Posted by: scblair | August 15, 2011

A bit of what Clinical Pastoral Education does


I thought I’d throw in a sample verbatim that I presented in CPE a few weeks ago.  These are presented in class and are a pretty significant part of what we do.  After a patient visit we write it up similarly to what you see below, although there are a lot of different ways to do it.  The main reason is to have the group look at what you did, ask questions, and look at the visit from a number of different angles.  Plus, the writing down of the visit and reflecting back on it afterward is very helpful in your own education.  I don’t write up every visit obviously, and while I used to look to try and find the “perfect visit” you can pretty much find something interesting in every visit you do.

Names and places have been changed obviously.  This references the Association of Professional Chaplains’ Common Standards, available here.  And pardon the weird formatting but I’m not fixing it on Monday morning.

 

Rev. Samuel Blair

Highland Dr. VA Medical Center, Pittsburgh PA

Verbatim #5

Supervisor: Rev. Eugene Reddel

CPE Unit 3, Level II

Field Placement: Gateway Hospice, Pittsburgh PA

 

  1. Reason for Presentation:  This visit deals with a lot of loss on the
    part of the patient, which he seemed to have a hard time verbalizing.  I did not sense a lot of openness from him to
    explore deeper issues, so I chose not to.
    However I would like the group to explore areas that I could have
    touched on and didn’t, and also to see about next steps with him to use in
    further visits.

 

  1. Preliminary Information

    1. Date of Visit: 8/5/11
    2. Length: about 45 minutes
    3. Location: a personal care home in rural Butler
      county
    4. Patient:
      Rich is 87 years old and is on hospice for “adult failure to thrive”.  He has no significant medical condition
      besides a recent broken hip, however he has lost a significant amount of weight
      (33# in past year) and some confusion.  He
      was a heavy machine operator, lower income.
      A year ago he was living independently with his spouse.  Apparently there was some sort of violent
      altercation with his grandson resulting in his being committed for psychiatric
      treatment for about 7 months at a skilled facility.  He then came to this facility.  He has no funds to speak of, and the facility
      is apparently caring for him pro bono.
      He has an active death wish and has talked about suicide but stated that
      he won’t because he’s “too chicken”.[1]  He also lacks the means to take his life,
      however staff feel his poor intake is evidence of his wanting to starve himself
      to death.  Our social worker has
      contracted with him that if he feels suicidal that he is to tell us.  His wife has not visited him and I was told
      that she lives with the grandson.  I
      don’t hear anything about children, so I do not know if they are dead or simply
      uninvolved.  They do not visit and she
      also has filed a PFA on him, which is odd given that he can’t leave the
      facility.  The relationship between the
      grandson, the wife and the patient seems very odd from what I know, and it
      seems as if the grandson has taken on a surrogate husband role.  The only visitors he has are his niece and
      nephew.  He has never been religious and
      doesn’t speak much of faith or spiritual issues according to them.  I spoke with the niece prior to this visit
      who stated that she feels he may be at a point of spiritual breakthrough,
      though this may be their own perception of what he needs.[2]

 

  1. Prior to Visit:
    This is only my second time visiting Rich.  I had seen him not long ago, but he asked the
    social worker during her last visit if I could come again and that he “needed
    to see the chaplain”.  Given that he
    might be suicidal I thought that an increased presence would be beneficial as
    well.  I know that loss and grief is a
    primary concern going in, as he has lost most everything he had before and is
    morning the loss of himself in death as well.[3]  When I arrive Rich is seated in a wheelchair
    in his room with a lunch tray, which has a piece of fish and some other things
    which I can see he has only picked at.
    He has a lap blanket covering himself, his hair is wild, and he is
    unshaven.  He appears pale and thin.  In the past when I saw Rich he was in bed, so
    I’m glad he’s up.  His roommate is also
    in the room watching TV.

 

  1. Visit Narrative:

C1:          Hey
Rich – how are you?

P1:          No
good.  No good at all.

