Spiritual AIM and the work of the chaplain: A model for assessing spiritual needs and outcomes in relationship
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Palliative and Supportive Care (2015), 13, 75 –89.
# Cambridge University Press, 2014 1478-9515/14
doi:10.1017/S1478951513001120
Spiritual AIM and the work of the chaplain:
A model for assessing spiritual needs
and outcomes in relationship
THE REVEREND MICHELE SHIELDS, DMIN, BCC, ACPE SUPERVISOR,1
ALLISON KESTENBAUM, MA, MPA, BCC, ACPE SUPERVISOR,2 AND
LAURA B. DUNN, MD1,3
1
Spiritual Care Services Department, University of California San Francisco Medical Center and Benioff Children’s
Hospital, San Francisco, California
2
Center for Pastoral Education, Jewish Theological Seminary, New York, New York
3
Department of Psychiatry, University of California San Francisco and UCSF Helen Diller Family Comprehensive
Cancer Center, San Francisco, California
(RECEIVED September 5, 2013; ACCEPTED November 12, 2013)
ABSTRACT
Objective: Distinguishing the unique contributions and roles of chaplains as members of
healthcare teams requires the fundamental step of articulating and critically evaluating
conceptual models that guide practice. However, there is a paucity of well-described spiritual
assessment models. Even fewer of the extant models prescribe interventions and describe
desired outcomes corresponding to spiritual assessments.
Method: This article describes the development, theoretical underpinnings, and key
components of one model, called the Spiritual Assessment and Intervention Model (Spiritual
AIM). Three cases are presented that illustrate Spiritual AIM in practice. Spiritual AIM was
developed over the past 20 years to address the limitations of existing models. The model evolved
based in part on observing how different people respond to a health crisis and what kinds of
spiritual needs appear to emerge most prominently during a health crisis.
Results: Spiritual AIM provides a conceptual framework for the chaplain to diagnose an
individual’s primary unmet spiritual need, devise and implement a plan for addressing this
need through embodiment/relationship, and articulate and evaluate the desired and actual
outcome of the intervention. Spiritual AIM’s multidisciplinary theory is consistent with the
goals of professional chaplaincy training and practice, which emphasize the integration of
theology, recognition of interpersonal dynamics, cultural humility and competence, ethics, and
theories of human development.
Significance of Results: Further conceptual and empirical work is needed to systematically
refine, evaluate, and disseminate well-articulated spiritual assessment models such as
Spiritual AIM. This foundational work is vital to advancing chaplaincy as a theoretically
grounded and empirically rigorous healthcare profession.
KEYWORDS: Chaplaincy, Spiritual assessment, Spiritual care, Conceptual model,
Palliative care
INTRODUCTION
In primitive times, the healer cared for mind and
Address correspondence and reprint requests to: Michele body, and also, importantly, spirit (Sigerist, 1951,
R. Shields, Director, Spiritual Care Services, UCSF Medical Cen- p. 136). As medicine evolved, the role of spiritual
ter and UCSF Benioff Children’s Hospital, 505 Parnassus Avenue,
San Francisco, California 94143-0208. E-mail: Michele.Shields@ healer diverged from that of medical practitioner
ucsfmedctr.org. (Temkin & Temkin, 1967, p. 207). Although spiritual
7576 Shields et al.
leaders (e.g., clergy, teachers) have provided spiritual example, the biopsychosocial model is a conceptual
healing for the physically and mentally ill for centu- framework of health and illness that gained traction
ries, the field of professional chaplaincy has emerged as a way to teach doctors in training that patients are
largely during the last century (Cadge, 2012, p. 24). more than their disease or symptoms (Engel, 1979).
