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Theory and practice of chaplains spiritual care process: Apsychiatrists

experiences of chaplaincy and conceptualizing transpersonal model of
Ramakrishnan Parameshwaran

Harvard Divinity School, Harvard University, Cambridge, MA 02138, USA, Adibhat Foundation for Integrating Medicine
and Spirituality, Greater KailashI, NewDelhi, India


Background: Of various spiritual care methods, mindfulness meditation has found consistent application in clinical
intervention and research. Listening presence, a chaplains model of mindfulness and its transpersonal application in
spiritual care is least understood and studied.
Aim: The aim was to develop a conceptualized understanding of chaplains spiritual care process based on
neurophysiological principles of mindfulness and interpersonal empathy.
Materials and Methods: Current understandings on neurophysiological mechanisms of mindfulnessbased
interventions(MBI) and interpersonal empathy such as theory of mind and mirror neuron system are used to build a
theoretical framework for chaplains spiritual care process. Practical application of this theoretical model is illustrated
using a carefully recorded clinical interaction, in verbatim, between chaplain and his patient. Qualitative findings from
this verbatim are systematically analyzed using neurophysiological principles.
Results and Discussion: Chaplains deep listening skills to experience patients pain and suffering, awareness of his
emotions/memories triggered by patients story and ability to set aside personal emotions, and judgmental thoughts formed
intrapersonal mindfulness. Chaplains insights on and ability to remain mindfully aware of possible emotions/thoughts in
the patient, and facilitating patient to return and rereturn to become aware of internal emotions/thoughts helps the patient
develop own intrapersonal mindfulness leading to selfhealing. This form of care involving chaplains mindfulness of
emotions/thoughts of another individual, that is, patient, may be conceptualized as transpersonal model of MBI.
Conclusion: Chaplains approach may be a legitimate form of psychological therapy that includes inter and intrapersonal
mindfulness. Neurophysiological mechanisms of empathy that underlie Chaplains spiritual care process may establish
it as an evidencebased clinical method of care.
Key words: Chaplain, empathy, healing, mindfulness, mirror neuron, religion, spiritual

Spiritual care is reportedly provided in various forms
such as prayers by religious/spiritual(r/s) care providers
in hospital settings,[1,2] faith healers at religious places of
Address for correspondence: Dr.Ramakrishnan Parameshwaran,
Center for Study of World Religions, 42 Francis Avenue,
Cambridge, MA 02138, USA.
E-mail: par469@mail.harvard.edu

How to cite this article: Parameshwaran R. Theory and

practice of chaplains spiritual care process: A psychiatrists
experiences of chaplaincy and conceptualizing trans-personal
model of mindfulness. Indian J Psychiatry 2015;57:21-9.
Indian Journal of Psychiatry 57(1), JanMar 2015

worship[3,4] or as part of traditional, complementary and

alternative medical(TCAM) treatments.[5,6] Over the last
several decades, in United States and few other developed
nations, hospitalbased r/s care services had evolved
into a professional department of chaplaincy/pastoral
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Parameshwaran: Theory and practice of spiritual care

