J o u r n a l of Religion and Health, Vol. 26, No. 3, Fall 1987

Spiritual Issues in Mental Health Care MARY DOMBECK and JOHN KARL ABSTRACT: Religious and spiritual issues in mental h e a l t h are explored in the context of four conceptual models: the medical, the nursing, the humanistic, and the pastoral. This is done by looking at each model in terms of content, diagnostic focus, language and t r e a t m e n t goals, and primary qualities in the h e a l t h provider. The models are illustrated by case studies gathered from a multidisciplinary setting. The discovery t h a t each model can incorporate the religious and spiritual dimension in mental h e a l t h care, but t h a t each model does this in distinctive ways, is a key point.

Religious and health care institutions have not always been the uneasy bedfellows they are today. In fact, the history of most culture, including our own, reveals an integration of health activities with religious and ritual activities. Since ministerial and health care professions became formally distinct, however, there has been a varied relationship between them ranging from open hostility to cooperation and collaboration. 1 Religious and spiritual needs have been traditionally relegated to the clergy. Religious observances such as baptism, last rites, communion, and even prayer have been considered functions properly performed by the religious and ritual leaders. Yet most health care professionals have had the experience of being faced with a client's spiritual questions such as those concerning the need for faith and forgiveness. At those times the health care professional has had the option of: (1) (2) (3) (4)

ignoring the spiritual dimension of the client; referring the client to a clergy person without participating in t h a t aspect of care; cooperating with the clergy person so t h a t relevant information is shared; collaborating with clergy in an interdisciplinary mode, each contributing the unique skills of his or her discipline to address such problems.

Mary Dombeck, R.N., D.Min., is Senior Associate in Nursing on the faculty of the University of Rochester School of Nursing, and Associate Counselor and Nursing Consultant at the S a m a r i t a n Pastoral Counseling Center in Rochester, New York. The Reverend J o h n Karl, D.Min., is Executive Director of the S a m a r i t a n Counseling Center in Rochester, New York, and a Diplomate of the American Association of Pastoral Counselors. 183

"~ 1987 I n s t i t u t e s of Religion and H e a l t h

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This paper explores the models used by different mental health care professionals in an ecumenical setting which provides a context and an idiom for religious concerns of the client. We seek to explore the following questions: (1) Who (which professional disciplines) assess religious and spiritual needs, and how are these needs assessed by each profession? (2) Would an interdisciplinary approach increase the possibility for spiritual assessment and response to spiritual needs? (3) Is the assessment of spiritual needs important in making correct diagnoses? We make the assumption t h a t spiritual care is a legitimate part of health care and that the spiritual needs of clients deserve attention from the entire health care team even though clergy persons have a specific and specialized role in this area. We also attempt to identify the key focus of different health care professionals' responses to the spiritual condition of a person through an exploration of the model they use most typically, namely, the medical, the humanistic, the nursing and the pastoral models respectively. This is done by looking at each model in terms of content, diagnostic focus, language and t r e a t m e n t goals, and primary qualities in the health provider. Before proceeding it will be necessary to define some terms. Interdisciplinary is defined here as a process by which the solution of problems or completion of tasks requires the independent talents of different professionals, each contributing different aspects and different skills. The terms religious and spiritual, though related, are not synonymous. Religion is defined as an organized body of thought and experience concerning the fundamental problems of existence; it is an organized system of faith. Spirituality deals with the life principle t h a t pervades and animates a person's entire being, including emotional and volitional aspects of life. Roman Catholicism, Judaism, and Buddhism are religions. The search for meaning and purpose through suffering and the need for forgiveness are elements of the spiritual life. Every person can be understood to have a spiritual life, although some persons do not subscribe to any established religion. Therefore, while it m a y be appropriate to refer certain religious issues of clients to clergy, spiritual concerns are a part of the concern for health and cannot be ignored by any professional in health care.

The setting The pastoral counseling center described here is a small agency in a city of 220,000 in a larger metropolitan area of 900,000. Oversight of the program is provided by a pastoral counseling commission, a body of clergy and lay persons from various religious communities who are members of an ecumenical organization. The center provides approximately 3,000 hours of counseling for individuals, couples, and families. Sixty-five percent of the referrals come from pastors. The client population is varied.