Board certification in chaplaincy is an even more re- Training and board certification in professional
cent development, beginning in the 1940s (Cadge, chaplaincy require that chaplains utilize spiritual
2012, p. 24). assessments to guide their care (Spiritual Care
As with any practice that matures into a “pro- Collaborative, 2004; Association of Professional Cha-
fession,” the process of professionalization brings plains, 2009). The Joint Commission requires only
benefits, challenges, and obligations. Professions that spiritual assessments be conducted (Joint
strive to enhance the quality and consistency of Commission, 2010). Recent literature pertaining to
care provided by their practitioners, guided by stan- the professionalization of chaplaincy advocates for
dards of practice and ethical principles. In the case greater articulation of interventions and outcomes
of chaplaincy, benefits of professionalization should that correspond to spiritual assessments (Handzo,
accrue to patients and their loved ones, as consistent 2012; Peery, 2012). However, it is unclear to what ex-
standards of chaplaincy permeate healthcare set- tent professional chaplains formulate, utilize, and
tings and practices. A number of studies have shown articulate spiritual assessment and the theoretical
that chaplain visits have a positive impact on patient models from which they emanate (O’Connor et al.,
satisfaction (Gibbons et al., 1991; Jankowski et al., 2005). Further, there remains a relative paucity
2011). Benefits also accrue to professional chaplains, of published, well-described spiritual assessment
who may experience greater professional gratifica- models (HealthCare Chaplaincy, 2011; Jankowski
tion, recognition, and opportunities (VandeCreek & et al., 2011).
Burton, 2001). Therefore, the purpose of the present paper is to de-
Challenges for the field of chaplaincy include the scribe one clinically implemented spiritual assess-
need to distinguish the unique contributions and ment model, called the Spiritual Assessment and
roles of chaplains as members of healthcare teams Intervention Model (Spiritual AIM). Spiritual AIM is
(VandeCreek & Burton, 2001; VandeCreek, 1999; based on more than 20 years of chaplaincy experience
Jankowski et al., 2011; Cadge, 2012). In addition, and teaching, is currently taught to chaplain trainees,
concerns about the costs of healthcare increasingly and has been disseminated to multiple clinical disci-
challenge chaplains to justify their cost effectiveness plines. After describing the development and theo-
and clearly articulate their added value. Another retical underpinnings of Spiritual AIM, three cases
challenge for chaplaincy is the basic work of agreeing illustrating its use will be presented, the model cri-
upon definitions, goals, outcomes, credentialing, and tiqued, and areas in need of further study discussed.
other directions for the field (Lucas, 2001; Ellison &
Benjamins, 2013; Krause, 2011).
As a profession, chaplaincy also must meet its ob-
SPIRITUAL ASSESSMENT VS. SPIRITUAL
ligations to adhere to the highest possible standards
SCREENING
in training, to articulate required competencies for
certification, as well as to assure ongoing quality of At the outset, a fundamental distinction must be
practice (e.g., through peer review, continuing edu- made between spiritual assessment and spiritual
cation, and regular consultation with colleagues). screening or spiritual history (LaRocca-Pitts, 2012).
In addition, chaplains must adhere to a code of ethics Spiritual screening and spiritual history have been
that guides their practice. Furthermore, procedures more widely studied and purposefully designed to
must be in place for addressing complaints from col- be conducted by clinicians from any discipline (Mas-
leagues and recipients of care when chaplains do sey et al., 2004; Fitchett & Canada, 2010). These
not adhere to ethical principles (Spiritual Care screens usually employ a limited set of questions de-
Collaborative, 2004; Association of Professional Cha- signed to gather data about a patient’s faith, the im-
plains, 2009). portance of their faith and/or faith community, and
A critical obligation of chaplaincy is to articulate their need for assistance or resources in having their
and critically evaluate theoretical models, to dissemi- spiritual needs addressed. Spiritual screening there-
nate these models, and to educate chaplains in their fore connotes the essential, but necessarily circum-
appropriate use (Fitchett, 2002; Jankowski et al., scribed, goal of screening for spiritual needs and
2011). Models provide the framework for professional resources. However, even tools with “assessment” in
clinical application and are the common language their name may be more appropriately termed spiri-
that professionals employ to communicate their ideas tual screening tools (Borneman et al., 2010). Such
and assessments within the field and beyond. For screens do help identify the need for a professionalSpiritual assessment and intervention model 77
chaplain and can lead to appropriate referrals from that some aspects of the model were described in pre-
other healthcare providers (Jankowski et al., 2011). viously published work by a non-chaplaincy scholar
Spiritual assessment, in contrast, should only (specific attribution to MS was not made, however,
be completed by a professionally trained chaplain as the scholar was describing clinical pastoral edu-
(Handzo et al., 2012). Spiritual assessment is not a cation as an ethnographer) (Lee, 2002). Finally, the
scripted or generic set of questions asked in the interdisciplinary work of our Spiritual AIM research
same way of each patient. Spiritual assessment is team (see the Acknowledgments section) has helped
an evolving dialogue, established within a compas- refine the model even further through conceptual
sionate encounter with the patient, regarding those and empirical discussions occurring during team
issues that most concern that patient. Spiritual as- meetings. These meetings included in-depth discus-
sessment involves diagnosing an individual’s pri- sions of transcripts of chaplain sessions (conducted
mary unmet spiritual need and devising a plan with outpatients receiving palliative care for ad-
about how to address that need through a process of vanced cancer), critical inquiry into the origin and
particular interventions aimed at healing outcomes. meaning of specific language used in the model,
and exploration of novel concepts and themes emer-
ging from the evidence.
