David Biale: Please describe your work as a spiritual caregiver. How does it differ from the role of a religious chaplain in the American context (i.e. a rabbi or priest who works in a hospital setting)?
Avi Rechtman: Over the last year and a half, I have served as a spiritual caregiver in the Hematology Institute, which is directed by Dr. Ariel Aviv of the Ha-Emek Hospital in Afula, Israel. I belong to a team in the institute that includes doctors, nurses, administrative staff, along with two social workers and a psychologist. I work in close coordination with all of them.
My work involves sessions with out-patients and their families who come to the institute for treatment, as well as hospitalized patients and their families. I also hold regular meetings and consultations with the members of the staff as part of the supportive and holistic treatment of patients. At times, this involves support for the staff itself. The meetings with patients are either the result of offering my services during treatment or as the result of a referral from the staff when they believe it appropriate for the patient. There are many patients who continue these sessions willingly over a long period of time, since hematological treatment itself often takes place over a long term.
It is inevitable that, at times, differences arise between the medical staff and the patient and his or her family, differences that require mediation to improve communication and understanding. Special care is also needed in end-of-life situations, which involve practical, psychological and spiritual dimensions.
The role of the spiritual caregiver in Israel is not religious. The core of our work involves listening and being present, as well as a recognition of the spiritual meaning in the fact that all human beings must die and that we are all subject to forces greater than ourselves. This recognition at times provides inspiration and a sense of spiritual transcendence, but at other times leaves us feeling powerless, confused and in despair. The religious dimension of our work finds expression in the special cultural contexts of Judaism and Islam and especially around questions of faith. However, it is not part of the role of the spiritual caregiver to perform religious rituals or provide explicit religious guidance.
DB: How do you measure success in this work?
AR: Since the work of the spiritual caregiver consists primarily in deep, curious and active listening to the patient, there is a question about what constitutes “success” or “failure” in this work. Since this work has no specific goal, it may not be possible to measure its success or influence. Despite this lack of a goal, one can still speak of results of this work, some more dramatic and some less. First is increasing and sharpening the consciousness of the end of life when unnecessarily aggressive medical intervention ends and palliative care takes over. At this stage, the presence of the family with the terminally ill patient becomes more critical. This is the time to try to renew contact with distant or estranged family members for one reason or another, as well as contact with family members abroad. In addition, this is a time for increased communication between the family and the medical team.
Second, since the spiritual caregiver is not seen as part of the traditional member of the system, in many cases, patients feel comfortable expressing their travails or their thoughts about their medical treatment. The spiritual caregiver can serve to mediate between the patient and the medical team about these matters.
Third, medical practice is based on active interventions, but many times, hematologists are actually unable to predict the effect of their treatments. The spiritual caregiver can “inhabit” this realm of uncertainty together with the patient as well as the medical team in order to recognize and respect this stage of the treatment until it becomes clarified.
DB: Are there unique characteristics to working as a spiritual caregiver in hematology? How does it differ from other medical conditions?
AR: Treatment in the Hematology Institute has a number of elements that shape the work of the spiritual caregiver. First, since hematological therapy is often long-term, a web of relationships involving trust can develop with patients and their families. Second, since this therapy often involves cycles of improvement and decline in the health of the patients, these fluctuations in many cases create emotional and spiritual roller-coasters that require support and understanding.
Third, the fact that treatment of blood diseases is directly connected to palliative care, which continues even after the treatment of the disease itself ends, means that the medical staff and the spiritual caregivers must continue their work even in the terminal stages of the disease. Fourth, since the physicians and other medical staff have long-term and continuing relations with their patients, the spiritual caregiver is able to work with staff who are personally connected to their patients. Fifth, the range of therapies available in hematology raises medical and ethical questions about whether to continue treatment or to provide only palliative care. This is always a difficult step since it involves abandoning therapeutic treatment in favor of concentrating on the quality of life of the patient. This decision demands a multi-disciplinary approach together with the patient and his or her family and directly involves the spiritual caregiver, who helps the patient confront both despair and hope. The differences between the special character of the long-term relationship between patient, family and medical staff in the case of hematology and other medical specialties that involve either short-term or episodic relationships naturally end when the patient is transitioned to palliative care.
DB: The hospital where you work in Afula is quite unusual in its mix of populations (both medical staff and patients). Please describe this mix and explain how it influences your work as a spiritual caregiver. What kind of cultural assumptions do patients have in your work with them? How do you address those assumptions?
AR: Hospitals [in Israel] and Ha-Emek Hospital in particular treat patients from many different faiths and ethnicities. In our hospital, there are Jewish patients from all of the various communities of origin, Muslim and Christian Arabs, as well as Christians who are not necessarily Arabs. And one finds all of this variety among the staff of physicians and nurses as well. There are often, in addition, sharp political differences among patients and among medical staff. The role of the spiritual caregiver is to listen to every person on any subject he or she chooses to speak about, which troubles his spirit, without any exceptions. It is not unusual for me to hear opinions with which I disagree. However, my work does not involve educating or shaping opinion. In my experience, deep listening ultimately leads the patient who loves to talk about politics to focus on himself or herself and to their struggles with their illness. A spiritual caregiver also has to develop curiosity about different cultures. The caregiver must understand behaviors and values that motivate the decisions that the patient considers appropriate. The fact that the spiritual caregiver is not obligated to take any action with respect to the patient liberates him to engage more deeply in listening. In my experience, in situations of crisis, such as anger at the medical staff or at a certain medical therapy or at the hospital in general, the presence of the spiritual caregiver as a listener who has very little influence on the practical level of care creates a space in which the caregiver can lower the temperature and create better communication and solutions for the patient and the staff.
DB: Do you think that the Israeli experience of spiritual caregiving can be applied to other cultures (America, Europe, etc)?
AR: The central question for spiritual caregiving is: what does “spiritual” mean and how does one relate to it personally and culturally? While spirituality is at the center of this discipline, what it means is open to subjective definition based on one’s cultural stereotypes. A religious person can, of course, embrace faith and religious practice or can reject these, as might a complete atheist, who also can either hold to his “faith” or totally change it. Even those who reject spirituality totally as utterly irrelevant still have associations with the word and the emotions and ideas that it arouses. The spiritual caregiver becomes more and more adept at creating a space for listening to the patient as they investigate what the word “spirituality” means for them.
I believe that the experience of spiritual caregiving in Israel can make two contributions. First, as opposed to the model where a spiritual caregiver is sent for a one-time consultation by an outside agency, in our system, the spiritual caregiver is an integrated member of the department’s staff. This integration makes possible a profound connection with the patients and medical staff. The second — and perhaps even broader contribution — is that the spiritual caregiver in the Israeli setting does not represent any religion. We bring spirituality into the discourse of the hospital without any prior religious assumptions and thus create a space for the individual patient and their family to investigate their own personal understanding of the spiritual needs that they all confront.
About the Author:
Avi Rechtman completed an MA in Jewish thought and in spiritual caregiving at the Schechter Institute in Israel. He serves on a part-time basis as a spiritual caregiver at Ha-Emek Hospital in Afula, Israel.
Translated by David Biale.