Medicare regulations in the United States require all hospice patients to receive spiritual assessments and spiritual care from hospice staff if they desire. Ideally, patients would receive spiritual care from a religious community with whom they have enduring relationships and shared beliefs, but this is not always the case. This is especially not these case for patients who have severe psychiatric conditions what pastoral theologian John Swinton calls “mental health challenges.” Patients with psychiatric conditions are unfree on several levels and often face involuntary hospitalizations. Religious communities are often unaware of how to help patients with mental health conditions and label them “possessed” or tell them to “pray their way through” a mental illness (evangelical and Pentecostal Christians) or simply advise them to seek medications without addressing the spiritual ramifications of their condition (Liberal and mainline Protestants and some Roman Catholic). Patients with mental health challenges often have frayed family relationships and can lack strong advocates. In such cases, hospice workers can walk alongside a patient’s search for God.
The early 20th century Clinical Training Movement mostly placed students in psychiatric facilities to work with psychiatric patients. This is no longer the case and not all CPE students have experience with caring for patients with severe mental health challenges. This is no longer the case. Most current CPE programs do not give trainees extensive exposure to patients with severe mental illness. This is a change from the early days of the Clinical Training movement when Anton Boisen, argued that training students on patients with psychiatric problems hallowed them to encounter ”individuals whose behavior is guided and controlled by certain value judgements. We see these individuals breaking down or broken down under the stresses and strains of love and hate and fear and anger. See them grappling with spiritual issues of life and death, of survival and destruction; and we can observe the end results and diverse ways in which individuals deal with failure to measure up to the moral standards which they have accepted as their own”.[1]
Boisen’s Freudian model of mental illness is now supplanted by biological psychiatry. However, chaplains need to develop frameworks for thinking about mental health, so that they can provide spiritual care to patients made vulnerable by mental health challenges. Still, it is theologically problematic to dismiss the religious experiences of psychiatric patients and attribute them to delusion or psychosis alone. Religious traditions affirm God’s ability to communicate with individuals in many situations. This paper will argue that we cannot reduce a patient to a mental health diagnosis, but that knowing what they struggle with can help illuminate the forces shaping their perception of the divine. Knowing a patient has depression may help a chaplain understand why they cannot feel God’s presence. Chaplains can help inform the medical team the ways that psychiatric patients can still have sustaining religious experiences. I will also argue that greater awareness of a mental health challenge in a patient can foster non-anxious presence in a chaplain. I will use a case study to show how a chaplain can cooperate with other staff to provide appropriate and ethical spiritual care for a patient with a severe mental health challenge, noting how mental health conditions complicates the use of some models of end-of-life spiritual care. Nonetheless, even in times of great distress, chaplains can help patients experience greater spiritual freedom amid difficult circumstances.
This paper explores the challenges of end-of-life spiritual care with patients who have severe mental health challenges. I argue that chaplains can play an important role as an advocate for these patients. I also argue that chaplains can approach their work with greater skill and care when they are aware of a patient's medical diagnosis, and can advocate with the medical team for the continued possibility of sustaining religious experience even amid severe mental illness. In addition, I explore how mental health challenges make it complicated if not impossible to adapt some standard models of end-of-life care, but that ways of caring for patients with mental health challenges can be found.