care.[7,8] The spiritual care providers from this department

are called as chaplains. While the rest of the world may
still be unaware of this specialized profession, pastoral
care providers/chaplains are graduates, with masters
degree in theology, and they undergo rigorous, 1year long,
nationally accredited training[9,10] in providing spiritual care
to hospitalized patients. This training and education, called
as ChaplainResidency and clinical pastoral education(CPE),
helps a chaplain to provide spiritual care to pluralistic
patient population without the necessity of prayer/religious
rituals and/or other techniques of TCAM.
Research studies on chaplaincy have focused on
understanding their role in health care,[11,12] their service
utilization,[1315] as well as the clinical outcomes of
their services,[16,17] but there are no studies describing
their spiritual care processes and/or possible scientific
mechanisms underlying this approach. This paper presents
a typical clinical interaction between a chaplain and his
patient. It focuses on understanding possible mechanisms
underlying chaplains spiritual care while describing the
care process for informed understanding of chaplaincy by
other health care professionals.
The authors experiential understanding of the theory and
practice of chaplains spiritual care process is described,
followed by literature review on the current understandings
mindfulnessbased interventions(MBI) and interpersonal
empathy with an attempt to build a theoretical framework
for the chaplains model of care. Achaplainpatient clinical
interaction is presented in verbatim demonstrating a
typical spiritual care process in chaplaincy, and it is used
for a qualitative basis in this paper. The literature review is
used to explain/analyze how what happens in the verbatim
may be explained by neural mechanisms. With examples
of empathetic interactions from the verbatim and the
neurophysiological theories demonstrating one another,
this paper attempts to conceptualize chaplains care as a
transpersonal model of MBI.
Introduction to chaplains model of spiritual care
Described as Listening Presence, the chaplains model of
spiritual care is described by Wolfelt[18] in his single author
textbook/guide for chaplainsintraining and this is the
model of care adapted effectively by CPEtrained chaplains,
however not grounded in any scientific theory. The steps in
this model of care includes, a chaplain(1) actively listening
to emotional pain and struggles in a patients story(2)
becoming aware of how the patients story is triggering
emotional memories within,(3) remaining mindfully aware
but without suffering from them(4) avoiding cognitive
calculations or judgments about patients behavior or lifes
choices,(5) returning focus to empathize with patients pain/

struggles using verbal and nonverbal communication,(6)

facilitating patient to share painful emotions/stories, which
increases their intrapersonal awareness(7) while resisting
own urge to rush the patient out of their pain and suffering,
that is, avoids making treatment plans for the patient.
Thus, with its key ingredients of empathy and mindfulness
of patients emotional state, this model of Listening
Presence has close resemblance to the MBI;[19] which in the
context of a dyadic relationship such as chaplainpatient
interaction takes a transpersonal/transcendental form of
mindfulness. Mindfulness meditation and its intervention
in clinical care has been the most widely studied model
of spiritual care;[20,21] elaborate understandings on the
neurophysiological mechanisms of this model would serve
to build our theoretical framework of chaplaincy process.
Literature review on mindfulness based intervention and
interpersonal empathy
Mindfulness meditation and its application in medicine
Mindfulness is a meditative art of being in a state of
nonjudgmental, compassionate and purposeful awareness
of thoughts and feelings that arise in the present moment
within an individual.[22,23] Because of its positive effects on
wellbeing, in the last few decades it has been increasingly
incorporated to augment existing cognitive and behavioral
therapies.[1921] These MBI typically start as therapist guided
meditation sessions which progress into independent
patient practice.[21] The aim of MBI is to enhance
metacognitive awareness of negative selfdepreciative,
automatic, ruminative thoughts and feelings as mere
mental events rather than aspects of or direct reflections
of truth.[24] In the parlance of chaplain/pastoral education
metacognition is described in terms of innerdialogue[25]
which enhances exploration of ones own experiences in
newer ways[26] and strengthens their responsibility for their
feelings, values and perceptions[25] allowing the individuals
to become compassionate witnesses to their own painful
experiences ultimately leading to selfhealing.[27]
Neurophysiological mechanisms of emotional pain, suffering,
mindfulness and healing
Physiologically, the hippocampus and amygdalaparts
of the limbic brainwork together to detect emotional
threats from current events[28] based on past memory/
historical experiences; of the two, amygdala is the alarm/
freightraiser,[29] sending impulses to all parts of the
brain for effective flight/fight action. Pathologically,
hyperfunctioning of amygdalae causes excessive
ruminations of past pain and/or worries about the future
which characterizes suffering and depression[30] and
other psychiatric symptoms such as anxiety, panic or
paranoia. On the other hand, cortical circuits arising from
hippocampus, cingulate, prefrontal and temporoparietal
areas, involved in learning and memory processing, help in
modulating cortical arousal and its responses to emotional
stimuli.[31,32] Insulayet another cortical regionis
Indian Journal of Psychiatry 57(1), JanMar 2015

