Below is a document is recently presented to my CPE group as a sample of my pastoral care. It is an alternative to the traditional CPE verbatim format, since after spending an entire year assigned to Adult Psych, where I have the responsibility and privilege of leading a weekly spirituality group, I wanted to spend some time reflecting on the development of my process and invite my peers and supervisor to that process to get their feedback. I share that document here, as a working document, hopeful that it may be a resource to others who facilitate similar groups, as well as serve as a starting point for continued conversation and development.

Background

Group therapy forms part of the therapeutic milieu of the psychiatric inpatient units in the hospital. In groups, patients interact with number of therapeutic factors that contribute to their healing, including participating in one another’s healing, taking part in cathartic activities, and building supportive relationships with staff and other patients.[1] For about eight years, the spirituality group—co-facilitated by a chaplain and another member of the care team—has been one of these groups offered for patients to attend on a voluntary basis.

Currently, this group is generally offered Wednesday afternoons from approximately 2:30-3:15. With some exceptions for safety concerns, all patients are invited to attend, and the number of participants regularly ranges from 2-10. The patients’ ages, religion, diagnoses, and level of functioning can vary significantly, as can those who attend from one week to the next. As the unit chaplain on Adult Psychiatry, I have been leading the spirituality group for nearly eleven months, since the beginning of September 2017, and currently I co-facilitate alternately with the two creative arts therapists (CATs): a drama therapist and a dance/movement therapist.

Approach, Planning, and Assessment

My goal for each group is to create a safe space where participants can be empowered to connect with their own spiritual resources—both the familiar and the new—in ways that foster healing. Participants have the opportunity to engage in a form of communal worship through interacting with music, poetry, and one another. The experience is quite unique from my pastoral encounters in other parts of the hospital, where I usually minister to one individual or family unit at a time. Here, I generate spiritual assessments based on what individuals share about themselves in group, as well as my observations of how they engage with the material and one another. I recognize the group participants come from diverse backgrounds and bring varying ideas and associations of what constitutes “spirituality,” while some may be skeptical of the concept of spirituality altogether, and some may have been deeply hurt by religious institutions or individuals. Mindful of the importance of establishing a common language and expectations within the spiritual and cultural diversity present in any given group,[2] I always begin by offering some basic definitions and guidelines, establishing that this is not a group based around a specific religion or religious practice, and all are welcome.

My approach to preparing for the group has evolved over the months. Whereas, at first, I wrote out an agenda for myself ahead of time, estimating how much time would be dedicated to each activity or intervention, I have since adopted a more spontaneous style. This is partly in response to the fact that it is impossible to predict who will show up for group on a given week, and what their level of functioning will be. And, on a theoretical and theological level, leaving more room for spontaneity takes seriously the collective wisdom that participants bring into the room, gives them agency in their own healing, and leaves room for the holiness of mystery. Still, there are clear boundaries and structure. The 45-minute group is typically grounded in a song and/or a poem that I select ahead of time, and follows a basic framework:

In selecting material, I strive to bring poems and songs from a diversity of cultural experiences so that from week to week, or even within the same session, no single culture or religion becomes the dominant voice. Inspiration comes from different places: I will often take some time beforehand to reflect on what has felt meaningful to me recently, such a song or poem that particularly moved me or brought me comfort. Sometimes I will be inspired by something a patient said or suggested in the previous week’s group. Occasionally, I take inspiration from the time of year, seasons, or holidays.

