Monday, March 12, 2007

Chaplain Stress

My job as a volunteer ED chaplain is to be, more or less, unfailingly kind and compassionate. I'm not supposed to allow myself to be cranky; I'm definitely not supposed to be tempted to slap poorly behaved family members upside the head, which is emphatically not What Jesus Would Do. (Some of my church friends, the ones who spend a lot of time studying non-violent communication, would banish me to the Outer Darkness for even using that language, but I'm trying to be honest here.)

I take the compassion-and-tolerance job seriously, and most of the time, I do a fairly good job of practicing it. But, because I'm human, certain kinds of behaviors push my buttons.

Near the top of the list are parents who frighten or guilt-trip their sick children. You know: the mom who tells her feverish, miserable kid all the horrible things that will happen if the doctors can't fix this -- brain damage! seizures! -- or talks about it on her cellphone within the kid's hearing, which boils down to the same thing. Or the parents who bring their little girl to the ED on Christmas because she has a really bad ear infection, and then go on at great length, in front of her, about how she always does this to them, and sure enough, she's done it again: she's ruined their day.

Two notes before I continue: 1) Most parents in the ED behave beautifully: they comfort and reassure their children even though they're worried sick themselves, and remain calm and sympathetic in the face of nonstop howling and bouts of projectile vomit. In short, they behave like adults. 2) I'm not for a second claiming that I'd be a model parent myself; I don't think I'd be a very good parent at all -- I have neither the stamina nor the patience -- which is one reason I've chosen not to have kids. It's the hardest job in the world, and people who do it well have my unstinting admiration.

Most of the time, I control myself around inappropriate parents. Instead of lecturing the parents, I sympathize with the kid and offer any reassurance I can. "I had ear infections when I was your age, and I know how much they hurt. But the doctors will give you medicine to make you better." And then I offer crayons or a stuffed animal or both, anything to distract the kid from nausea and needles. Most of the time, I manage to remember that I'm not seeing the whole context, and that the adult caregivers may be under pressures I can't imagine.

But I was having a bad night last night anyway: I'd had neither enough sleep nor a chance to exercise before my shift, and the ED was pretty quiet, which can be paradoxically stressful because it gives you more time to think about how you feel yourself, instead of concentrating on patients.

Enter Family Unit: sick, alarmingly lethargic Child, Adult1, and Adult2. Adult1 is in tears, arguing with another relative on a cellphone. Adult2 is issuing dire predictions about how Child's Willful Refusal to be healthy will result in organ failure in two days. (Yes, really.) Child is lying in bed, motionless and wide-eyed.

Chaplain is not happy. Chaplain snaps at Adult2, "Did the doctor tell you that? About the organ failure?"

Adult2: "No."

Chaplain: "Then please don't talk about this where Child can hear it."

Adult2: "But Child needs to know the consequences of Willful Refusal to be healthy!"

At that point, fuming, I gave up on Adult2 and talked to the kid. "I know you don't feel well, but you know what? I think you're going to be just fine. The doctors are going to make you feel better. They're really good at that. Would you like crayons, or a stuffed animal?"

The kid shyly asked the adults if it would be okay to ask for a stuffed animal; the adults, returning to some semblance of rational behavior, said yes, of course. I experienced unexpected delay in delivering the stuffed animal, because the first one I found was claimed by a nurse who said it was so cute that she just had to have it herself (and then another nurse started fighting her for it: I told you we were having a slow night!), but the critter I did give the kid appeared to be a hit. From then on, the adults were model grown-ups, and the kid did so well after treatment in the ED that the whole family got to go home, instead of facing a hospital admission (which had been the initial game plan). The adults thanked me repeatedly for my help, not that I did that much. So that was a happy ending.

Except that I was still fuming. I vented to two nurses, who listened sympathetically. Then I realized that they had work to do and I shouldn't be taking their time, so I went upstairs to find a staff chaplain.

What I wanted to hear was, "Yeah, we all feel that way around clueless parents, and this is how to deal with it." And I got that, eventually. But first I got a long, gentle lecture about inappropriate boundaries, about how it's not my job to fix years of family dysfunction, about the intellectual arrogance of thinking I can tell people how to behave around their children.

I wasn't trying to fix years of family dysfunction. I know I can't do that. I was trying -- badly, no doubt -- to remind the adult that the child had ears. I was trying to make that moment a bit easier for everybody.

At one point I told the staff chaplain, "Okay, look, I think part of where I was coming from is that when I was a kid, other adults sometimes called my adult caretakers on less-than-optimal behavior, and it helped all of us."

The staff chaplain said, "In my experience, that's unusual." What he wound up telling me is that I should have just concentrated on interacting with the kid in the first place, rather than saying anything to the adults (which I already knew).