Parameshwaran: Theory and practice of spiritual care

reported to be responsible for selfawareness of internal,

both nonconscious physical and emotional sensations,
as well as the awareness of conscious motivational and
social, feelings.[3335] Mindfulness training, as evidenced
by neuroimaging studies, increases thickness of the said
cortical areas to enhance their attention monitoring systems
and improve conscious awareness of the internal emotional
sensations. It effectively modulates emotional arousal and
cultivate compassion while downregulating emotional
centers such as amygdala.[31,3639] Mindfulness meditation also
trains the prefrontal cortex to promote stable recruitment
of nonconceptual sensory pathwaysan alternative to
conventional cognitive reappraisal strategieswhich in
turn reduces habitual negative selfevaluative processing
of the brain, and consequentially leads to healing.[20,31]
Vago and Silbersweig[40] suggest that mindfulness training
enhances the cortical control system by integrating various
parts of the frontal, parietal and even cerebellar areas of
the brain responsible for metamonitoring necessary for
selfawareness and selfregulation of emotions.
Though MBI has been reported to be very effective in
various medical and psychiatric disorders, clinicians and
researchers conclude that it is difficult to apply in acutely
symptomatic patients.[41,42] However, chaplains do visit even
acutely illpatients(physically and mentally), to provide
an empathetic presence, which helps in selfregulation of
emotions within those symptomatic patients. Therefore,
understanding the chaplains transpersonal model of MBI
may become more important even for acutesetting patient
Theories and neurological mechanisms of interpersonal empathy
Based on our emotional experiences, when we intuitively
conceptualize the existence of a nonobservable entity
such as a mind then we are said to have a theory of
mind(ToM). Further, this ToM helps us deduce that other
individuals also have a mind, and this knowledge helps us
to understand the emotions and feelings of others.[43,44]
Empathy is described, by neuroscience researchers, as
having a capacity to experience the feelings of others within
oneself as if those emotions are ones own;[45,46] Spiritual care
providers[25] also describe empathy in the same way and
hence the mechanism underlying interpersonal empathy,
as understood by neuroscientists may be acceptable to
spiritual care professionals as well. Neuroscientific research
on ToM,[47] and Simulation theory[48,49] helps us understand
the mechanism of interpersonal empathy. This empathetic
process is said to be processed by a network of neurons that
are active during an individuals own cognitive and motor
behavior as well as when that individual sits merely observing
the behavior of others;[50,51] this set of neurons is called as
mirror neuron system(MNS). Further studies revealed that
these mirror neurons not only respond to the observed
physical activities of other individuals but also involuntarily
resonates/mirrors the feelings as well as being responsible
Indian Journal of Psychiatry 57(1), JanMar 2015

for understanding the intentions and motivations behind

the actions of others thereby establishing empathetic
connection between two individuals.[47,5255]
Ramachandran and Brang[56] reported that this resonance
comes from a dynamic equilibrium between individual
brains; other researchers suggest that resonance is due
to an individuals involuntary and unconscious ability
to develop theories (ToM) about what another person
is thinking.[45] Oberman et al.[57] elaborate that MNS in an
individual functions by matching the external environmental
perceptions with preexisting representation present
within their internal sensorymotor cortex of the brain.
Researchers[58,59] suggest an interplay between the ToM and
MNS mechanisms to produce the emotional contagion[60,61]
and empathetic understanding of others while invoking
selfempathy within the individual recipients in the
relationship,[62,63] and in case of a patientrecipient this
invoked selfempathy helps in producing desirable clinical
benefits. Judging other persons weaknesses, wisdom,
intelligence, and intentions is a major stonewall that
prevents interpersonal empathy; suspending judgment is
another major process in interpersonal empathy,[25] which,
again, is a function based on metacognition and insular
Similar to the analogy of a waterfall versus
neurophysiological mechanisms reviewed above are tied to
various reallife examples of mindfulness, and interpersonal
empathy noted in the verbatim of chaplainpatient clinical
interaction described below.
Study setting and methodology
This clinical encounter occurred on the medical floor of a
tertiary care medical center under the Franciscan Health
System(FHS), a Catholic institution in Washington, USA. The
primary encounter that is reported in this paper was about
45min long, there were couple of brief, 15min, followup
visits, the highlights of one of them is included in this
paper/table. The patient is an elderly Caucasian, American,
devout Christian, female patient with a history of recurrent
pneumonia, under investigation for a possible lung cancer,
currently her symptoms were in remission. The patient
was also diagnosed with mild depression. As described
elsewhere in this paper, so as to provide a nonjudgmental
presence this chaplain avoided knowing patients diagnoses
prior to visiting with the patient. Hospital guidelines were
followed to take care of issues related to patient privacy
and informed consent.
The spiritual care provider/chaplain in this case is a
psychiatrist by profession and he could draw on all
his knowledge in neuropsychological mechanisms of
interpersonal empathy as well as psychotherapeutic skills
obtained from past professional training and experience.

