중 재 the spiritual assessment intervention the functions and activities of chaplains.

중 재

the spiritual assessment interventionthe functions and activities of chaplains

Specifying chaplaincy interventions ; Henry G. Heffeman

원목활동이 전문적인 활동으로 규정되기 위해서는 원목자간의 차이를 제한하고 용어 서술에 있어 모호함을 줄여야만 한다 .

원목활동은 단순히 환자와 있었던 일들의 나열이나 어떤 중재 유형인지를 정하는 것이 중요한 것이 아니다 .

각각의 중재나 활동들은 그 자체로서 보다는 그 목적에 따라 , 또 활동의 구조에 따라 , 사용한 의사소통의 내용에 따라 , 결과물에 따라 다양하게 이해할 필요가 있다 .

Purpose of the activity 같은 활동이라 하더라도 그 목적에 따라 틀려질 수

있다 . 환자 방문에 있어 영적 사정을 위한 것이 있고 , 깊은

대화가 있고 , 간호사나 의사의 referral 에 따른 방문이 있고 , 임종을 위한 대화가 있고 , 종교의식을 위한 것일수 있고 , 상담을 위해서 , 안 좋은 상황에서 지지를 위한 방문도 있고 , 지역 사목자를 대신한 방문일 수 이도 있다… .

원목활동의 목적은 그 구조나 내용 , 결과에 따라 달리 작용한다 .

the structure of the activity 구조라 함은 활동의 구성요소나 연속적인 단계를 의미한다 . 그러나 실제에 있어 그 단계나 과정이 엄격히 고정된

것이라고 볼 필요는 없다 . 예후에 따라서 얻고자 하는 목적이 또 다른 목적으로

바뀌어질 수도 있다 . 목적한 바에 이르기 위한 길은 매우 다양하다 . 환자의

반응에 따라 또는 어떻게 해야 바람직한 결과를 도출하는지 경험적으로 알고 있는 원목자의 이해에 따라 매우 다양할 수 있다 .

1. 환자의 진단이나 동료의 조언등을 고려한다2. 첫 사정이나 가정을 통해 환자의 욕구를 추정한다3. 영적문제를 가지고 환자와 대화한다4. One Core or principal problem 에 대해 식별또는

해석을 제한한다5. 원목자의 반응은 주된 문제에 맞춰서 중재한다6. 차트에 diagnosis 와 intervention 을 요약한다7. 환자의 사정 결과를 interdisciplinary team 과

교류한다8. 적절하다면 환자에게 제공된 것들을 가족에게

전달한다 .

the cognitive content of the communications

원목자가 설명하고 논의하려던 주제들이나 상호 주고받은 대화 속에서 사정한 개념들이 환자와의 의사소통의 내용이다

원목자의 중재활동의 어떤 내용은 쉽게 범주화 할 수 있지만 어떤 내용은 원목자의 경험에서 비롯된 내용들이기에 매우 광범위 할 수 있다 .

원목자의 경험이나 성향 , 교육 , 또는 전에 방문했던 결과에 따른 특별한 목적에 따라 원목자 마다 중재가 다를 수 있다 .

Self-worthReconciliationMeaning and direction

Meaning Existential Value Transcendence Connecting Becoming Coping Spirituality Religion Philosophical Peter Speck

the outcomes

계획된 중재에 따른 결과는 구체적이고 분명한 용어들로 언급되어야 한다 .

결과를 언급할 때는 달성되었는지 아닌지를 알 수 있는 표시여야 한다 . 달성했는지 , 덜 달성했는지 , 달성 못했는지 등 측정할 수 있어야 한다 .

방문 목적은 일반적인 범주로 규정될 수도 있지만 , 결과는 경험적으로 입증할 수 있는 정확하고 분명한 용어여야 한다 .

