perhaps the most fragile and important aspect of the relationship between chaplain and patient is trust and every attempt must be made not to break it. Patient confidentiality should be the basis from which anything is written. If you have a doubt about their safety or the safety of people around them, your notes are not the place to record this in the first instance, you should seek immediate and appropriate support, almost certainly from the lead chaplain. Before you discuss a patient with anyone else it’s an article of faith that you discuss it first with the patient themselves. Saying “I’d like to talk to my boss about this,” creates a space for meaningful communication, you’re demonstrating that you know your limitations, that you’re confident in discussing your limitations with the patient – because it’s not a matter of weakness to know when things are going beyond your remit, quite the opposite. And it models the normality and safety of knowing that we can’t deal with everything on our own, that discussing a difficult matter with someone trustworthy is worthwhile.

When you’ve talked with the lead chaplain and come to a decision, put that in the notes. A patient told me he was going to try to abscond. We talked about why and what this might achieve and so on and still, he declared he was going to try to escape. I didn’t actually believe that this was the case at all, but an expression of despair, a desire for boundaries and attention which would be achieved when I told the staff, which I was obliged to do. But first I told the patient that this was the case (as he knew it was) and that I would have to talk to my boss. I made a verbal contract with the patient that they would not abscond and not make a final decision about absconding until I’d spoken with my boss. Then I asked for an urgent meeting with my boss which primarily served to help me feel better about talking to the ward staff, 15 minutes later. My notes remained very short, about 2 sentences more than normal and limited to absolute fact. Life in hospitals is dramatic and gossipy enough: there’s no need to add to it or get caught up in it.

Confidentiality is entirely breached if you are summonsed by a court, which may happen if your patient does something unlawful or accuses the hospital of something unlawful. In my private psychotherapy practice I simply don’t keep client notes any more which simplifies matters no end and I shred my personal reflections, which are about me rather than clients, around a year after we finish meeting. But hospitals keep notes for a minimum of 5 years and particularly in psychiatric care they can be kept a lot longer and have the potential to be incendiary.

Some of the patients I see are likely to reoffend when they leave hospital and it’s possible that some years into the future I may be asked to give evidence in court. What are my responsibilities? Who am I serving? My answer is that I am serving the cause of truth, that I am not a judge or a jury and that justice will be served by them, not me. The relationships that are co-created with the people I see are delicate, part of the healing process is served by offering and being able to sustain deep trust. If they are then accused of something grave I have to just answer questions as faithfully as I can and put a great deal of trust in the Goddess. I fervently hope it never happens.

Note keeping is a vague subject at the best of times and there are differences between US and UK practice. In the US the Health Insurance and Portability Act appears to cover this minefield. (In an avalanche of impenitrable information, Wikipedia seems to have the best coverage. But my keyboard doesn't have a hash key and the link requires it.)

Here is something less fuzzy for US chaplains that is also of interest to UK chaplains.

Frankly, I have little idea what the Data Protection Act has to say on the matter but believe in keeping it really simple: I keep no chaplaincy notes on my own computer. I used to send my notes by email, but now write them at home, print them out, hand them over to the Chaplaincy Office at my next visit, and keep one copy in a file in a locked filing cabinet. If I know my next visit is going to be longer than a week I’ll write the notes at the end of the day in the hospital itself and take them to the office.

Wherever you practice your chaplaincy notes should be kept separate from the clinical notes. Although spirituality has a proven positive contribution to wellbeing and health, chaplains are not part of the clinical team for excellent reasons. We are not primarily concerned about cure or illness or insurance, it’s not our role to be involved in diagnosis or medication or anything other than the wellbeing of that persons essential being that exists beyond their body or their mind. It’s impossible to capture that relationship on paper and so lets not attempt to. Keep it simple: 'Met with X. Spirituality discussed'

Thursday, 6 August 2009

Missed Sessions

From time to time patients don’t want to come to sessions. At first I used to worry about this and tended to take it personally – what had I done to cause someone not to want to see me? This question remains part of my reflection on missed sessions but I’ve learned that frankly, it’s not all about me!