DEVELOPMENT OF SPIRITUAL AIM:
ROOTS IN CHAPLAINCY MENTORSHIP
“Being in Relationship”: Fundamental to
One of us (MS) developed the theoretical model of
Spiritual AIM
Spiritual AIM over the past 20 years to address these
limitations. Initially, the first author was part of a Relationships are the context for spiritual develop-
small group of chaplains mentored by the Reverend ment. Object relations psychology provides an impor-
Dr. Dennis Kenny as part of their supervisory train- tant framework for understanding this assumption
ing. For two years (1991 – 1993), the first author was about the spiritual nature and potential for healing
part of this working group. At the outset, the work (Rizzuto, 1981). As noted by other authors, spiritual
primarily drew from a Lutheran-based perspective development, and therefore spiritual care, cannot
regarding what people needed spiritually and how be seen as separate from relationships (Clinebell,
people grew spiritually. The group met weekly to dis- 1984). Personality takes shape through people’s ex-
cuss, question, and comment; dialogue and disagree- periences of relationships and social context, specifi-
ment were welcomed and helped develop the first cally how a child appropriates, internalizes, and
author’s ideas about the model. A primary focus of organizes early experiences in the family (Chodorow,
this group involved observing how different people 1978). Spiritual AIM posits that spiritual dynamics
responded to health crises. The constellation of core and core needs are shaped in a similar manner.
needs and the idea of interventions designed to ad- As the individual grows, she carries the internal
dress those needs emerged from this dialogue and su- drama of childhood experiences within her memory.
pervision. Individuals assimilate new experiences with old dra-
During that time, MS began observing what occur- mas, rather than experiencing the new in its contem-
red in the relationship between the patient and the porary form (Pine, 1990). This living out of personal
chaplain, which led her to read and draw from the history in relation to others is termed “transference.”
field of object relations psychology. It also caused A person develops compelling beliefs acquired by in-
her to reflect more deeply on her own theology, which ference from experience. These beliefs are largely un-
describes healthy relationships between individuals, conscious and guide a person’s behavior and form a
and between individuals/communities and the Di- spiritual life script about how the person needs to
vine or Ultimate Reality. These relationships demon- relate to God and others in order to be loved and ac-
strate both autonomy and connection, as well as love cepted (Kenny, 1980). Patients often transfer their
toward the self in balance with love toward others experience with their parents onto their assumptions
and the Divine or Ultimate Reality. about God, their relationship and experience with
Over the next 18 years, the model gained greater God, and the way they speak about God (Rizzuto,
specificity in interventions. During that time, the 1981). For example, one of us (MS) visited a hospital
model’s language has been modified to be more in- patient who, based on experiences in childhood with
clusive of other faiths. In addition, substantial efforts alcoholic parents who were emotionally distant,
were made to “translate” the model more effectively expressed a spiritual perspective in which God
to other disciplines within the hospital setting. Ad- was remote, detached, and, theologically speaking,
ditionally, the model had been extensively utilized transcendent (i.e., outside the patient’s world or
in clinical work with patients and in supervisory experience). This detachment also played out in re-
work with chaplaincy students. It should be noted lationship with the chaplain, who struggled to78 Shields et al.