Parameshwaran: Theory and practice of spiritual care

While psychotherapeutic skills enables the spiritual care

process, intellectual activities such as diagnosis and
treatment plans, that are essential part of psychiatric care
are in fact judgmental behavior and hence a hindrance in
establishing and maintaining the ToM basedempathic,
healingloop between the provider and the patient[Figure1].
Spiritual care residency training provides a chaplain the
skill in staying with the feelings, avoiding all distractions
including diagnosing and/or planning the next steps in
treating the patient that are normal processes of psychiatric
assessment and care. Nonetheless, this author believes that
the desirable clinical outcome in this case was due to his
past training in psychiatry and psychotherapy along with
regular practice of mindfulness meditation that helped him
in strengthening listening skills of chaplaincy. Though the
patient was unaware of this chaplains psychiatric/medical
background, her appreciative comment[Appendix1, P32]
would make the reader wonder as to what qualifies a person
to be called as a physician, in the eyes of a patient.
The whole chaplainpatient interaction was recollected,
as much as possible out of memory, recorded in
verbatim[Appendix1] by the chaplain, immediately after
exiting the patients room so as to maintain the accuracy of
the qualitative data. The encounter is traditionally organized
into three columns, for CPE studies:(1) Patientchaplain
interaction, verbatim,(2) objective observations of patient

and self/chaplains behavior, and clinical environment

and(3) subjective description of chaplains own thoughts
and feelings. Further, the qualitative clinical data from
the verbatim is systematically organized and studied
under two separate, chaplain and patient phases, which
actually occurred concurrently as seen in the schematic
Analyzing the qualitative data[Appendix 1]
Chaplains phase
Chaplain enters the patients room mindfully aware of his
emotions/curious feelings. Mindfulness is known to prepare
an individual to remain aware, be receptive to newer and
ever changing emotions,[22,23] which helped chaplain remain
calmly aware of his emotions triggered by the clinical
situation(S2, S8) as well as remain dynamically present to
patients ever changing momentary emotions and fleeting
thoughts(P4). Being mindful also helped chaplain to become
aware of how patients stories are triggering his emotions
and memories(S15). Mindfulness improves individuals skills
to listen deeply to understand the patients emotions and
thoughts in a better way;[63] with his deep listening skills, the
chaplain, reflectively and vicariously feels and understands
the patients pain and suffering accurately(P16, C11, P17).
Using ToM,[43,44] the mindful chaplain became fully attentive
to patients facial expressions, body language and emotional

Figure 1: Schematic representation of the intra and transpersonal model of mindfulness in a chaplains spiritual care process

