Opinion ID: 1400623
Heading Depth: 2
Heading Rank: 2

Heading: Aspects of the Chaplain Service Under Challenge

Text: Freedom From Religion does not challenge the overall existence of the VA's Chaplain Service; rather, it objects to four specific aspects of the chaplaincy: (1) the clinical focus of the Chaplain Service; (2) the spiritual assessments that the VA gives to its patients; (3) the provision of pastoral care to VA outpatients; and (4) the integration of spirituality/religion into VA treatment programs. According to Freedom From Religion, the historical focus of the Chaplain Service was sacramental in nature and involved caring for the seriously ill and dying patients, leading worship and administering the sacraments. In the past ten years, however, the Chaplain Service has shifted to clinical, direct patient care-termed pastoral care. The VA believes that the spiritual dimension of health must be integrated into all aspects of patient care, research and healthcare education. The Service has been reorganized to reflect this change, and current VA policy requires that the chaplaincy maintain a clinical focus. Under this reorganization, VA chaplains must be educated professionally in Clinical Pastoral Education (CPE) and endorsed ecclesiastically by a particular faith tradition. CPE, an interfaith professional education for ministry, teaches its students to help hospital patients as they deal with existential questions. According to the VA, a chaplain who employs CPE principles allows patients to direct the conversation and to identify both the patients' concerns and the available resources for dealing with their situations. CPE-trained chaplains avoid initiating or guiding religious instruction; however, they are trained to encourage helpful religious and spiritual coping processes. It is undisputed that VA policy prohibits proselytizing. Indeed, the VA patients' bill of rights states that each VA patient has a right not to be coerced into engaging in any religious activities against his or her desires. 38 C.F.R. § 17.33(b)(7). It is further undisputed that the provision of pastoral care is overtly religious in content only if the patient wishes; Freedom From Religion, nonetheless, disputes whether pastoral care can be completely non-religious. According to the VA, pastoral care describes a relationship characterized by expressions of compassionate care, including spiritual counseling, guidance, consolation, empathetic listening and encouragement. The VA notes that the term spiritual refers not only to the practice of a philosophy, religion or way of living but also to that which gives meaning and purpose to life. R.20, Ex. 2 at 1. Accordingly, chaplains have three main responsibilities to patients at every VA facility: ensuring that inpatients and outpatients receive appropriate clinical pastoral care; protecting each patient's constitutional right to free exercise of religion; and ensuring that patients do not have religion imposed upon them. To facilitate the provision of pastoral care and to allow VA chaplains to tailor their services to specific patients, the VA conducts, what it terms, spiritual assessments to measure each patient's religious characteristics. The VA explains that these spiritual assessments also are required for accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an independent, not-for-profit, nationally recognized organization that evaluates and accredits healthcare organizations and programs in the United States, including VA healthcare facilities. According to the JCAHO manual, [s]pirtual assessment[s] should, at minimum, determine the patient's denomination, beliefs, and what spiritual practices are important to the patient. R.21 ¶ 11. The VA does not mandate any particular standard spiritual assessment. It has, however, collected examples of the various assessments that have been developed over the years, and it has made them available to VA chaplains to help them develop their own assessments. Despite the differences among the various spiritual assessments that are used by VA chaplains, Freedom From Religion asserts that all of the assessments emphasize formal religious belief systems and resources. In the early 1990s, VA Chaplain Gary Berg, stationed at the VA Medical Center in St. Cloud, Minnesota, developed the Computer Assessment Program (CAP). CAP specifically was intended to help in understanding the role of religious faith in the maintenance of health, and it focuses on the alleged importance of assessing religious beliefs in order to make accurate religious diagnoses. To this end, CAP asks questions such as: (1) How often do you attend religious services during the year? (2) How much is religion (and/or God) a source of strength and comfort to you? (3) How often do you privately pray? (4) How often do you read the Bible or other religious literature? There is some dispute between the parties as to whether CAP is still used. [9] The parties, nevertheless, agree that many VA chaplains used CAP as a source for creating their own assessments. The spiritual assessment recommended by the VA includes a scoring index whereby a score on the Religious Resource Index of 15 or lower indicates that the patient should be referred to Chaplain Service. R.26, Ex. 17 at 4. Patients' religiosity or spirituality is measured using four categories: (1) Organized Religious Activity Scale; (2) Subjective Religious Scale; (3) Non-organized Religious Activity Scale; and (4) Spiritual Injury Scale. Another example of a spiritual assessment is that of the VA Healthcare Network in Upstate New York. This assessment explains that [c]ompleting this assessment questionnaire will help us to better understand your spiritual care needs and emphasizes that the VA believe[s] that faith plays an important role in a person's sense of health and wellness. R.27, Ex. 23 at 1. The assessment also asks questions such as: (1) What is your religious preference? (2) How often do you attend church, synagogue, or other religious meetings? (3) Do you consider religious or spiritual beliefs systems to be important in your life? (4) Does your faith or beliefs influence the way you think about your health or the way you take care of yourself? (5) Would you like to receive any devotional materials while you are hospitalized? (6) Would you like to address any religious or spiritual issues with a chaplain? The VA concedes that some VA assessments are very in-depth, but it asserts that the assessment will end if a patient indicates that he or she has no interest in receiving spiritual or pastoral care. Additionally, the VA distinguishes between two types of assessments that chaplains employ. The first type, which is given at intake, asks patients whether they identify with a particular faith group and whether there are any religious practices that they view as important to their health. The second type, a more in-depth assessment, is reserved for patients who indicate in the intake assessment that they are interested in receiving pastoral care. The VA also uses spiritual assessments for outpatients, who comprise 80% of patients at some VA facilities. The VA offers pastoral care to outpatients regardless of whether outpatients' ability and opportunity to practice their religion are in any way burdened. The VA's goal is to provide pastoral care from a veteran's initial visit that continues as he or she receives any VA medical services. According to the VA, research has shown that the result of giving outpatients access to quality spiritual and pastoral care is significant improvement in quality of life, reduced inpatient admissions and costs savings. Freedom From Religion also challenges the treatment programs currently implemented at four separate VA facilities. Dayton VA Medical Center integrates the Lament and Fowler's Stages of Faith Development into the treatment of patients with post-traumatic stress disorder. Veterans are introduced to the Lament, which is addressed either to God or to a higher power, as a form of prayer. Sheridan VA Medical Center provides a drug and alcohol treatment program entitled the Spiritual Recovery Support Group (SRSG). SRSG provides intervention and support to veterans suffering from low self-esteem because of significant spiritual injuries, as measured by a Multi-Level Spiritual Assessment (MLSA). SRSG is a vehicle for change and growth because, according to the VA, [w]hen God's gift of spiritual faith and grace is applied, it is good medicine. R.27, Ex. 26 at 1. A recommendation is made to veterans at Sheridan to attend SRSG whenever a veteran shows a significant spiritual injury as measured by the MLSA, which is offered to all patients at the Sheridan Medical Center. The VA Medical Center in Gainsville, Florida also incorporates spirituality into its detoxification treatment program. Its program is entitled Spirituality in Substance Abuse Detoxification Treatment. Finally, the Detroit VA Medical Center likewise integrates spirituality into its chemical dependency program. Its purpose is to integrate the spiritual side of chemical dependency program into the multi-disciplinary treatment plan so treatment can be approached from a holistic perspective. R.27, Ex. 28 at 4. The VA claims that these spiritual programs are offered on a voluntary basis, and Freedom From Religion does not put forth any evidence suggesting that there are no alternative, nonreligious/spiritual programs available to veterans who refuse to participate in the programs to which Freedom From Religion objects.