C2:          What’s
wrong? (I sit down on his bed next to him)

P2:          This. (he motions to his plate in front
of him) I can’t eat it.  No
appetite.  No taste.  And when I do eat it just comes right back
up.  It’s like it gets stuck or
something.  I can drink a little bit but
that’s it.  But even that comes out my
nose. (big sigh) I dunno.  Hey you’re the
chaplain right?

C3:          Yeah,
I saw you before and Marcie said you wanted to see me.

P3:          Yeah!  The Chaplain!
That’s what I need! (making a lot of eye contact)

C4:          Well
good!  How can I help you? What did you
want to see me about?

P4:          (sighs again) I dunno.  I’m just so tired anymore.  And I can’t eat.  No appetite. (looks down)

C5:          Does your throat feel tight? (I feel
puzzled and confused.  This isn’t where I
thought he would go.)

P5:          No
it just won’t go down.

C6:          Hm
– but you can drink ok? (I’m out of my pastoral mode and into diagnostic mode)

P6:          Sometimes.  I drink milk and that’s about it. (He takes a
glass of milk and tries to take a big quick gulp, and chokes a bit on it.)  See?

C7:          It looks like you’re trying to drink
too fast.  Try to slow down. (I see that
part of his issue might be trying to hard not only at eating and drinking but
at everything – and he can’t do it which makes him depressed.)

P7:          Yeah.
(pauses, silence)

C8:          Would you want to go outside?  It’s not too bad out yet. (I think a change
of scenery, as well as an outward focus and less stressful environment, could
be helpful.  I feel back in pastoral
mode.)

P8:          I
don’t know.  I like to go outside but I’m
so tired anymore.

C9:          Well
I can push you.

P9:          I
don’t know.  It might do me some good,
but I don’t…(he trails off)

C10:       Just give it a try.  If
you get tired we can come back in.

P10:       Ok.

I
get him a pair of pants and help him get his hair brushed down.  I take him outside in his wheelchair.  Along the way he talks about going outside so
he is obviously looking forward to it.
Once outside he talks about the other residents who are outside and
especially about fishing.  We sit on a
large deck with some other residents.  There
is a small lake at the facility with some fish in it that he likes to go
to.  He starts to talk about his home.

P11:       …I got to drive by there last week.

C11:       Really?  I heard that
your niece and nephew took you.  How was
that?

P12:       It was ok.  At least I got to see the outside of the
place.  Last time I went in the place was
a wreck.  Everything emptied out, drawers
all opened up, there was $100 in my nightstand and that was gone.  I was hoping to be able to go back there but
they say I can’t live there on my own.  I
thought maybe my granddaughters could stay there and then I could stay in part
of it, but they don’t want to do that.  I
can’t even rent it, my wife doesn’t want me to.

C12:       Where is your wife?

P13:       She’s at a home too.
She doesn’t come see me either.
Neither does my grandson.

C13:       That’s really too bad.

P14:       The only people that see me are my niece
and nephew. (long pause)  I don’t
know.  I’m going to be 90 next week.  I don’t know what will happen after
that.  We’ll see if I make it to next
week.

C14:       Well when next week comes we’ll have to
have a party for you.  I’m glad your
niece and nephew visit.  That shows that
they care for you.  And I’ll come and see
you too if you think that would help.

P15:       Well we’ll see.  We
probably should go back in now.

C15:       Sure.  I’ll take you in.

I
wheel him back inside.  He’s quieter now.

C16:       It was very good to see you Rich.  I’ll try and see you more often.

P16:       Good to see you too (smiling; I take his
hand and he shakes it firmly).  Good to
see you.  Thanks for coming.

C17:       Anything else I can do for you? (this is my way of seeing how
open he is to prayer)

P17:       No, not really.

C18:       Ok.  I’ll keep in you in
my prayers this week.  I hope you get to
feeling better.

P18:       Thank you.  Thanks very
much.