Indian Journal of Psychiatry 57(1), JanMar 2015

Parameshwaran: Theory and practice of spiritual care

stories and connected those dots with his own internal

emotions, thoughts and was thus able to match the patients
emotional struggles with similar ones of his own(S2, S15).
It helped the chaplain to empathize with patients pain/
struggles.[47] As described elsewhere, neurologists describe
this process in terms of ToM[47] or simulation theory[48,49]
which also involves MNS networks of empathy. Chaplains
mindfulness also includes metacognitive abilities that help
in setting aside judgmental thoughts and avoiding advice.
Conventional wisdom of helping such a patient as in this
verbatim would include statements such as eat something,
you need some energy(S8), or asking what happened
to your husband, how did he die? or dont worry about
your cat, your friends will take good care of it(C8, C10
not shown in truncated table). Statements such as these
would belie a chaplains ability to stay mindful of patients
painful emotions. They demonstrate his own need and/or
internal urge to move quickly to a more comfortable place
of cognitivesolution seeking role. While, staying with the
feelings that underlie patients statements demonstrate
chaplains empathy to patients painful emotions as well
as to her maladaptive cognitions. Patient starts to model
the chaplain in staying connected with her own emotions
and that in turn helps the patient to selfempathize with
her own painful feelings. As a provider, chaplain returns
and rereturns his focus to be mindful of patients pain and
sufferings; sharing only his empathetic feelings of patients
pain and suffering and avoids cognitive derivations of
those feelings(C11). He facilitates the patient to share
more of her stories, using carefully worded openended
and selfreflective statements expressing/labeling the
Patient phase
Initiated by the chaplain(C3, 4), patient shares her painful
stories and becomes unconsciously aware of her emotions/
thoughts(P4, P8) and further, observing the chaplains
emotional expressions, she reflectively and consciously
starts to feel her own emotions. Patients intrapersonal
mindfulness improves further as she poses a question,
probably rhetorically, when she said, How does it
feel?(P11). Also likely, she was hesitant/afraid to even look
at her own painful emotions; then probably encouraged
by the chaplains continued attention to her painful/fearful
emotions, she confronts them herself(P16, 17). With each of
patients story chaplain responds with expressions labeling
those painful emotions which helped the patient to identify
reflectively and become aware of her own feelings(C11).
Needless to say, even this patient was equipped with
her own ToM. However because of the intensity of
emotional preoccupation she was unmindful of her own
emotions. Initially the patient did not care for anything
outside of her selfconsuming thoughts, she had poor eye
contact(O2) and she would not care whether the chaplain
was a Catholic or Protestant or a Rabbi(P2) but eventually
Indian Journal of Psychiatry 57(1), JanMar 2015

comes out of her preoccupations to be able to focus on

the externalby inquiring about the chaplains whereabout and faith tradition. She breaks off from her negative
automatic thoughts and starts to inspect and corrects
her own thoughts and speech (P19,P20a, b); this may
be chaplaininduced metacognition within the patient
or rekindling of her ToM. Patient returns and rereturns
to feel her emotions by retelling her painful stories in
greater depth and details(P16), indicating her feelings of
comfort and security of an empathetic and nonjudgmental
chaplain; clearer understanding of self and others[65]
rapport building are described to be functions of MNS.[65,66]
Development of rapport indicates initiation of patients
transpersonal mindfulness which becomes obvious when
she starts to reflect on the intentions of the empathizing
chaplain(P18). While ToM is known to help us understand
the emotional intentions behind the behavior of others,
MNS provides us the neural basis for that understanding.[67]
Patient comes to feel and believe that the chaplain is able
to empathize with her painful emotions without judging
her. Empathetic behavior can be automatically grasped by
the observer through MNS mechanisms;[50,51,54,55] chaplains
behavior becomes involuntarily and reflectively mirrored
by patients brain[48,49] leading her to develop improved
awareness(P19-20, S34) of her painful emotions and
automatic judgmental/negative thoughts. As the patient
remained aware of them without feeling the need to move
away, reflecting the chaplains behavior, intuitively she
understood that those thoughts and emotions are mere
works of her mental activities and not actual truths[22] thus
leading to selfempathy/compassion and eventual healing.
Improved clinical outcome was evident from her
improved eye contact, reversal of sad, angry mood(O34),
becoming cheerful, relaxed(O36) making positive
statements, and attending to her nutritional needs(P25,
26-not shown in table). Her cheerful mood continued
into the followup visit, the next day when she thanked
the chaplain profusely for the previous night visit saying
that she woke up(in the morning) with feet above the
grass and had a good breakfast. Patients friend had also
acknowledged the improved mood of the patient(P29,
O52- not shown in table).
Improved awareness of emotions and metacognitive abilities
indicates activation of patients insular[3335] and cortical
functions[31,3639] respectively, which subdue amygdala
leading to reduced emotional reactivity[29] resulting in
selfhealing evidenced by the significantly desirable clinical
outcomes. Spiritual care process of a chaplain involving
his mindful empathetic presence to another individuals
emotional pain and suffering may be understood as
transpersonal mindfulness mediated through ToM. The
existence of such a process may be empirically evident
from the significantly desirable outcomes noted in this