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The staff cannot properly be described as a multidisciplinary team because each discipline does not perform a separate piece of the task. However, it can be described as interdisciplinary in a broad sense, as it incorporates the input of several disciplines into one t r e a t m e n t plan, even though only one professional m a y have contact with the client. This input is acquired mainly through the regular staff meetings. These meetings consist of case presentations which highlight issues of: (1) clinical diagnoses, more specifically the correct use of the standard psychiatric diagnostic manual (DSM III); (2) interactional and family issues and different t r e a t m e n t modalities; and (3) religious and spiritual concerns. The staffparticipates by presenting cases, receiving feedback from peers and members of the other disciplines. The cases are reviewed in light of the diagnostic manual, appropriate t r e a t m e n t modalities, and spiritual issues. One monthly staff meeting focuses on religious resources and pastoral themes. 2 This environment, where religious language is common within interdisciplinary dialogue, is an appropriate setting for studying models of assessment of religious and spiritual aspects of mental health care.

Models for assessment of the spiritual aspect of mental health care Before professionals from different disciplines can cooperate and collaborate about a problem, it is essential for them to know something of one another's disciplines and role functions2 Bloom's Taxonomy has been useful in understanding interdisciplinary team development. Carter-Jessop has suggested t h a t health care professionals move through similar stages of cognitive learning and team skills, beginning with knowledge and ending with evaluation of their own and each other's roles and functions. 4 Similarly in the affective domain they move from awareness to valuation of their own and each other's roles and team skills. Each of the helping professions takes seriously the moral and h u m a n i t a r i a n concerns of persons. Each evolved out of service traditions t h a t had religious roots, although these gradually became secularized. The tendency to secularization in Western society is one of the reasons t h a t the spiritual aspect of patient care has been neglected in health care. Another reason is the mind-body dualism which has influenced Western t h i n k i n g since the Greek classical era and the dawn of Christianity. More specifically, the explicit separation of church and state in the United States and the implicit separation of religious and secular matters in most Western nations have both had a part in identifying medical professionals with the body and science, and clergy with the soul and religious matters. This makes it seem somehow inappropriate for medicine to deal with spiritual problems or clergy to be part of health care teams. Nurses, in an effort to be wholistic, have remained open to identifying spiritual problems, though with some degree of discomfort because of their tradi-

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tional affiliation with medicine and the scientific method. Psychologists and social workers, who have more recently become identified with secular humanism, deal with religion as a social institution and have few explicit categories describing spiritual experiences. This climate, however, is changing. Many health care professionals are attempting to overcome the mind-body dualism and to become more wholistic, but it is still rare to find multidisciplinary care settings where the pastoral model is equally represented, or a team where the spiritual aspects of care are considered by each member of the team as valid health-illness issues. ~ The typology (Figure 1) is presented with some trepidation, because like any other typology it can be misunderstood and made to restrict rather t h a n distinguish. Few nurses would wish to assert that they never use the pastoral or medical model, nor would physicians wish to imply that they never use a humanistic framework. That is why the typology is presented in terms of model or primary focus rather t h a n just professional role or function. The key questions in each model will be illustrated by case examples.

Assessment of the spiritual aspects of care using the medical model The primary focus of the medical model is the diagnosis and treatment of disease. Whether the disease is conceptualized as a lesion or an imbalance, the diagnostic process involves collecting information about the signs, symptoms, predisposing factors, and historical course. The clinical data are clustered mainly around biological systems. The empirical evidence is examined by a logical process to pinpoint a medical diagnosis as accurately as possible. The treatment goal is to cure the pathology, by excising or otherwise diminishing the lesion or by correcting the imbalance. In making a psychiatric diagnosis, the first question when encountering God-talk or religious or spiritual behavior is to assess whether it is related to the pathology. A case example describes a man who became elated after an inspirational religious experience--a group retreat. The man's elation and ecstasy continued to increase, and his speech began to accelerate. When he called a radio station to tell of his experience, he was referred by the pastoral counselor to the consulting psychiatrist, for psychiatric diagnosis and care. The man demonstrated insight and sophistication when he asked the psychiatrist, "Do you think I have had a religious experience, or am I hypomanic?" The psychiatrist wisely responded, "I think you have had a religious experience and you are very hypomanic." His experience was not denied, but a diagnosis of bipolar affective disorder was confirmed. He was hospitalized briefly, put on a medication, and continued his psychotherapy. The religious experience was not in this case integral to the pathology. It provided an exaggeration of the man's effort to express the situation in his life. After exploring what if any connections exist between the pathology and the