But thinking over the incident this morning, I wonder. I have a long history of small interventions with adults who are being inappropriate with kids in public (in post-office lines, on New York public transit). For a long time, my strategy with adults berating children in public has been to walk up and say something pleasant and off-topic (compliment the kid on his sweater, ask if the adult has the time). This serves several purposes: 1) It distracts the adult from the immediate frustration with the kid, and may defuse that frustration; 2) It reminds the adult that other adults have ears and eyes and are watching this behavior; and 3) It may show the child, however subtly, that other people watching this behavior don't think it's okay.

I think number three is the most important. If a kid is treated badly in public and nobody does anything, what message does that send to the child? That this is normal and acceptable behavior, or that nobody cares? I know that many people might say that other people's family dynamics are none of our business, but my approach has always been that if something's happening where I can see it, out in the open, it is my business. Maybe small distractions don't ultimately work; maybe all they do is to drive the behavior behind closed doors, where it will become worse. Maybe the kid will never catch the subtle message delivered by a stranger. Maybe I really am just an arrogant person with bad boundaries.

But maybe, just maybe, that child will grow into an adult who'll one day remember what happened so long ago, and will think, "Someone saw that, and didn't think it was okay."

In the meantime, I still need to be better at controlling my temper with clueless parents in the ED. I won't be back there for three weeks, until after our Maui trip. The vacation's obviously coming none too soon!


  1. Oh gads, I really feel for that kid. Yes, parents can get totally unreasonable when concerned with their own issues. I hope the gentle intervention you did helped the child.


  2. I dunno; the Jesus I remember (Ted Neely, that is) is the one who ripped the moneychangers a new one for inappropriate behaviour in the temple.

    If there is a place that corresponds to G-d's temple, it has to be a hospital, where people attempt to heal Hisser creation.

    And actions that don't lead toward and support healing efforts correspond quite well to moneychangers invading the temple.

    The short of it is that pointing out that people are Behaving Badly at least makes them realise they are being observed.

    You did the right thing.

  3. Thanks, Lee! (Although my fear was that the intervention wasn't gentle enough.) And Ken, thanks for that very thoughtful comment.

    Actually, yeah, the parallel to the moneychangers had occurred to me, but it's also worth noting that this is one of the passages that sends people into triple backward somersaults of justification and rationalization, since it doesn't square with our usual sense of Jesus. My reading, here and in the other two places where he Behaves Badly (cursing the fig tree, and being initially very rude to the Syro-Phoenician woman seeking healing for her daughter) is that in all three cases, the human side of him was getting the upper hand over the divine. In two of those cases, he was within a week of his own death, and knew it; in the third, he'd fled his usual territory to try to get away from demands on his time and challenges about ritual purity from the religious establishment. So while his behavior in all three cases is humanly understandable, I don't think anybody would see it as ideal.

    We forgive him, of course, because he forgives us, but I can also imagine a disciple or two taking him aside and saying, "Yo, boss: d'you think you were a LITTLE harsh in through there?"

  4. Really, Susan, what you said doesn't sound so bad to me. Obviously the calmer and more positive your demeanor the better, of course, but did the parents appear to think you were inappropriate, or is the it just you and the other chaplain who are second-guessing you?

  5. And by the way, having a vacation coming up is a VERY good thing. I hope it's fantastic.

  6. Hmmm. Well, I've been trying to think of two things: what I might have done, and what I might have said had I been the staff chaplain you sought out.

    Regarding the first: I'd need to credit some judgement in the moment about what would best serve the child. Wanting to stop the parent from frightening the child is a worthy goal. I think I would have gone directly to the child myself, not because I would think there was no room for intervention, but because I wouldn't expect the parent to hear. I would also be concerned as to whether I thought responding directly to parent 2 would bring an eruption that might endanger a lot of things, not least the child but also including me. As I said, it would be a judgement call, based largely on gut.

    So, in the second case I think I'd have to give you space and trust to have made that judgement in the moment, and then see what else was going on. I'm not particularly fond of the "boundary issue" here: we already have the authority as chaplains to enter those situations; and once we're there, we have the authority to take some actions. I would agree in the sense of not having high expectations of accomplishing change; but that's not in itself grounds not to act. (Sorry about the double negative. Chalk it up to a literary idiosyncracy.) I still think I would have advised addressing the child first. Parent 1 is not addressing the child at all. Parent 2 is addressing the illness, not the person - and doing that pretty poorly to boot.

    As to your own reaction: I don't think it was inappropriate in and of itself to seek some collegiality from the nurses in ER. They could also give you meaningful perspective, because they were there and might have seen the situation. Yeah, they're busy; but allowing them to help you can support a relationship in which they allow you to help them.

  7. Thanks for your response, Marshall! I was hoping you'd read this, and wondering what you'd say, and your comments are really helpful.

    I think the staff chaplain's worries were motivated partly by concern for my safety, also. In this case, I didn't think the adults were likely to lash out, and in fact they responded well. But yeah, next time I'll go directly to the kid, as I've done in the past. (That also models, of course, that paying attention to the kid is what the adults should be doing!)