Parameshwaran: Theory and practice of spiritual care

clinical encounter, and this argument is best supported

by evidencebased, neuroimaging studies validating
the existence of providerpatient empathicloop by
lightingup interpersonal corticocortical connections
that are described by MNS.[70]
Though this chaplains intervention resulted in significantly
desirable clinical outcome, some of his subtle subconscious
thoughts(S15, S20) may have influenced the way the
interaction took shape; there can be several educational
pieces from this verbatim for chaplaincy but they are not
the focus of this paper. As Rev DrJohn Switon[64] suggests,
in our attempt to study spiritual care process from a
scientific perspective, we had to deconstruct the beautiful
waterfall of a chaplainpatient empathic interaction into
two separate, chaplain and patient, phases as well as into
two, intra and transpersonal, modes of mindfulness. While
such breakdown is necessary for better understanding of
various components of this complex process of chaplaincy,
it also robs the process of its various other unmeasurable
qualitative aspects. With mindfulness processes occurring in
both chaplain and the patient, healing process may also be
occurring in both of them, and no doubt, it is a common belief
among chaplains that spiritual healing is never provided but
received by both individuals in a dyad. Chaplains mindfulness
helped him to instantly and reflexively feel patients
painful emotions and stay with it leading to the desirable
clinical outcome observed at the end of the visit. The
clinical benefits could be mediated through ToM and MNS
mechanisms leading to the corticocortical connections[55]
and the dynamic equilibrium[56] between chaplain and
patients brain. The chaplain, being a psychiatrist, was
able to draw on his knowledge of neuropsychological
processes involved in providerpatient interaction. Training
in mindfulness meditation further helped him to remain in
the everchanging present moment during the clinical visit.
Thus, this author believes that, training in both psychiatry/
clinicalpsychology and mindfulnessbased methods of care
are essential for an effective chaplaincy.
The clinical outcome may also be dependent on various
provider variables such as a chaplains personal practice of
mindfulness meditation and unmeasured patient variables.
Some of the patient variables that may have contributed to
the outcome would be milder symptoms and the wisdom
of an elderly person who could touchbase with her innate
strengths in mindfulness reinspired by the chaplain; one
would imagine that it will be highly impossible to regain
ones strengths of mindfulness within one session. The
clinical outcome, even though very positive, may also be a
fleeting change in patients behavior.
Implications of this study
This paper is first of its kind to illustrate a chaplains spiritual
care process of listening presence in terms of mindfulness,
and with this we attempt to bridge the chaplains clinical