Sample Encounter

Date/time of encounter: Wednesday, 2:30-3:15 PM

Six patients in attendance:

1. “Suzie” a 40-something Caucasian American Christian woman, admitted 9 days ago. Her admitting diagnosis is bipolar disorder (current episode depressed, severe) and opioid dependence with opioid-induced psychotic disorder. This was my first encounter with this patient.
2. “Zora,” a 40-something Bulgarian Christian woman, admitted 4 days ago for severe recurrent depressive disorder, with psychosis. I had multiple encounters with Zora during a previous admission about a year ago, both in group and one-on-one, but this is my first encounter with her during this admission.
3. “Linda,” a 40-something Caucasian American Roman Catholic woman, admitted 12 days ago for severe depression, with a history of depression and suicide attempts. This was my second encounter with this patient, the first being when she came to group the previous week.
4. “Philip,” a 20-something African American Christian man voluntarily admitted 22 days ago for severe depression and alcohol dependency following his mother’s sudden death in April. He has cerebral palsy and a multi-year history of alcohol abuse. During this admission, I have had several previous encounters with this patient, both in group and one-on-one.
5. “Anita,” a 30-something African American Christian woman, voluntarily admitted 3 days ago for a breakthrough severe manic episode, with psychosis, after a 16-year history of bipolar disorder. This was my first encounter with this patient.
6. “Margaret,” a 60-something African American woman originally from the island of St. Vincent, with no stated religion. She has a history of psychiatric admissions and was admitted 21 days ago with a diagnosis of schizophrenia, complicated by worsening dementia. I have encountered her several times during this and previous admissions, in and out of group.

Conversation

Patients are permitted to join the group no more than five minutes late. Six patients, the dance/movement CAT and I sit in a circle of chairs, facing one another. I open the group much in the same way I always do, introducing myself and the group guidelines:

Chaplain1: Welcome, my name is Chaplain Meghan Janssen and this a spirituality group. For the purposes of this group, spirituality is defined very broadly, because spirituality can mean different things to different people. For many people, spirituality is religion or a relationship with God. Others might connect to spirituality though meditation or art, music or nature. We can think of spirituality as the ways we connect to ourselves and the ways we connect to others. So, everyone is welcome in this group, even if you aren’t religious. I encourage you to reflect on and talk about your own form of spirituality, and you absolutely can and are welcome to talk about your own religious beliefs, but remember that this is not a place to tell other people what to believe.

Anita1: (raising her hand) Can I share about myself and why spirituality is important to me in my own story?

Chaplain2: Yes, but first we’re going to take some time to go around the circle and introduce ourselves.

Anita2: Okay.

I instruct everyone, when introducing themselves, to offer their name, a word that they associate with spirituality, and a movement or gesture with their hands that represents them or their word, that the rest of the group will mirror back to them. I offer an example:

Chaplain3: My name is Meghan. A word that I connect with spirituality is rhythm. And this is my movement… I stomp my feet and tap my knees back and forth, inviting the group to do the movement with me. Most of the patients are able to do this; only one patient, “Margaret,” doesn’t mirror back my movement. I invite Suzie, to my left, to go next.

Suzie1: I’m Suzie. The word I associate with spirituality is Jesus Christ. And this is my movement. She presses her hands in front of her in prayer; everyone but Margaret mirrors. We go around the circle, then do a second round to review everyone’s gestures. Only Margaret and occasionally Suzie refrain from mirroring back others’ movements (Margaret’s word and gesture is “prayer”).

A conflict emerges at the beginning of the group. Anita asks if she can share the meaning of her word (“currents,” with the movement of arms crossing over each other in opposite directions) and how it relates to her story. I feel cautious, and hesitate before giving her permission; her voice and manner indicate she is manic and I am nervous that, if given license, she will dominate the group. But I also don’t want to silence her. I welcome her to speak. She shares that she grew up Christian, going to church with her mother and aunt, but later made bad decisions and associated herself with the wrong kind of people. Now the current of her life is directing her back toward the faith she grew up in. She speaks for about two minutes.