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described religiosity, it is necessary to make some tentative translation of the God-language or symbol used. This happened during a case conference and staff meeting at the pastoral counseling center when the multidisciplinary staff was puzzling over a man's obsessional thoughts about "swearing at the Holy Spirit." These thoughts disturbed him immensely because of the seriousness of the offense from a religious point of view, since sinning against the Holy Spirit is considered by him and his church community the one unpardonable sin. This man's religious history revealed a background in a community in which the use of this term was not uncommon. There were multiple problematic family dynamics. The case reporter said t h a t the onset of the obsession coincided with the out-of-wedlock pregnancy of the man's son's girlfriend. The question was asked in the staff meeting whether symbolically the Holy Spirit could be understood to have a n y t h i n g to do with virility or fertility. The clergy in the room began to connect the clinical data with theological themes. "Jesus was supposed to have been conceived by the Holy Spirit and born of a virgin." There was general agreement t h a t the man was at least extremely ambivalent about the Holy Spirit for allowing or being responsible for out-of-wedlock births. This was a very helpful clue. The symptom decreased when his ambivalence toward his son became the context for therapeutic work. It is not surprising t h a t it was the psychiatrist who asked the key question during t h a t meeting. It is important to remember, when translating between two languages, t h a t something is always lost in the translations. Symbols are multi-vocal-t h a t is, they have m a n y meanings. There is never a totally correct single translation of a symbol3 Assessment of the spiritual aspects of mental health care using the humanistic model

The primary focus of the humanistic model is the encounter between the helper and the one helped. Moreover, this model assumes t h a t persons contain within themselves the potential for health and creative growth. In humanistic psychology the concept of causality is replaced by that of motivation. When persons are miserable or dysfunctional, it is because their basic needs and growth needs have not been met. 7 There are several different approaches within the humanistic tradition emphasizing phenomenologic description, problem-solving goal-orientation, and psychosociat assessment of the conditions t h a t influence the quality of life respectively. The humanistic ethos is well expressed by Alexander Pope in the eighteenth century by lines from his poem A n Essay on Man. Know then thyself, presume not God to scan. The proper study of mankind is man. Then say not man's imperfect, Heaven in fault. Say rather, man's as perfect as he ought.

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The diagnostic focus, then, is description of h u m a n existence, definition of social problems, and the application of resources to improve h u m a n potential. There is a definite secular bias. Religion and religious institutions are looked upon as any other institutions, either growth-restricting or growth-producing. Spiritual needs are not described explicitly but occur implicitly as needs for self-actualization and aesthetic beauty and harmony. It is assumed, however, t h a t physiological and safety needs are more basic and receive attention first. The key questions when making an assessment in the humanistic model are: How can this person achieve his or her potential? What are the personal and social problems t h a t prevent this person from achieving his or her highest potential? In the following example we explore a therapeutic relationship in which the therapist used the humanistic model because of the nature of the client's needs.

Case example. Mr. B is a 38-year-old professional man who has been in therapy for several years. His therapy can be described as successful because, in the past five years, he has redirected his energies in productive, successful, and satisfactory ways. He has terminated certain destructive relationships in his life, and started and maintained relationships satisfactory to himself. He is on the verge of achieving a cherished goal: to become an ordained minister. He is at present working through angry feelings he has about God and the church coming from past experiences with church-related people. The fact t h a t the therapist is not ordained places her in a position neutral enough to give the client the freedom to express his anger, although it is very clear t h a t he does not use the therapist as a spiritual counselor. The role distinction became apparent when he realized t h a t he needed spiritual counsel from an ordained pastor. His need baffled him precisely because he felt positively about the therapy. He said to the therapist, "In a sense with you, I talk about my relationship with God and the church as if it were any other relationship. With a pastor there would be another dimension. I would confess my anger, and something would happen. Then I could continue to work with you." Is his perceived need for a pastor an indication t h a t he is resisting something in the therapy? The therapist and client both considered this as a possibility, but the client insisted t h a t he wanted to see a pastor in order to celebrate his reconciliation toward the church by a religious ritual which, in his eyes, the therapist was not qualifled to perform. There is a difference between "talking about" something and confessing it. When using the humanistic model, one of the most therapeutic ways to respond to the client's spiritual need is through: (1) sensitivity to the need for appropriate referral when necessary, and (2) sensitivity to implicit rather t h a n explicit reference to the spiritual life. Clients who are comfortable with the hu-

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manistic model with its secular bias, however, are often not comfortable with God-language. So any God-language or spiritual issue is better introduced by them.