care model with that of MBI programs. Further, by

conceptualizing a transpersonal form of mindfulness,
which may be applicable in acute care settings, we can
establish chaplaincy as a powerful model of spiritual care.
Defining chaplaincy as an MBI model would attract clinicians
and researchers towards chaplaincy, deservedly, with the
same vigor they bestow on MBI programs. Achaplains care
may be viewed as a forerunner to introducing patients,
nave, to mindfulnessbased techniques. Chaplains being
recognized as experts in spiritual care[71] may benefit by
identifying the key element of mindfulness in their model
of care and understanding neurobiological processes
involved in it. Illustrating neurological processes underlying
chaplains spiritual care will help in bridging chaplaincy
with neurosciences and establish it as a scientific clinical
subject. Training and practice of meditation is reported to
activate brain circuits linked with empathy and ToM for an
enhanced and effective response to emotional stimuli,[72]
promoting mindfulness in psychotherapistsintraining had
significantly improved the desirable therapeutic course
and outcome among their patients.[73] Clinical outcomes of
chaplains spiritual care may as well improve by promoting
mindfulness in chaplaincy training. While MBI programs
may adapt the chaplaincy model to care for their actively
symptomatic patients, clinical chaplains may consider
incorporating MBI programs patient training module[74,75]
for patients continued selfcare upon discharge and
empowering them as active participants in their own
healing process and preventing relapse.[76]
Spirituality is not quantifiable, and manifestations of spiritual
care process are often unique, findings are qualitative in
nature and are nongeneralizable. Other limitations include
nonideal collection of qualitative data; the chaplainpatient
interaction could not be recorded electronically due to
institutional policy of FHS and more importantly any
attempt to record such a sensitive and intimate spiritual
care conversation will interfere with rapportbuilding, care
process, and clinical outcome; readers may be informed
that even taking physical notes while visiting with a patient
is discouraged in chaplaincy practice. Though the whole
verbatim was recorded immediately after exiting the
patients room there may be few inadvertent omissions by
To develop into a scientific, clinical discipline, Spiritual care
providers have to demonstrate evidencebased interventions
and outcomes. Understanding the spiritual care process
using neurological principles may be an inevitable step in
further development of Spiritual Care/chaplaincy as a clinical
subject. Notwithstanding the limitations, further studies
are possible and needed to strengthen our argument.
Indian Journal of Psychiatry 57(1), JanMar 2015

Parameshwaran: Theory and practice of spiritual care

I am deeply indebted to my CPE supervisor, Dr.Rev. Garrett
Starmer, for his patient guidance and his Socratic-teaching
skills which helped me understand the spiritual care process
in an experiential way. Special thanks goes to my colleagues in
the CPE residency group for their continued critical as well as
validating feedback that helped me understand my strengths
and growing edges. Iwould like to thank the entire faculty
especially, Chaplains Kathy Olson, Paula, and Jane Profont at the
Spiritual Care Department of Franciscan Health System group for
compassionate and wayside lessons in spiritual care. Igreatly
appreciate Ch. Judy Klontz, Ch. Glori Schneider(my chaplain
supervisors), Dr.Kevin Flannelly,(Chaplain and editor of JHCC),
Dr.Pratima Murthy(Professor of Psychiatry, NIMHANS) and
Dr.David Vago(Instructor, Functional Neuroimaging lab, Harvard
Medical School) for their valuable inputs.


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Source of Support: Nil, Conflict of Interest: None declared

Appendix 1: Following is the verbatim(qualitative data) of clinical encounter between the chaplain
(spiritualcareprovider) and patient
Verbatim: Clinical encounter between
chaplain(C) and patient(P)

Objective findings: Observation

of patient, myself and the clinical

Subjective feelings and thoughts of chaplain:


C2: Did you ask for a Catholic priest for

prayers, communion or anointing?

O2: Iwas standing by the side of her bed at

this point. She appeared distraught, her face
was dull, leaning into her pillow and eyes
were shut-I spoke with a gentle tone and kept
a compassionate face
O8: Her voice was forceful and frustrated.
She was still looking away. There was no eye
contact. She appeared to be in her late 70s or
early 80s. But she also looked energetic and
not physically weak, but definitely depressed.
Istooped a little bit and made an empathetic
face-reflecting her sadness. Ipaused a bit

S2: Icould feel some kind of sadness in her by looking

at her distraught looking face. Ibecame concerned and
wondered about the reason

P4: Idont feel like eating. Idont want to

live, I want to die

P8: Idont have children

O15: She appeared sad and kept turning

pages of her album. Istood silently with an
empathetic face

P11: For 40 long years we were married-we

had a son. How does it feel when a small
kid is taken away?(Actually, only later on
in this visit, P14, she informs me about her
second marriage)