결과를 제대로 돌출했는지 알 수 있는 factors 환자의 core spiritual needs 가 무엇인지 그 요구에 대해 환자에게 적절하게 initial counseling

을 제공했는지 Interdisciplinary team 과 제대로 교류 했는지 필요하다면 가족들에게 제대로 알렸는지

다른 사람 Active-listening skills Identification of spiritual/emotional

issues Effective referrals to spiritual

specialists Ongoing communication

Practice of compassionate presence Listening to patient’s fears, hopes, pain,

dreams Obtaining a spiritual history Attentiveness to all dimensions of the pa

tient and patinet’s family;body,mind,spirit

Incorporation of spiritual practice as appropriate

Chaplains as members of the interdisciplinary health care team

White paper3. Supportive spiritual care 슬픔과 상실의 돌봄 치유되어야 할 영적 갈등을 규명 영적 사항과 관련된 촉진 (facilitation) 위기 개입 영적 사정 Caregiver 와 의사소통 부원 (staff) 간의 의사소통 촉진 Staff, 환자 , 가족들의 갈등해소 내외간의 협진 임종과 관련된 협력과 조언 부원의 개인적 어려움이나 업무 스트레스 해소를 돕는다 기관의 위기과 변화시 기관에 협력

5. Design and lead religious ceremonies of worship and ritual

기도 , 묵상 , 聖讀 예배와 거룩한 날의 준수 ( 주일참례 ) 축복과 성사집행 기일의 기념과 장례식 생일의 예식과 특별한 생의 날 기념

9. 종교적 전통에 따른 보완치료 상상과 이완 훈련 묵상 , 선수행 (meditation) 음악치료 Healing touch

. Spiritual care options or interventions Listening to the concerns, feelings, and beliefs of the patient Providing a safe environment and an attentive ear so that the pa

tient can express feelings and experiences associated with illness, stress, and dying

Providing opportunities for the patient to express grief, anger, despair, sorrow, happiness, joy, and confusion

Suggesting important relationships that might help the patient (sharing feelings with family/friends, chaplains, counselors,clergy)

Referring to professional spiritual care providers (chaplains, pastoral counselors, spiritual directors, clergy)

Spiritual Practice (yoga, meditation) Rituals, sacraments Worship and other spiritual services Prayer Sacred reading (scripture, other spiritual texts) Reflective readings from poetry, literature Journaling Reading groups (bible, other texts) Nature walks with meditation and reflection Joining spiritual support groups Puchalski

Spiritual support Be present and available to the family in a non-hurried manner Respect the family’s spiritual orientation and support their practices Encourage and support comments that reflect the family’s need for spiritu

al growth

Spiritual well-being Support and encourage the family’s use of spiritual resources as desired Assist the family in locating spiritual groups and resources in their commu

nity Support, acknowledge, and applaud verbalized comments of peace, harmo

ny, and satisfaction with family circumstances and relationships Encourage continual spiritual growth

Spiritual distress Attempt to determine the reason(s) for the distress, and support the famil

y’s efforts to examine their beliefs and values Acknowledge the family’s position, but if necessary, obtain their consent t

o consult with a spiritual leader of their preference Provide research-based evidence to the family about the positive impacts

of spirituality on family health and functioning Continue to display empathy, acceptance, kindness in a non-judgemental

manner Ruth Tanyi

Table 1 Guideline to spiritual assessment for familiesRuth Tanyi

meaning of lifeWho or what does the family consider the most meaningful?

What gives the family meaning in their daily routines? What gives the family peace, joy, and satisfaction?

Strengths What gives the family strength? What helps the family to deal with crises? What does the family do in order to rebuild their strength?

Relationships What do family members like about their family? Does the family have a relationship with God/Higher Power, universe, or other? If yes, how do they describe it? Is the family involved in community-based spiritual activities? If yes, which ones?

Beliefs What are the family’s beliefs? And what do these beliefs mean to t

heir health? Does the family practise rituals such as prayer, worship, or medita

tion?

Individual family member spirituality How do family members express/describe their spirituality? And what does this mean to their health? Are there conflicts between family members because of their spirit

ual views? If yes, what is the impact, if any, on the individual and family’s hea

lth?

Family’s preference for spiritual care How does the family describe/express their spiritual views? Can the family give examples of how nurses can integrate their spi

ritual views when working with them? Does the family consider anyone their spiritual leader? And if necessary, can the spiritual leader be contacted to assist wi

th providing care to the family?