establish rapport with the patient. The patient was strength, and with all your mind; and your neighbor
initially skeptical that the chaplain would be interes- as yourself” (Deuteronomy 6.5; Leviticus 19:18; Luke
ted in her as an individual. Using a poem, “God Says 10:27) (Levine & Brettler, 2011). Spiritual AIM was
Yes to Me” by Kaylin Haught (Kowit, 1995), the developed with these fundamental themes in mind
chaplain helped the patient connect with a warm as the standard for spiritual maturity and healing.
and loving experience of God. The chaplain also Healing requires both autonomy and connection.
asked the patient to reflect on her most loving One must be autonomous enough to love oneself
relationship. The patient described her childhood and value connection to achieve fairness in balancing
nanny. When the chaplain asked the patient, “What love for oneself, others, and God.
if God were named [the nanny’s name]?” the patient Thus, central to Spiritual AIM is our understand-
began to cry. Over the course of a several-week hospi- ing of spirituality as expressed through relation-
tal stay, this brief intervention helped the patient ships. Spirituality addresses relationality in four
cultivate a relationship with God (whom she now dimensions: the individual’s relationship with him-
called by the nanny’s name). God had become— self, with his community, with nature, and with the
theologically speaking—immanent (i.e., fully pre- divine or that which transcends the self. Further-
sent to her in an immediate way). From the cha- more, extensive experience with asking care provi-
plain’s perspective, the care shown by the chaplain ders what they believe to be core spiritual needs of
to a patient as an individual was representative of human beings—regardless of culture, origins, reli-
God’s love and care for her individually as well. As gion—revealed consistent responses, including: con-
this case illustrates, patients may view the chaplain nection, community, self-worth, self-esteem, hope,
as an extension, conduit, or representative of God— peace, meaning, to love, to be loved, reconciliation,
or of another dimension greater than oneself. and forgiveness. Regardless of the length of this list
Therefore, the process of spiritual healing entails of needs, the following three core spiritual needs
exploring how patients relate to others, why they re- seemed to encompass the majority of responses: (1)
late in these ways (i.e., what patterns of object re- meaning and direction, (2) self-worth/belonging to
lations guide his/her behaviors), and how the patient community, and (3) to love and be loved/reconciliation.
may benefit from modifying these dynamics. The
goal of the chaplain is to assist in the patient’s healing. Definition of Spirituality in Spiritual AIM
The process of raising the spiritual life script to con-
sciousness, testing and disconfirming it, largely in re- Thus, we came to define spirituality as encom-
lationship with the chaplain, often frees the patient passing the dimension of life that reflects the
from her spiritual life script or primary dynamic of re- needs to seek meaning and direction, to find
lationship developed in childhood. She has greater self-worth and to belong to community, and to
freedom and is then brought back into the balance of love and be loved, often facilitated through
loving self, God, and others equally. This spiritual seeking reconciliation when relationships are
life script may need to be disconfirmed many times broken. This definition seeks to recognize each
in many different ways for lasting integration to occur. patient’s individuality in terms of their deepest need
As Spiritual AIM draws upon object relations for and evaluate where the patient is located along the
its foundation, it also has roots in foundational path toward healing and wholeness. In addition, Spiri-
ethical and theological themes, namely, the ethic tual AIM uniquely posits that, when individuals face
of reciprocity, more widely known as the Golden any crisis, one of the three primary spiritual needs
Rule—“Treat others as you wish to be treated” surfaces in a clear and immediate manner.