O20: She repeated her story once again, this

time about her second marriage and sons
death. There was some anger in her voice.
Though she did not mention it, I sensed she
was probably referring to God having taken
away her son


S8: Wow! Her statement shocked me. Idid not know

what to say-its a painful feeling that someone wants
to or feels like dying. Her statement, want to die,
sounded like more of a reactive statement. Icould feel
her sadness. She is an elderly lady, what could be her
stressors and problems? I was curious
I felt tempted to say eat something, you need some
energy-but I kept it aside
S15: Ha! So thats her problem-no children. What
happened? She never had any, or did they die? May be
it will be sad and tough not to have children in our old
age. Ido wonder at times about my own life: we, me and
my wife, dont have children-we may adopt if not have
biological ones. Ilooked at my thoughts and feelings and
set them aside to refocus on patient
S20: Ifelt she was hesitating to say she is angry at God.
Ithink i would get angry at God. But I was not sure if
she wants to hear my opinion or if her question was
rhetorical? I just wanted to remain feeling my feelings
and thought that probably hers may be similar-I was not
Indian Journal of Psychiatry 57(1), JanMar 2015

Parameshwaran: Theory and practice of spiritual care

Appendix 1: Contd...
Verbatim: Clinical encounter between
chaplain(C) and patient(P)

Objective findings: Observation

of patient, myself and the clinical

Subjective feelings and thoughts of chaplain:


P16: My friends cannot be here with

me. Idont have children to take care of
me. Ihave nobody-everyone I loved and
whatever I had was taken away. What a
cruel God he is?

O27: She was angry, but of less intensity

than before, when she hinted at it in P11.
Her anger was obvious all through, right
from the beginning but only now she
acknowledged it

C11: Yes, that feels cruel, it can be very

painful. Getting angry at him is okay, he
wont hold it against you
P17: Yes, it is very painful
P18: You have a very honest face

O28: Iexpressed my compassion and

validated her feelings

S27: Wow! Finally she expressed her anger towards

God. Ifelt relief that she was not suppressing her anger
anymore due to fear or whatever reason/inhibition. Ifeel
a very personal relationship with God and i express all
ranges of emotions towards him. Iwas angry at God
when I lost a job in my past. This patient had suffered a
lot more
S28: It feels cruel to take away everything that we like-I
could not help but empathize with her feelings

P19: Idont feel like living, I want to

Is it okay to ask?(pause). Iwill not kill
myself-its a sin I know(pause) but he also
doesnt give(long pause)
P20a: He does not give whatever I ask of
him, he takes away everything that I like
P20b: He took away my mom, my husbandtwice and my son and now even my dogif I ask him for death he will not give it
P21: Where are you from?(C15: Iam from
P22: Inever thought I will meet someone
from India-I thought I might meet someone
from Italy or Europe. What is your?(your

O29: She said loudly-there was less emotion

and more of vehemence in her words this
time unlike the earlier statements at the
onset of this visit. Inodded empathizing
with her feelings. She was attentive towards
O34: She was hesitating to complete that
sentence. She started to repeat the same
statement as P4 but was not sounding bitter
or sad or angry while saying it. This time she
also looked questioningly at me with a twinkle
in her eye-unlike the poor eye contact that she
had in P4
O36: Ipaused briefly to see if our thoughts
were in unison. When she started to share
her P20b, then I joined to say those words
in unison with her. She ended her statement
laughing out in glee-I joined her with a
restrained chuckle

Indian Journal of Psychiatry 57(1), JanMar 2015

S29: Iwas happy that she was able to say that her
emotions are painful

S34: Iwas delighted to see the twinkle in her eyes. Ifelt

as if i felt her feelings and knew her unspoken thoughts;
she is probably hesitating to say God doesnt give
whatever she asks, including the death wish. Iset my
thoughts aside
S36: Iwas at peace-felt comforted in sharing her
thoughts and a smile. Iwas happy that she was now
relaxed and cheerful
S37: There was a feeling of affection in her questioning


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