Being with the patient Presence is standing with another, empathetic listening, and bei

ng fully present. 현존하는 데에도 여러 단계가 있는데 가강 이상적인것은 physic

ally, mentally, emotionally, and spiritually 환자와 같이 있는 것 (Taylor 2002)

개방적이고 솔직한 태도 / Actual listening : Effective and attentive 적절한 교감 : 말로써 또는 행동이나 몸짓 , 표정으로 환자와 현재 이루어지고 있는 일들을 느끼고 탐색 Aliving 적절하게 설정된 한계를 유지

Storytelling 신뢰를 형성 말하는 고통이나 문제를 규명하고 참여함 Skill 을 가지고 고통스런 느낌이나 감정을 해소해줌 희망적인 미래나 앞으로 행동을 설계하도록 도움

종교적 ; 기도 / 봉성체 / 영적대화 / 영적 돌봄 / 병자도유 상호적 ; 돌봄 / 희망유지시킴 / 지지 / 수용 / 만져줌 / 위로 /

존중 / 관계유지 관계적 ; 경청 / 방문 / 대화 / 나눔 / 노래 / 낭독 / 쓰기 / 논의 / 전문적 ; 탐색 / 의뢰 / 가르침 / 지지문제해결 / 지속돌봄 /

정보제공 / 조언 / 묵상

1. There is not much I can do to help myself. 1 2 34 5

2. Often, there is no way I can complete what I have started.1 2 3 4 5

3. I can’t begin to understand my problems. 1 23 4 5

4. I am overwhelmed when I have personal difficulties and problems. 1 2 3 4 5

5. I don’t know how to begin to solve my problems. 12 3 4 5

6. There is not much I can do to make a difference in my life.1 2 3 4 5

7. I haven’t found my life’s purpose yet. 1 23 4 5

8. I don’t know who I am, where I came from, or where I am going. 1 2 3 4 5

9. I have a lack of purpose in my life. 1 2 34 5

10. In this world, I don’t know where I fit in. 1 23 4 5

11. I am far from understanding the meaning of life. 12 3 4 5

12. There is a great void in my life at this time. 1 23 4 5

Prayer of St. Francis Listening for the Heart of Healing Hatred -----------------------------Love Communion * disconnected * isolated * separate * alone * angry *

suspicious * mad * cut off * refuse to talk to * divided family * unity * union * empathy * association * relationship* affectionate * fond of *care for * want to be with * connection * feel close to * adore *

Injury -------------------------------Pardon Grace * hurt * wary * wounded * upset * offended * pain *

guarded * distress * damage * caution * blame * broken heart * kindness * blessing * forgiveness * renewal ** forgive * excuse * absolve * release * go free * exonerate *

Doubt ------------------------------ Faith Awareness of the Holy * unsure * confused * hopeless * disbelief * don’t

understand * fear * skeptical * suspicious * anxious * distrusting * reservations ** sacred * reverence * divine * blessed ** confidence * trust * belief * assurance * steadiness * reliance * conviction *

Despair ------------------------------Hope Providence * misery * hopelessness * anguish * depression * gloom *

despondent * dejected * what’s the point?* fate * destiny * divine intervention * God’s face* expect * anticipate * wish * want * desire * look forward to * trust *

Darkness -----------------------------Light Repentance * dark night of the soul * shadows * can’t see * blind *

confusion * frozen * numb * heaviness * stuck ** regret * remorse * responsibility * sorry * contrite * * sight * vision * clear * open * opportunity * newness * vibrant * glow * alive * bright * future *

Sadness -----------------------------Joy Vocation/Purpose * grief * sorrow * unhappy * miserable * depression *

misery * melancholy * depressed * gloomy * woe * tears * * meaning * purpose * work * path * course * journey * calling * career * cause * future * giving back ** happiness * delight * creating * pleasure * fun * enjoyment * bliss * laughter *

Table C. Pruyser’s Pastoral Diagnostic Elements Pastoral Diagnosis Elements From The Minister as Diagnostician, by Paul Pruyser

1. Awareness of the Holy A. What is sacred? B. What is revered? (Is this idolatry?) C. Has the person experienced awe or bliss? D. How does the person experience personal limitations? 2. Providence A. What does this person feel is God’s intention for him or her? B. Is there cosmic benevolence expected? C. Is there a desire for guidance? D. Is there a desire for nurture? E. Distrust ------------------------------------- Trust F. Is this person a hoper (global, accepting) or a wisher (specific, prescriptive)? G. What does this person feel God has promised him or her? 3. Faith A. Does this person have an affirming or negating view of life? B. Embracing or turning away? C. Constricting and limiting or promoting greater openness and curiosity? 4. Grace A. What does the person say about kindness, generosity, giving? B. How able is the person to receive? C. What does the person show of forgiveness? D. How is gratitude felt and shown? E. What does the person do with a blessing given?