  1. Pastoral/Relational/Theological Reflection

 

I went in to the visit expecting more of a formal
“pastoral” visit, given that he had specifically asked for a chaplain.[4]  This was also confirmed for me in P3.  Given his desire to die I expected him to
have questions about God and faith, perhaps express fear of dying, confess,
want to accept Christ – I wasn’t sure.
However when I opened up the door to conversation, religious discussion
was not on his mind.  This surprised me,
and I felt myself switching from a pastoral to more of a diagnostic role in
order to see what was happening.  I
wondered for a minute during the conversation why he had wanted a
chaplain.  I realized that he probably
didn’t even know what to ask, and that he may just have needed pastoral
presence in his life.  He asked for me
because I had shown up before.  I decided
not to press too hard in terms of his suicidal thoughts, religious themes or
theological questions as I felt it would be better to let him bring them
up.  I felt that taking Rich outside
would change the situation, make him feel a bit more free and open, and help
him to talk about his losses and inner experience.  I also wanted to show him acceptance and
companionship as I felt that he probably expected to be rejected, just as he
has been rejected by his family and probably feels rejected by God as well.

 

I also came in to this visit with a bit of
uneasiness, because I was not sure exactly how much religious power he was
going to give me.[5]  I’ve been more comfortable in my role as
chaplain than I have in my prior role as a more formal minister, and even much
less so as an evangelist.  I wonder if he
is going to expect me to be an evangelist or confessor of some sort.  In terms of my own authority provided to me
by my position, it pushes my comfort boundaries because I’m not comfortable
pushing people or confronting them to make decisions.[6]  I feel that building the relationship and
witnessing through that relationship is more beneficial in this situation.  I could have gone in with the intent to
witness to him, given his terminal prognosis and need for an understanding of
Christ.  But I took the path that seemed
the most natural.

 

Relationally I think he may see me as a
son.  I know very little of his family
except to know that they aren’t involved in his life.  He sees himself as alone, though he seems to
interact with the other residents there, especially some of the men and his
roommate.  He seems helpless and
hopeless.  His abandonment defines
him.  Our social worker stated that she
has been frustrated talking with him in that whenever she has tried to point
out positives to him he ignores them and remains fixated on his losses.  She expressed this as “he just doesn’t want
to do anything for himself”.  I believe
he doesn’t because he doesn’t see any reason to do anything for himself – his
“self” is gone.  He has lost everything
that has given him meaning in the past.
I’m not sure what he holds on to or what is keeping him going.  It may be that this reaching out to others
and trying to rebuild relationships in the time he has left (which he thinks is
short) is his purpose right now.  This
desire to connect with me is evidence of that.

 

Presence was very important to him.  The fact that I visited him before, however
briefly, was an important starting point.
The fact that he sought out that presence again shows he trusts me and
that he felt supported while I was there.

 

While I felt sadness, I overall felt peace
during the visit.  Moving the visit
outside helped me as well, as I tend to feel less pressure and more comfortable
with silence when I’m outside.  I also
switched from a more active role to a more passive role.  This opened him up quite a bit I believe, as
he moved more from the negatives of his present to more positive aspects –
fishing, going outside, and the other residents.  He also visited with me much longer than I
expected.  My first visit with him was

rather short, as have most of his other visits with our staff.  I feel that he trusts me and I feel that I
need to reinforce that trust.

 

Spiritually I felt as if I were an
incarnational presence to Rich.[7]  I don’t know what spiritual or religious
questions he has, but I know that he needed more of a presence in his life at
that time.  He may be dealing with a lot
of guilt and shame from this event that ended up in his being committed, and
I’m sure that he feels that life isn’t just or right.  Being gracious to him will, I hope, make him
more open to forgiving himself and releasing the shame that makes him want to
die.


[1]
APC Common Standards: PAS4

[2]
APC Common Standards: PAS3, TPC3

[3]
APC Common Standards: PAS5

[4]
APC Common Standards: IDC2

[5]
APC Common Standards: IDC3

[6]
APC Common Standards: IDC3

[7]
APC Common Standards: TPC1


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