(Flew, 1979, p. 134). This theme is prominent in Jew-
ish and Christian teachings and scripture (“Love
DESCRIPTION OF SPIRITUAL AIM
your neighbor as yourself,” Leviticus 18:18, Matthew
22:37 – 40), and is expressed in some similar fashion As described in further detail in Table 1, Spiritual
in all ethical and faith traditions (Flew, 1979, AIM provides a conceptual framework for the cha-
p. 134). For example, it is expressed in the negative plain to: (1) diagnose an individual’s primary unmet
in Confucianism—i.e., “What you do not wish for your- spiritual need—through observing the patient’s
self, do not impose on others” (Huang, 1997, p. 14). words and behavior in relationship with the cha-
Spiritual healing is a process in which people live in plain, as well as through the chaplain’s self-aware-
balance with what is considered in one author’s theol- ness of the interpersonal dynamic with the patient;
ogy (MS) the “Greatest Commandment,” and, in rabbi- (2) devise and implement a plan for addressing this
nic literature, the “greatest principle in the law”—that need through embodiment/relationship; and (3) ar-
is, “You shall love the Lord your God with all your ticulate and evaluate the desired and actual outcomes
heart, and with all your soul, and with all your of the intervention. Analogous to medical diagnosisSpiritual assessment and intervention model 79
Table 1. Spiritual Assessment and Intervention Model (Spiritual AIM)
Primary Identified Spiritual
Need
Self-Worth &
Belonging to Reconciliation/to Love
Meaning & Direction Community and Be Loved
Primary Spiritual Task
Learn to Be in Relation to Self and Learn to Love Self Learn to Love Others (God)
Therefore Others (God)
Assessment—Observing the Patient
† Patient does not place blame. † Patient blames self, not others. † Patient blames and mistrusts others.
† Patient tends to intellectualize † Patient does not complain. † Patient complains (e.g., about food,
circumstances. staff).
† Patient accepts current reality
† Patient sees and articulates both without questioning or † Patient expresses unrealistic
sides of most situations. evaluation. expectations that others should know
patient’s needs.
† Patient is concerned about the † Patient expresses concern for
meaning of own life/identity and others and fears burdening † Patient does not take responsibility
making sense of his/her illness. them. for own healing or choices.
† Patient has difficulty focusing and † Patient prioritizes caring for † Patient presents with combative
making decisions. others and may minimize their energy and angry affect early in
own needs, healing and/or self- process.
† Patient employs several metaphors,
care.
images, or analogies in † Patient’s comments focus on their
conversation. † Patient shows deep appreciation assumptions about other’s flawed
for social support and actions and inner lives, rather than
† Patient asks questions and
opportunities to tell their story. their own.
demonstrates curiosity (e.g., about
illness, the nature of God or † Patient discusses strained, broken, or
religion). estranged relationships, need to
forgive or be forgiven, inability to
† Patients feels enticed, yet
grieve losses, or unwillingness/
encumbered by exploring infinite
inability to say goodbyes.
possibilities.
Assessment—Chaplain’s Self-Awareness
Chaplain may feel in a fog or have Chaplain may feel that patient Chaplain may feel him/herself being
difficulty following what patient is attempts to serve as a caregiver for drawn into a triangle. Chaplain feels at
saying. the chaplain. risk of alienating patient easily.
Chaplain may feel that patient puts
chaplain up on pedestal.
Plan for Embodiment of the Chaplain—“to Be”
Guide Valuer and Community Prophet and Truthteller
Intervention—“to Do”
† Name and reflect back emotions † Surface anger as source of † Demonstrate ability to tolerate
(especially anger) as a source of energy; accompany him/her as patient’s anger.
clarity. they feel it.
† Surface and explore sadness, fear,
† Surface what decisions need to be † Surface old, unhealthy, unkind grief, loss of sense of control beneath
made or questions need to be beliefs about self. the anger.
answered.
† Create a “community of two” by † Acknowledge brokenness, tension, or
† Ask patient how he/she has coped keeping patient company and estrangement in the relationships
with similar crises and listening to his/her story of patient discusses.
circumstances or made decisions in illness/suffering.
† Remind patient of own internal
the past.
† Make specific, genuine resources/abilities to advocate
† Help patient to name resources to statements of affirmation about appropriately for self.
help make decisions, answer attributes, role, and behavior of
† Hold patient accountable for creating
questions, or achieve clarity about patient.
safety for self and choosing to trust
their heart’s desire.