I don’t subscribe to the theory that there is no such thing as a meaningless occurrence: sometimes a missed meeting is just a missed meeting. And sometimes there is a greater pattern to events. It can be a test, to see if the discussion of returning as much personal authority to a patient as possible has any real meaning; to test that boundary and the boundary of continued relationship. If I am rejected, how will I respond? This has implications too for modelling how rejection might be managed in other relationships.

The therapeutic literature offers different understandings of missed sessions. My own experience suggests that if a client is serious about addressing their distress they will make the effort not to miss sessions. For some clients, therapy is the equivalent for them of buying a new handbag or doing yoga, it’s primarily a statement about who they believe themselves to be and how they want to portray themselves, and when something more interesting than therapy turns up they’ll give up therapy. Some clients are told to go to therapy, very often to gain access to their children or to mime their desire to change, and these clients too are very unlikely to really engage in the relationship. Why should they? They haven’t chosen to, they’ve been ordered to.

When a person finds themselves in an institution where conformity is given high value and behavioural modalities are to the fore they - we, you, I - will seek ways of not conforming at the same time as not being punished for non-conformity. Many of the people I see do this by saying they’re Pagan, which is also a way of demonstrating that the institution cannot fulfil their individual rights. Instead, they manifest me. I’m not part of the medical team and I’m not a mainstream representative. I’m not an employee of the hospital and I don’t have any institutional power. The first question they ask me is if I will do a spell to change their situation. Who can blame them for wanting to know where my boundaries are? I make contractual safety boundaries clear from the beginning “I don’t hurt you, you don’t hurt me,” and very early on in our meetings we talk about the importance of relationship and the uses and abuses of power.

For me, missed sessions can be part of that discourse. One or two missed sessions now and again, well, that’s life. Any apparent pattern can be interesting. A missed session with no reason given is worth talking about, several missed sessions in a row are definitely worth talking about, particularly if this happens around the same time that a client told me something that might result in shame for them, or if they’re also pushing other people away.

Authenticity is central to being Pagan, central to being a properly functioning human being and entirely peripheral to life in an institution. Institutions demand Approved Behaviour rather than authenticity. Just the right amount of crying, but no self-pity; being positive but not manic; sufficient sorrow for past deeds, perhaps even a little panic, but don’t get stuck there. In some US institutions it’s wise to become a very practiced, repenting Christian. For people with anything like psychosis this is terrifically dangerous. Knowing that you will be rewarded if you just consistently appear one way rather than another is very unhealthy. (Which is exactly how we are all expected to behave.) For people who then become dangerous to the people they’ve charmed, this has implications. As a Chaplain I don’t get told and have a positive disinterest in a patients past, but I’d be foolish to ignore the implications of our setting.

There’s an institutional significance to the notion of missed sessions for Chaplains. If a patient doesn’t want to meet with a psychologist or doctor or nutritionist or any other professional it’s too bad, they have to get to the meeting or the meeting comes to them. This is reflected in their notes, a judgement about them and their behaviour is made, formally and informally. If a patient doesn’t want to see the Chaplain, he doesn’t have to, and he doesn’t have to give a reason. This offers religious freedom, protection from religious abuse and is useful in other ways too. But the difference in response between any other professional service and the Chaplaincy service reflects the importance that spirituality – all of them, not just Paganism - is afforded by institutions. That’s not the end of the world. “Professionalism” is the last refuge of many things.

The liminality around the role of chaplains and spirituality offers more space in which to practice, and that’s a double-edged sword. We have to be very clear about our boundaries and behaviours. Once more, I am thrown back on the importance of authenticity: I need to be aware of my own responses. Am I annoyed, interested, bored, upset, sad, glad to be getting off early when a patient doesn’t want to see me? What does that tell me about the relationship, about my role, about my way of being? Once I have that clear-ish, I can bring my authentic self to the relationship. What happens when I say, “I felt dismissed when you wouldn’t meet with me last week. And I still care for you”? Possibilities, sometimes in the form of terrifying chasms, can open up.

Chaplains can offer a model of relationship which is caring, boundaried, deals with power with a clarity and complexity that may never have been encountered before. That’s a heady responsibility and a wonderful opportunity.

pic by Terry Border "Bent Objects"