Assessment of the spiritual aspects of mental health care using the nursing model The nursing model arose out of the needs associated with the suffering of persons2 The first nurses were women in religious orders who had a vocation for caring for the sick and the injured. Now the majority of nursing practitioners are secular. The founder of modern professional nursing, Florence Nightingale, is credited with seeing the ailing person in continual interaction with the environment. Nature could not cure if sanitation, diet, and living conditions were poor. Nurses began to see themselves not only as carers of the sick and dying but also as promoters of health in persons through skillful management of the environment. There are m a n y conceptual frameworks and theories of nursing. However, most nursing theories retain some of these key concepts: (1) the importance of patient-environment interaction, (2) the promotion of health, and (3) the tradition of wholeness and client self-direction. Often this becomes translated practically into the question of how persons, sick or well, function daily in their environment. Nursing diagnoses are perceived as a process of clinical thinking which guides the nurse in m a k i n g assessments through a functional health pattern typology. Religious and spiritual needs have always been an accepted part of nursing care and compatible with the nursing model. The nursing classification of nursing problems, according to Abdellah in 1959, contains an entry that reads, "to facilitate progress toward achievement of personal spiritual goals. ''~' The Basic Needs Classification according to Henderson has an entry, "Worship according to one's faith. ''~~ In the current functional health-pattern typology, spiritual care is represented in the value belief pattern. 11 The key questions, then, relating to the spiritual aspects of health care are: "Is this person's spiritual and value pattern health inducing or health inhibiting? .... Is this person in spiritual distress? .... Does this person need spiritual comfort?"

Case example. Miss A is an attractive 25-year-old woman whose presenting problems are dissatisfaction with her life and an indecision about whether to get married or not. She has been engaged and has cancelled the wedding twice to the great dismay of her family and fiance. She recently quit her position as administrative assistant in a large business firm because of her plans to get married. After the wedding plans were cancelled, she was not able to get her job back, thus adding unemployment to her present problems.

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During the interview, the nurse discovered t h a t Miss A had had an abortion at the age of 19 after getting pregnant by another boyfriend who had had problems with alcohol and had been physically abusive to her. She had decided to have an abortion and leave him and was still sure t h a t t h a t had been the right decision. Her parents, who are described as traditional Italian, did not and do not know about the abortion. Her family history reveals a close, supportive, and healthy family. The present fianc6 is described as a steady and caring person and a good sexual partner. Miss A thinks it is time to settle down. She doesn't really miss her job but needs something to do. She is healthy, eats well, and works out every day, but has started sleeping fitfully for the past few weeks since the wedding was cancelled. She has never considered herself a very religiously oriented person but still goes to church regularly. The nurse makes the following preliminary nursing diagnoses: (1) there is probably a disturbance or potential disturbance in her self-perception, selfconcept pattern, owing to the developmental transition into a different social role, accentuated by the loss of her job; (2) there is probably a problem with dysfunctional grieving related to the abortion; (3) there may be spiritual distress. The nurse is not sure. The nurse decides to work on the first two problems. The client responds well. She makes an effort to find a job and talks briefly about her feelings related to the abortion. After two sessions, she finds a job and discontinues her therapy because of time conflicts; she feels better and will consider a new wedding date. From a crisis model point of view this woman is functioning and feeling better. But the nurse is left with a feeling of incompleteness because the spiritual problem was never adequately explored. Her clergy colleague suggests t h a t maybe the spiritual problem w a s the crisis. Miss A is not defining herself as a religiously oriented person, and she still goes to church; however, she might be in spiritual distress because of the abortion. She might need forgiveness, and t h a t need might be felt most acutely whenever becoming a wife and mother comes closer to reality. Placing the problem only in functional terms did not help in assessing the inner spiritual environment to determine whether it was health inducing or health inhibiting. It is also important to ask the questions, "Is this person in spiritual distress? .... How can this person derive spiritual comfort?" These questions, which are part of the nursing model, are difficult to answer. The categories for spiritual distress are not neatly enumerated in a diagnostic manual. Moreover, if the spirit is the breath of life, and spirituality deals with the very life principle t h a t animates the whole person, then would it not be true to say t h a t all ailments have a spiritual component? E v e n if this statement is true, it is not much more helpful t h a n saying t h a t all ailments are psychosomatic in the sense t h a t they involve the total person. We are still left with the problem of recognizing spiritual distress and providing spiritual comfort. Health care professionals who are not familiar with the pastoral model