5. Repentance A. Is the person currently working to change for the better? B. How does the person see him or herself as responsible for the

situation? C. What is the person’s understanding and awareness of sin? D. What is the person’s inclination toward repentance? 6. Communion A. Does the person demonstrate connectedness with others? B. Is the view toward unity and inclusion or division and exclusion? C. Is the person more Embedded or estranged Open or encapsulated United or separated D. Does the person show patterns of estrangement? E. Where are the estrangements in this person’s life? F. Is there a sense of guilt and shame attached to feelings of alienation

and isolation? 7. Vocation A. What level of importance does the person place on work? B. What is the person’s vocation and what does it mean to him or her? C. Does the person show enthusiasm and engagement for work? D. How does the person relate “Divine Purpose” to vocation? E. Is the vocation congruent with the person’s ideals of Faith and

Providence? F. Stinginess --------------------------- Richness G. Gravity ----------------------------- Humor

Multimodal Assessment Guide: Family Interview Family: _____________________________ Date: ___________________Location: _________________________

__ Duration: ________________Members present (list): 1) __________ 2) _________ 3) __________ 4) ___________________________________________________________________________________ Follow-up Referral Scheduled next appt: ______________1. Presenting Problem:[i] __________________________________________________________________________________________________________________________________________________________________________________________________2. Transgenerational Patterns:[ii]3. Family Life Cycle:[iii] Person1YNGA2NEWM3CHLD4TEEN5LEAV6LATE4. Family Structure:[iv] (rate strength from 0 to 10)Parental: 1 ---- 2 ---- 3 ---- 4 ---- 5 ---- 6 ---- 7 ---- 8 ---- 9 ---- 10Subsystems: 1 ---- 2 ---- 3 ---- 4 ---- 5 ---- 6 ---- 7 ---- 8 ---- 9 ---- 10Alliances: ___________________ _______________________5. Communication Styles:[v] (identify members’ preferred styles) Placator: ___________________ _______________________Blamer: ___________________ _______________________ Super-reasonable: ________________ _______________________Distractor: ___________________ _______________________ Congruent: ___________________ _______________________6. Family Rules and Roles:[vi] (name those influencing current situation) 1. _______________________________________________________ 2. _______________________________________________________3. _______________________________________________________7. Ethnic, Cultural, and Socioeconomic Influences:[vii] ____________________________________________________________________________________________________________________________________________________8. Differentiation [viii] (rate from 0 to 100) _________Parent 1: _______ Parent 2: _______Child 1: _______ Child 2: _______ 9. Physical or Mental Conditions: (include any DSM diagnoses)_____________________________________________________________________________________________________________________________________________________________________________________________10. External Stress or Support: ________________________________________________________________________________________________________________________________________________________________________11. Dynamics of Symptom Maintenance:[ix] _______________________________________________________________________________________________12. Strengths: 1. _________________________ 4. _________________________2. _________________________ 5. _________________________ 3. _________________________ 6. _________________________13. Special Circumstances? ________________________________________________________________________________________________________________________________________________________________________________________14: Narrative Summary: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

[i] Satir, V. (1983). Conjoint family therapy. Palo Alto, CA: Science and Behavior Books. [ii] See Murray Bowen’s work as detailed on the Bowen Theory web site: http://www.thebowencenter.org/pages/murraybowen.html.

To learn more about genograms, consult Genograms: Assessment and Intervention, by McGoldrick, Gerson, and Shellenberger (NY: W.W. Norton, 1999).

[iii] Carter, Elizabeth and Monica McGoldrick. The Expanded Family Life Cycle. (Allyn & Bacon, 1998). [iv] Friedman, Edwin H. Generation to Generation. (NY: Guilford Press, 1985). [v] Satir, Virginia. The New Peoplemaking (Mountain View, CA: Science and Behavior Books, 1988). [vi] See “Life Commandments,” in John Savage’s Listening & Caring Skills (TN: Abingdon Press, 1996). [vii] To learn more about influencing factors on the presenting issue, see Narrative Means to Therapeutic Ends, by Michael White an

d David Epston (NY: W.W. Norton, 1990). [viii] See Murray Bowen web site; also, consult Generation to Generation (Friedman). [ix] See White & Epston, Narrative Means to Therapeutic Ends.