† Listen attentively while valuing others.
† Demonstrate support and guidance, patient’s story.
† Remind patient to say what they need
as if walking along side patient on a
† Empower patient to identify rather than expect others to intuit it.
path.
what is loveable about them.
Continued80 Shields et al.
Table 1. Continued
Primary Identified Spiritual
Need
Self-Worth &
Belonging to Reconciliation/to Love
Meaning & Direction Community and Be Loved
Plan for Embodiment of the Chaplain—“to Be” (continued)
† Honor when patient makes † Make referrals to spiritual † Ask patient about their part in
important decision (e.g., regarding communities, classes and illness- estrangement and conflict. Call them
treatment, to enroll in hospice, to specific support groups. to confess fully.
take an important trip).
† Regularly remind patient about † State impact of patient’s behavior on
† Honor when patient arrives at a loved ones and reference other you/others. Observe whether
new meaning (e.g., deciding upon a caregivers on team to build contrite/sorry.
legacy project like a video, letter for support.
† Patient takes responsibility to
child).
† Use faith tradition to challenge apologize and for behavioral
† Commission the patient for this old beliefs; create and offer new changes/acting differently.
decision/work/meaning with a cleansing belief and ritual.
† After patient has behaved differently,
blessing or ritual (religious or non-
discuss forgiveness from others, self-
religious/poetic).
forgiveness and forgiveness in their
faith tradition; offer ritual.
Desired or Proposed Outcome/Healing/Wholeness
† Patient learns and trusts that † Patient reports greater sense of † Patient realizes that his/her
whatever decision they make will be belonging to community. behavior has an impact on other
congruent with own values. people.
† Patient names how he/she is
† Patient identifies own primary/ addressing his/her needs. † Patient confesses part in conflict and
prominent heart’s desire. broken relationships.
† Patient prioritizes self-concern
† Patient attains greater clarity in equal balance with concern for † Patient expresses true remorse
regarding meaning or purpose of others. through feelings.
his/her life.
† Patient’s actions/behavior † Patient commits to new behavior and
† Patient reports less angst and more suggest enhanced self-worth. forgives self.
support about making a particular
† Patient may seek and may
decision.
experience forgiveness from others
and God.
† Patient experiences reconciliation.
and treatment, we assert that, when chaplains utilize place of egocentric, distorted self-love. Their concern
a systematic framework for spiritual assessment of for themselves is out of proportion with respect to lov-
the patient’s primary need, and when they select ap- ing God or others. In working with a patient whose
propriate interventions (from their armamentarium core need is reconciliation, the task involves helping
of tools) to address this need, the patient is much the patient not only to love herself, but also to love
more likely to experience healing in the spiritual do- and humble herself in relationship to God and others.
main. Further, Spiritual AIM’s multidisciplinary the- Patients with a core need of self-worth demonstrate
ory is consistent with the goals of professional the opposite dynamic, wherein they love God and oth-
chaplaincy training and practice, which emphasize ers but tend to exclude themselves. The primary
the integration of theology, recognition of interperso- spiritual task in working with a patient with this
nal dynamics, cultural humility and competence, eth- core spiritual need involves helping the patient feel
ics, and theories of human development. worthy of self-love. Patients with a core need of mean-
ing and direction may be out of touch with self and
others, and be out of touch with their own desires.
Primary Identified Spiritual Need and
They may be overly focused on the mind (e.g., intel-
Spiritual Task
lectualizing, asking questions, searching, wonder-
Patients with a core spiritual need of reconciliation ing). The primary spiritual task in working with a
tend to love self more than others and come from a patient with this core spiritual need involves helpingSpiritual assessment and intervention model 81
the patient get in touch with their own sense of pur-
pose, meaning, direction in life, and desires.
Assessment: Observing the Patient
The chaplain identifies the core need through their
personal interactions and experiences with the
patient, rather than the mask or persona that the
patient presents to the world. While experiencing a
health crisis, most people cannot hide their primary
spiritual need. The veil is thinner—the need surfaces
and is much more present and obvious, much like an
open wound. It becomes the dominant topic in the
conversation with the chaplain. The patient’s normal
defenses and coping mechanisms are challenged.