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have a hard time recognizing the themes t h a t express spiritual categories and are often at a loss as to when to use the pastoral model appropriately. Pastoral counselors use the medical model at times when making a decision about the presence of pathology in order to make appropriate psychiatric referrals. It is important for members of the health care team who are not pastors to become familiar with the pastoral model in order to make referrals and in order to deal with the spiritual discomfort themselves when referrals are impossible. Before the last case study, it is necessary to examine guidelines the pastoral counselor uses to assess religious and spiritual needs. Pastoral counseling is a specialized ministry with its own 20-year-old professional organization. Two "calls" to professional vocation shape the pastoral counselor's specialized ministry. The first call is to the ordained ministry with the accompanying professional formation of seminary training and parish ministry. Later, the potential pastoral counselor receives a second "call" and enters pastoral psychotherapy training. This training period is similar to the formation process of other psychotherapeutic disciplines--such as psychiatric nursing, social work, psychology, and psychiatry. It includes extensive course work in psychosocial theory, mastery of various psychotherapeutic modalities, a prescribed number of supervised counseling hours, and an extended experience of personal psychotherapy. Thus formed by two healing traditions (that is, pastoral/religious and mental health/psychotherapeutic), pastoral counselors combine and blend elements of both in their professional practice. Sensing these dual professional roots, many people who seek help from pastoral counselors anticipate that a religious framework will be one of the perspectives used in working with their problem. "Religious counseling" simply means t h a t one wants one's faith resources applied to present problems. Much as the role designation of medical doctor or nurse creates an expectancy set within which people not only discuss their bodily symptoms but also anticipate a curative intervention, so, too, does the role designation "pastoral" create a set t h a t fosters discussion and anticipates intervention in the religiously meaningful and problematic. The expectancy set places the pastoral counselor in a unique position to assess spiritual needs and resources and to interweave them into mental health diagnosis and treatment planning. Several guidelines in how the pastoral counselor assesses spiritual needs and resources will be briefly outlined. A short Hasidic story captures the assessment task.

A student asks his teacher, "I have a question about Deuteronomy 66 which says, 'And these words, which I command you this day,shall be upon your heart.' Why is it said this way? Why are we not told to place them in our heart?" The teacher responds. "It is not within the power of human beings to place the divine teachings directly in their hearts. All we can do is place them on the surface of the heart so that when the heart breaks they drop in."

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Guidelines for Taking a Religious History 1. Placement Within a Religious Community. Religious affiliation? Changes in religious affiliation? When did changes take place? What is the level of present involvement? What is the relationship with pastor and community?

2. Personal Meanings Attached to Symbols, Rituals, Beliefs, and Divine Figures. What religious practices are most meaningful? When and in w h a t ways does one feel close to the divine? What does one pray about? When? Where? What gives special strength and meaning?

3. Relationship to Religious Resources. What is relationship with God? How is God involved in your problems? Has there ever been a feeling of forgiveness?

In metaphorical language, we assess what has been placed upon the heart, what has or has not dropped in when the heart breaks, and what heals or cripples the heart in times of crises. In descriptive language, we start with a wide concentric circle to determine a person's placement within a religious community with its social and cultural dimensions. (See Figure 2.) Then the concentric circle narrows as we explore highly personal meanings that are attached to symbols, rituals, beliefs, and divine figures. Finally, we explore the healing or crippling nature of one's relation to these religious resources. Beginning with the widest circle of what is placed upon the heart, simple inquiries into a person's religious history yield useful information. The process is similar to taking a work or family history, but here one notes the n a t u r e of involvement with a religious community. The more knowledge one has of religious traditions, their sociology, practices, key symbols, and unique language, the more one will know what people are talking about. Important questions