Linda1: I’m going to interrupt you because you’re going to go on and on like you did in the last group but I want to hear what she has to say (indicating toward me) so I can decide whether it’s worth it for me to stay here or not. They begin arguing and speaking over one another. The CAT and I both attempt to intervene and redirect, first gently. Then I say more forcefully:

Chaplain4: I’m going to interrupt and say something here. It’s important to acknowledge that some of us may have come into this group with different expectations, and I hear your hesitation, Linda. All of you took a risk by showing up for this group today and you might still be uncertain whether “spirituality group” is something for you. So thank you for taking that risk and being present. We’re going to do an activity that I think is actually very related to what you were talking about, Anita. But before we move forward let’s all pause and take a couple of deep breaths…

We take a few deep breath together, then I hand out copies of “The Paradoxical Commandments” by Kent M. Keith (attached) and read it through three times, each time exploring different ways of reading it communally (taking turns, “call and response,” and organically reading through whatever lines we want) and pausing between each reading to reflect on what stood out, what felt different, what did we notice. Anita shares first, stating that she’s only going to share briefly because she doesn’t want this to become the “Anita Show.” Linda apologizes for what she said earlier.

Next I asked the patients to flip over their papers to the lyrics of “Beautiful” by Carole King. I shared some of King’s biography, that she had a career as part of a songwriting duo with her husband, writing songs for other musicians to perform, but her marriage was bad and she got divorced. Shortly after, she started writing new songs and performing them herself. “Beautiful” was one of these. I then asked everyone to help keep the beat by tapping their feet or clapping while I played the song on the guitar and sang. Some, but not all, of the patients sang along. Participants then reflected on the song, what they noticed, what lines stood out, and what other songs came to mind on the theme of “being true to yourself.” A few patients offered the following musical reflections:

Suzy: “Beautiful” by Christina Aguilera and the hymn “Amazing Grace”

Anita: “Numb” and “Faint” by Linkin Park and the hymn “Lift Every Voice and Sing”

Margaret: “You Saw Me Crying in the Chapel” by Elvis Presley

The songs that were familiar to me were easier for me to engage with than the ones I did not know. I was unfamiliar with both of the Linkin Park songs, and Anita begged me to play them on my phone, which I declined to do. When Margaret started singing “You Saw Me Crying in the Chapel,” she asked me to play it on the guitar, but I didn’t know it. I asked her if she had any memories related to the song, to which she replied, “It’s Elvis!”

When Anita suggested “Lift Every Voice and Sing,” she explained to the group, “If you grew up in the Black church then you know this song.” I invited her to sing it, and Margaret and Philip sang along. I did not know all the words by heart, but did my best to follow. Linda, who over the course of the group had made amends with Anita (at one point they were even high-fiving one another) was very curious about the song and intent on remembering the title, after Anita explained to her it was considered the Negro National Anthem. I asked Anita what the song meant to her, and she said “Perseverance,” relating the theme to her personal struggles with adversity.

To close the group, we chanted a line from the song “Beautiful,” creating a beat and repeating, “You’re beautiful as you feel.” As we chanted, we went around the room and repeated the gestures participants had used to identify themselves at the beginning of the session. I invited participants to name what they were taking with them from the group, and responses included, “Never give up,” “community,” and “this paper” (indicating the printout of the “Paradoxical Commandments” and “Beautiful”).

Conclusions

A. Evaluation

A challenge from the beginning of this group—as in any group—was establishing trust: with the other members of the group, with me as a facilitator (Linda1), and also the individual participants’ willingness to trust themselves and the value of what they contribute to the group process. In this case, I was challenged by how to respond to the immediate emergence of one member who was more dominant (Anita) and the conflict this produced between her and another strong personality in the group (Linda). In this case, the two were able to redirect themselves and choose new behaviors in order to re-engage in the process. Anita did still need to be redirected or patiently asked to allow other patients to speak at a few points, and I left the group feeling uncertain about my decision to not play the Linkin Park songs she requested on my phone. I felt it would interfere with the flow of the group, and told her the speakers on my phone were not good enough for that kind of use. She let it go, but I wondered if I could have engaged her request differently. When I looked up the lyrics afterward, I discovered they had themes of resolve in the face of being misunderstood or pressured to be someone you’re not. I suspect other patients would have been able to relate to these themes, too. Trust goes both ways: just as the patients must establish trust in me, the group, and themselves, I also need to trust that there is value and meaning in what the patients bring forward.