The patient may discuss how support systems may
not be working, or may have been fragmented or
weak to begin with. This provides the chaplain with Fig. 1. Spiritual AIM conceptual model.
an opportunity to make an assessment about where
the patient places themselves in relationships with
others. The patient may also consider their concerns observes the patient behaving in a demanding way
about mortality in the midst of a medical crisis. The with nurses and aides. When behavior and self-de-
chaplain may also make an assessment based on scription conflict, the chaplain bases an assessment
the way the patient expresses their concerns about on behavior. Behavior serves as a more reliable indi-
the end of their life. cator for assessment than what the patient says
When in crisis, the patient’s primary spiritual about himself, when there is a conflict between be-
need manifests through their comments and behav- havior and self-description.
ior, through where they attribute blame, the ques-
tions they ask, and the concerns they raise (Shields Assessment: Chaplain’s Self-Awareness
& Joseph, 2010). The chaplain assesses the primary Core to Spiritual AIM is the chaplain’s use of herself
spiritual need, the level of acuity of the need, and and the relationship with the patient to make a spiri-
how far along the patient is on the path toward heal- tual assessment and facilitate healing. The chaplain
ing and integration, defined by Spiritual AIM. The makes her assessment through hearing certain phra-
chaplain leads the patient through a process of heal- ses or comments made by the patient, observing the
ing using specific interventions that correspond to patient’s behavior, and noting the chaplain’s aware-
the primary spiritual need. The chaplain does this ness of her own tendency to react in the presence of
through embodiment. The chaplain makes a choice each of the primary needs. Depending on the cha-
to step into a role and stance that personify certain plain’s individual characteristics (e.g., temperament,
characteristics: guide, valuer, or truthteller. culture, family history, and past experiences), each
It should be noted that patients may describe chaplain will likely react differently from other cha-
themselves in a certain way, but this description plains to each of the core needs. Each chaplain is en-
may be dissonant with the way the chaplain and couraged to become familiar with their personal
others observe the patient’s behavior. This patient’s reaction to each of the primary spiritual needs, to
self-description or self-explanation is described in help them make future assessments. For example,
Spiritual AIM as “persona” (see Figure 1)—or the some chaplains enjoy the energy of verbally wres-
way the patient wishes to appear. Similar to the key tling with a patient with a primary need of reconcilia-
relevance of collateral information, awareness of tion. Another chaplain may feel exhausted and afraid
transference and countertransference, and the men- of the anger expressed by patients with a primary
tal status examination in psychiatric assessment, need of reconciliation.
Spiritual AIM does not take the patient’s self-de-
scription at face value. Instead, the assessment is
Chaplain’s Embodiment
based in part on observing the patient’s behavior,
noting what occurs between the patient and cha- Once the chaplain has made an assessment, it is our
plain, and observing or assessing the relationships view that Spiritual AIM guides the chaplain in con-
the patient has with others. For example, a patient ceptualizing an intention (Breitman, 2005), embodi-
may say, “I don’t ask for much,” and yet the chaplain ment (what “to be”), or pastoral stance (Clark,82 Shields et al.
2006). Spiritual AIM uses the term “embodiment” to patients along a path of healing. Analogous to readi-
refer to this aspect of the chaplain’s role, but we ac- ness for behavioral change, the patient must be will-
knowledge that different terms for this concept are ing to travel together with the chaplain along this
used and may resonate differently in diverse disci- path. The interventions of Spiritual AIM guide the
plines and faith traditions. For example, Christians chaplain but are never spoken aloud to the patient.
may use the term “incarnation” to refer to embodi- This may seem like an obvious point, but one author
ment. What the chaplain embodies is who the cha- (MS), in teaching the model for many years, has
plain is for the patient. “To be” in relationship with found that this needs to be explicitly stated. The in-
the patient is as important as “to do” something in re- terventions in Table 1 describe what can best be un-
lationship to the patient. derstood as a pathway to healing; fundamental to
Central to the idea of embodiment in Spiritual AIM, devising an intervention. The chaplain first needs
the chaplain’s embodiment—or “being in relation- to assess where the patient is along this pathway.