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are: Religious affiliation? Any change over years? Level of present involvement? Relationship with pastor? In the next circle, we assess a person's spiritual resources. "Resource" is a rich word whose roots mean "to rise again," "to spring forth," and "a point of origin." It is something t h a t one turns to or t h a t springs up in the absence of usual means of supply and support. Victor Turner cites African healing rituals where healing medicines are gathered and then brought to a river "source'! where the healing takes place. 1~In a real and metaphorical way, there is an effort to discover where and in what ways the spiritual waters have broken through the earth's crust for this person. What are his or her resources? What has dropped into the heart? What does the person draw upon in time of need? Key assessment questions are: What practices are most meaningful? What does one pray about? When? Where? What gives one special strength and meaning? Symbols tend to stimulate m a n y sense modalities--namely, the kinesthetic, the auditory, and the olfactory. In the final circle, the relationships with important religious resources are explored. To use psychoanalytic language, religious resources are significant internal objects. They are especially important in the development of conscience and ego ideal. One can explore the domain of these objects as one would explore relationships with significant others. One can discover the texture of the bond, the range of affects, the ambivalences, the standards of valuation, guiding assumptions, and important internal dialogues with these figures. Key questions are: What is relationship with God? How does God feel about you? Any changes in this relationship? How is God involved in your problems? Have you ever felt forgiven? With these and similar questions, we enter a person's most private and intimate world. Answers to all of the questions in the above three circles tend to be cast in symbolic l a n g u a g e - - m o r e so as the circle narrows. Victor Turner reminds us t h a t symbols are "multivocal"l:~--that is, they refer to m a n y things at the same time. Referents range from the physiological to the psychological (at both conscious and unconscious levels) and to social experience and ethical evaluation. Symbols can be spoken in the concrete language of a child, but at the same time can be tapping complex and sophisticated emotional/cognitive/ spiritual processes. The more one can respect and speak within a person's primary religious language the more accurate the assessment task will be. While we "translate" a person's religious language into working languages of our professions, it is important to recognize that our working translation is not necessarily the reality for t h a t person. For example, a person's struggle with a judgmental God is not just faulty super-ego development based upon a distant relationship with a critical father. Both God and the father are real relationships for the person. He needs to come to terms with both, using his own unique language and symbol system.

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Assessment of the spiritual aspects of care using the pastoral model The focus of the pastoral model is the mediation of the relationship between the person, the creator, and the universe. The person is encouraged to see himself or herself as a created being cared for and in relation to a creator and to the world. These themes are usually communicated by symbol words, symbolic stories, and rituals. The guidelines for pastoral diagnosis refer to different aspects of this spiritual drama24 The key questions in making an assessment are: "What is the degree of this person's freedom or bondage in this situation?" "How can the religiously meaningful enable transcendence of the situational bondage?"

Case example. Mrs. C is a 32-year-old professional married woman who is pregnant for the first time. She came for counseling to sort out her ambivalence about having a baby. Other factors in her life at that time were the sudden loss by death of a close woman friend and neighbor. Mrs. C was grieving, rejoicing, and reluctant at the same time. After going through a difficult process in which the nurse's main function was listening and anticipatory teaching about the physical and emotional symptoms of pregnancy, Mrs. C became more accepting of the pregnancy and celebrated her acceptance by telling her parents, her in-laws, and her friends about her condition. She also bought a few baby clothes. Then at the twelfth week, she started bleeding vaginally, and it was discovered by ultrasound t h a t the baby had not been forming and t h a t she would miscarry. After the miscarriage she came with her husband for a conjoint session. Mr. C was weeping freely, frankly grieving for the baby they had lost. Mrs. C would cry sporadically and express puzzlement about the loss of something that had not been there. "But this is silly. I'm crying over something t h a t was never real. The baby was not developed. It's silly to cry about losing some tissue." Mr. C said t h a t for him there had been a baby because he had started fantasizing about being a father. As a mental health professional, the nurse recognized the potential for denial of loss and complicated grieving in Mrs. C. The nurse started talking about the differences the pregnancy had already made in her life. Both Mr. and Mrs. C were church-goers, and church was important to them, but they were not in the habit of t a l k i n g to their pastor. God was important to them, but they were unable to articulate how. They both enjoyed the ritual celebrations at church. The nurse knew that if she referred them to a clergy person they might not follow through. As she continued to listen to the ambivalent Mrs. C and the griefstricken Mr. C, she was wishing there was a way to express the baby's death ritually in the context of the community as at a funeral service. Mr. and Mrs. C had a spiritual need to express ritually the death of their hopes of having t h a t child. Ritual observance can represent a therapeutic way to express the termination of relationships.