The other four patients were quieter but also participated, sat in the circle, and offered reflections when I asked them directly about what they were experiencing or noticing. Zora’s brief comments did indicate that she valued the communal experience and sense of collaboration, and she approached me afterwards to talk one-on-one. Suzie was under the influence of medications that seemed to make her drowsy and affected her process. Margaret, whose social functioning was low and who did not mirror or engage with other patients, was clearly able to connect with the music. Philip was quieter in this group that I had experienced him in previous groups, and I realize now only in looking back that he was the only man among seven women. I wonder now whether it would have been appropriate to notice and comment on that dynamic without “putting him on the spot” that would have more fully welcomed his voice.

B. Dynamics

All of the participants share in common that they suffer from moderate to severe mental illness and they share the common challenge of the social stigma attached to that illness. These commonalities make it possible for patients in the group to be a support and resource to one another in ways that I and the co-facilitator cannot. The notion that those with mental illness are not “madmen” but individuals capable of determining and contributing to the course of their own treatment and healing is a relatively recent development in the history of mental health treatment.[3] I am conscious of ways I have internalized stigma and biases about those with mental illness whenever I catch myself reacting with surprise to the profound insights patients share about themselves and one another during group sessions, or when I feel challenged to trust that lower-functioning or particularly quiet patients may be gleaning something from the group that I am unable to see or measure, but such information their business or God’s business—not mine—and that’s okay.

This particular encounter raised my consciousness of my identity in the group as a White female facilitator. The song “Lift Every Voice And Sing” was striking in that it was well known to the three African American patients and completely unknown to any of the White participants. The cultural divides within the room became visible, and at least one person (Linda) responded to this with curiosity. Though I am usually mindful, when selecting material to bring into the group, to represent other cultures and religions, my own approach of choosing something that feels meaningful to me means that I will naturally gravitate toward what feels most comfortable and familiar. As it turns out, both the poem and song in this particular group were more representative of my own race and culture. Opening it up for patients to name their own songs provided a correction to my unintentional bias.

C. Theological Reflection

In many ways, my process and development as a facilitator of this group has paralleled my process in CPE and development of my personal and pastoral identity. Learning to lean further into trusting myself and others, to risk freedom, and to embrace the grace and mystery of play has yielded fruit in both the group (patients will often report experiences of feeling connected and accepted) and in my spiritual and professional development (increased confidence, and my own increased feeling of being connected and accepted).

The hymn “Leaning on the Everlasting Arms” engages these themes of trust and connection to a confident and triumphant tune. I invite my colleagues to sing it with me.

Using the Seminar for Learning

• In line with my goal to “reflect on my relationship to authority in others and in myself,” I would like feedback on how you see me using authority and responding to others’ authority.
• I ask for support from my peers and supervisor in allowing me to talk about how I see my strengths and weaknesses operational in this pastoral care encounter (in line with above learning goal).
• How could I have engaged the conflict between the two patients at the beginning of the session differently?
• I would like feedback on the format of this document. I have struggled with how to document these types of pastoral care encounters in writing, and would appreciate ideas on what could be clearer, more concise, or communicated differently if I were to use this or another spirituality group as an example of my pastoral care when I am preparing to apply for certification.

[1] See Irvin D. Yalom, The Yalom Reader: Selections From The Work Of A Master Therapist And Storyteller, (New York, NY: Basic Books, 1998), 5-41.

[2] Lynne M. Mikulak, “Spirituality Groups,” in Professional Spiritual and Pastoral Care: A Practical Clergy and Chaplain’s Handbook, ed. Rabbi Stephen B. Roberts (Woodstock, VT: SkyLight Paths, 2011).

[3] Sheila Wilensky, A Certain Slant of Light: Emerging From the Shadows of Mental Illness, 2014, 34.