    As for the boundary issue: I think this is a place where the professional/volunteer split may be coming into play, and where I'd be considered less able to handle certain situations because I'm a volunteer.

    And good point about the nurses and the reciprocosity of help: I'm always talking to patients who are mortified at needing for or asking for help from other people, so it won't do to be that way myself! Although my perception is that helping professionals (including chaplains and clergy) are expected to help others, and all too often feel isolated or stigmatized when they need help themselves. It's too easy to fall into the attitude that helpers shouldn't need to receive help.

  8. I wouldn't want to comment on the situation, other than to say you are very obviously a compassionate, intelligent human being with a good idea how you should go about your function as a chaplain.

    The important bit of the above are the words 'human being'.

    My concern is more general and I guess centred on our contemporary tendency towards relativism. When someone else does something that our society and philosophy hold to be wrong - clitorectomy or 'honour killing' to choose two ghastly examples - do we hold our tongues because those practices are acceptable - supposedly - to their mores?

    I realise this is a big step from your gentle admonishment of the parent, but they were doing nothing to care for their sick child. Indeed, they were exacerbating the situation.

    As a parent, I have the right to believe I can think myself well (not that I do think that) but do I have the right to think that for my dependent child?

    Cathie has problems with the family of a monstrously overweight patient whose family insist on bringing him take out food and insist they have the right to do so, even though they are certainly shortening his life. Rights, so often divorced from responsibilities.

    And, yes, I'm as human as anyone else in this regard.

    Recharge those batteries in peace and sunshine.

  9. Hi, Marshall! Nice to see you back here!

    The two adults acted kindly and appropriately for the rest of the visit, so I'm inclined to think my comment did some good. But it's also true that if I'd known the entire context of what they themselves were going through, I might have been more understanding. (Adult1, for instance, was clearly being berated by another relative and was very upset about it, although trying to exercise self-control.)

    And, once again, my own comment wasn't as gentle as I wish it had been -- which was a function of my context of being tired and needing vacation. For me, the issue here is that I didn't do enough to control my own tone and demeanor (which, as Claire points out -- hi, Claire! -- would have been more appropriate had they been kinder; I was kind later, but I was definitely cranky at the beginning).

    Cultural "relativity" issues are complicated. I think the best thing to do is to learn enough about the culture one's criticizing to be able to work with it on its own terms, in language its residents will understand. Have you read Fadiman's THE SPIRIT CATCHES YOU AND YOU FALL DOWN? It's a brilliant case study in the danger of not learning about another culture, in thinking you can simply impose your own values on people.

    And Claire: I forgot to say this before, but yeah, it was the other chaplain second-guessing me. And because I was letting myself be more visibly frustrated and upset with him than I had with the adults, I think he probably thought I'd handled it even less well than I did.

  10. Cheri Smith12:36 PM

    This whole incident reinforces why it's so important for me to be 'centered' before approaching patients and families. Thanks for the reminder! It's easy to just push through those doors and want to start 'helping others' when I really need to take care of myself first. If I speak and act from that center, usually things work themselves out.

    With that said, in reality, what a pain to have to deal with thoughtless family members and to see major injustices being done! I, like you, would tend to error on the 'looking after the underdog' side and probably say things that others might deem inappropriate. The way this incident turned out, tells me that you assessed the situation and people correctly (even though you didn't feel at your best) and you handled things the way they should have been handled, so the end result was postitive. So, my input (since you asked) is that you should have more confidence in your judgement and keep doing things just the way you are!

  11. I think you could benefit from a CPE (Clinical Pastoral Education) program. You would have a chance to process the difficulty of chaplaincy in a supportive environment with a peers who could hear you and understand. The one thing I would add is as a chaplain myself, my CPE supervisor has taught me that in your patient interaction it is all of your support going out, in your peer interactions it it a fairly equal exchange of support, and in your suupervision, you should be the one getting all support. In cases like this, that really helps.

    Also, when I encounter a crazy family spouting about spiritual healing, etc, it is important to ask them "What do you mean by that?" or "Gee, that sounds pretty important to you. Can you say more about that?" To hear about the parent's distress and move transference off of the child.

    I would say in this case, your frustration moved this from a moment of ministry to an encounter with your own feelings, which is will happen. The difference is that in a CPE program, you can process that and begin to work with your anxiety, so it is not running the encounter.

    Just a thought...

  12. Mammon -- Thanks for your comment. As long-time readers of the blog know, I started an extended unit of CPE several years ago, and wound up leaving pretty quickly because the sixteen hours a week were too much on top of other things going on in my life. CPE's no longer offered anywhere within reasonable distance of where I live, although that may change. If it's offered here again, I'll think about giving it another shot, although -- as blog readers also know -- I have extremely mixed feelings about the "CPE's the only way anyone can become a good chaplain" attitude that seems to rule all too many pastoral-care departments. And, as I explain in this post, it means a lot to patients to be visited by folks who aren't being paid (or receiving professional credit) for being there.


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