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Before the session ended, the nurse suggested a m om ent of silence in memo r y of the loss they had sustained. They all bowed their heads and said nothing, but all began to weep quietly. Mr. C got up and walked to his wife's chair. They both sobbed, and the session took on the appearance of a funeral parlor. There was a change in the tone of the session from verbal communication to ritual celebration. In this situation the ritual was a type of funeral observance within the counseling session. 1~ The next week, Mrs. C came alone. She said t h a t in the past week she had been full of grief. She was sure now t h a t there had been a child, but she was now ready to go on with her life. She wanted to wait a few months before getting p r e g n a n t again. The next pregnancy would never replace the old, but she could t h i n k about it as a possibility now. The counseling relationship was t e r m i n a t e d a week later. Mrs. C said to the nurse, "Maybe next time I see you I will be having morning sickness again." The nurse upon reflection realized t h a t she had been dealing with mourning sickness as well as morning sickness.

Summary In our secular society the spiritual and religious aspects of patient care receive little attention from health care professionals. Even where it has not been neglected, there has been little analysis and research on the role of different h ealth care professionals in the need for spiritual care. Chaplains, pastoral counselors, or other clergy are seldom part of heal t h care teams. Yet studies show t h a t pastoral care and the availability of spiritual care can have positive outcomes for patients.16 An interdisciplinary setting, in which pastoral persons participate and in which the pastoral approach is used, heightens the awareness of other health care professionals to the spiritual needs of persons. Knowledge of the capabilities of other professionals is the first step to the formation of heal t h care teams. In this paper we have described the association of therapists from different disciplines in a setting where spiritual and religious concerns are a part of the care. The possibilities for spiritual assessment were discussed in the context of four m o d e l s - - n a m e l y , the medical, nursing, humanistic, and pastoral. These models were examined in terms of context, language, and diagnostic approach. The key diagnostic questions in each model were illustrated by case examples. It was discovered t h a t each model can incorporate the religious and spiritual dimension in health care, although each model does this in distinctive ways. This is the first step toward moving from a unidisciplinary approach where only clergy deal with spiritual problems to an interdisciplinary approach where all heal t h care professionals assess and respond to religious and spiritual needs from different perspectives. This is an essential step toward the formation of interdisciplinary health care teams in which the pastoral perspec-

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tive is equally represented, and where the spiritual and religious care of patients is part of the total health care.

References 1. Marty, M. E., and Vaux, K. L., eds., Health Medicine and the Faith Traditions. Philadelphia, Fortress Press, 1982. 2. Karl, J. C., and Ashbrook, J. B., "Religious Resources and Pastoral Therapy," J. Supervision and Training in Ministry, 1986, 6. 3. Baldwin, D., and Schmitt, M., "Research and Evaluation on Health Care Teams: How to Shoot at a Moving Target," Interdisciplinary Health Care Proceedings, Kalamazoo, Michigan, 1982. 4. Carter-Jessop, L., and Mancini, J., "Team Education and Research: A Theoretical and Operational Prototype," Interdisciplinary Health Care Proceedings, Kalamazoo, Michigan, 1982. 5. Tubesing, D., et al., "The Wholistic Health Center Project. An Action-Research Model for Providing Preventive, Whole-Person Health Care at the Primary Level," Medical Care, 1982, 15, 3, 6. Turner, V. W., The Ritual Process. London, Routledge and Kegan Paul, 1969. 7. Maslow, A., Motivation and Personality. New York, Harper and Row, 1970. 8. Gordon, M., Nursing Diagnosis, Process and Application. New York, McGraw-Hill, 1982. 9. Abdellah, F., "Improving the Teaching of Nursing Through Research in Patient Care," In Heiderken, L., ed., Improving of Nursing Through Research. Washington, D.C., Catholic University of America Press, 1959. 10. Henderson, V., The Nature of Nursing. New York, Macmilan, 1966. 11. Gordon, op. cit. 12. Turner, V. W., The Forest of Symbols: Aspects of Ndembu Ritual. Ithaca, Cornell University Press, 1967. 13. Turner, op. cit. 14. Pruyser, P. W., The Minister as Diagnostician. Philadelphia, The Westminster Press, 1976. 15. Van derHart, O., Rituals in Psychotherapy Transition and Continuity. New York, Irvington Publishers Inc, 1983. 16. Best, J. K., "Reducing Length of Hospital Stay and Facilitating the Recovery Process of Orthopedic Surgical Patients Through Crisis Intervention and Pastoral Care," unpublished dissertation, Northwestern University, 1981.