Mental Status Examination 1. Appearance a. General impression? b. Nature and appropriateness of clothing? c. Cleanliness? d. Unusual physical characteristics? 2. Behavior a. Attitude toward counselor (e.g., eye contact, willingness to respond to questions)? b. Habits (e.g., smoking, rocking) c. Movement retardation or agitation? d. Tremors or tics? e. Other unusual mannerisms? f. Apparent disabilities (e.g., visual, motor, auditory)? 3. Speech a. Articulation or communication difficulties? b. Speech pressured or slowed ? c. Unusual or idiosyncratic speech or word usage? 4. Emotions a. Observable emotions, including affect and immediate as well as underlying, long-standing emotiona

l states? b. Range of emotions ? c. Appropriateness of emotions ? d. Lability of mood ? e. Flat or blunted affect ? 5. Orientation to reality a. Aware of time (hour, day, month, year)? b. Aware of place (where interview is being conducted)? c. Aware of persons (who client and counselor are)? d. Aware of situation (what is happening)? 6. Concentration and attention a. Able to focus on stimuli? (Repeat three words in reverse order) b. Able to sustain attention? (Count backwards from 100 by 7s) c. Alert and responsive, lethargic, or distracted?

7. Thought processes a. Capacity for abstract thinking? (Explain a proverb: Early bird gets the worm) b. Flight of ideas or loose associations (skipping from one topic to another)? c. Repetitions or perseverations? d. Coherence and continuity in thoughts? e. Responses delayed, confused, or tangential? 8. Thought content a. Suicidal ideation? b. Violence, aggression, rage? c. Delusions? d. Obsessions or compulsions? e. Fears and phobias? f. Ideas of suspicion or persecution? g. Other prominent thoughts? 9. Perception a. Hallucinations (auditory, visual, other)? b. Other unusual sensory experiences? 10. Memory a. Adequacy of immediate memory (5-10 seconds) b. Adequacy of short-term memory? (events from earlier today) c. Adequacy of long-term memory? (events in the last few days) 11. Intelligence a. Educational level? b. Adequacy of fund of information? c. Level of vocabulary? d. Overall intelligence? 12. Judgment and insight a. Decision-making ability? b. Problem-solving abilities? c. Awareness of nature of own problems? d. Impulsivity? e. Nature of self-image, including strengths and weaknesses?

1. To review your life? 2. To be accepted as a person? 3. To participate in religious or spiritual services? 4. To feel hopeful? 5. To find meaning in the suffering? 6. To feel a sense of connection with the world? 7. To be thankful or grateful? 8. To address unmet issues before death? 9. For companionship? 10. To have someone pray with or for you? 11. For peace and contentment? 12. To experience or appreciate beauty? 13. To find meaning and purpose in life? 14. For guidance from a power outside yourself? 15. To live a moral and ethical life? 16. To experience or appreciate music? 17. To address concerns about life after death? 18. To give or receive love? 19. To perform religious or spiritual rituals? 20. To keep a positive outlook? 21. To read spiritual or religious material? 22. To talk with someone about death and dying? 23. For compassion and kindness? 24. To have a quiet space to meditate or reflect? 25. For respectful care to your bodily needs? 26. To experience or appreciate nature? 27. To forgive yourself and others? 28. To understand why this medical problem occurred? 29. To experience a sense of laughter and humor?

Table 1 Stoll’s guidelines for spiritual assessment (Stoll 1979, withpermission)1. ‘Concept of God or Deity’Examines theistic and to some degree religious elementsExamples of questions‘Is religion or God significant to you?’‘Is prayer helpful to you?’‘What happens when you pray?’2. ‘Sources of Hope and Strength’Investigates sources of support, particularly surrounding peopleand relationshipsExamples of questions‘Who is the most important person to you?’‘To whom do you turn when you need help?’3. ‘Religious Practices’Reviews the impact that an illness might have on the patient’sability to maintain religious practicesExamples of questions‘Do you feel that your faith (religion) is helpful to you?‘Are there any religious practices that are important to you?’4. ‘Relationship Between Spiritual Beliefs and Health’Explores existential issues such as the patient’s concerns orvisions for the futureExamples of questions‘What has bothered you most about being sick (or in what ishappening to you)?’‘What do you think is going to happen to you?’