ship”—can help the patient heal according to their pri- Drawing on this image, the chaplain attempts to
mary spiritual need and task. Specifically, for the walk alongside the patient, working with the patient
patient whose primary spiritual need is meaning and toward an outcome related to achieving greater whole-
direction, the chaplain’s embodiment (“guide”) can fa- ness to meet their core spiritual need. This does not
cilitate the patient achieving greater clarity (e.g., mak- mean that the chaplain describes their assessment
ing a decision about goals of care, or gaining clarity or intervention to the patient; rather, the chaplain
about the meaning of one’s life). For the patient whose keeps these in mind as she walks with the patient.
primary spiritual need is self-worth and belonging, Furthermore, the patient’s responses to the
the chaplain’s embodiment (“valuer”) can help the chaplain’s interventions can be employed by the cha-
patient feel more worthy and learn to advocate more plain to assess whether the intervention is facilitat-
for their needs to be met. For the patient whose pri- ing healing for the patient. The chaplain may use
mary spiritual need is reconciliation, the chaplain’s this as informative feedback (similar to narrowing
embodiment (“truthteller”) holds the patient accoun- one’s differential diagnosis based on additional infor-
table for greater responsibility and humility. mation), and may even choose another course of
Furthermore, through one’s embodiment, the cha- action (intervention), or even reformulate the cha-
plain serves as a representative or reminder of the di- plain’s assessment of the patient’s core spiritual
vine in such a way that healing takes place in the need. Analogous to differential diagnosis and empiri-
relationship (Kushner, 1981, p. 151). The chaplain cal treatment in medicine, Spiritual AIM provides
becomes aware that “something more” than just the the framework for reaching an initial diagnosis
person and the chaplain is present in the room (through assessment), devising a treatment (inter-
when a spiritual care encounter is taking place. vention), and assessing the outcome in order to con-
The “something more” can even be surprising to the firm or disconfirm a diagnosis.
chaplain—and, frequently, to staff who may be pre- It may seem unusual to include ritual as an inter-
sent when healing interactions take place. The depth vention; however, it is integral to Spiritual AIM.
of intimacy of these powerful grace-filled moments of Rituals are one way by which humans mark life tran-
forgiveness, trustful surrender to the hands of mys- sitions (Shields, 2009). Spiritual AIM thus takes into
tery, and epiphany may be totally unforeseen and account spiritual care interventions that offer reli-
powerfully move us and transform our lives in the gious and nonreligious/poetic rituals for patients to
midst of a very clinical environment, such as a com- mark their movement along the pathway toward
mon hospital room. In the first author’s (MS’s) theol- meeting their core spiritual need. Rituals and cer-
ogy, these touching and surprising moments are emonies at the bedside are unique to the domain of
possible because of God’s presence, uniquely born spiritual care (Shields, 2009). For thousands of years,
in the midst of the chaplain and the patient, in their healers and spiritual leaders have performed cer-
coming together—i.e., “For where two or three gather emonies and healing rituals to observe important
in my name, there am I with them” (Matthew 18:20) occasions and to mark life events. Not only is the pro-
(Holy Bible (New International Version), 1978). fessional chaplain’s clinical expertise recognized by
their professional certification, but their spiritual ex-
pertise is also validated through their ordination/
Chaplain’s Intervention
authority within a lineage that often goes back thou-
The chaplain needs a plan (i.e., what “to do”) (Handzo sands of years in a specific faith tradition. Through
et al., 2012; Doehring, 2006). If the chaplain does not providing ritual as an intervention, chaplains tap
have a plan, the encounter may meander or stay into a heritage of healing (VandeCreek & Burton,
within the realm of a social visit. Spiritual AIM ar- 2001). The chaplain is uniquely positioned to bring
ticulates interventions that are intended to move these spiritual interventions into the realm of theSpiritual assessment and intervention model 83
clinical. No other professional caregiver is trained to CASE EXAMPLES
provide the full spectrum of rituals from the world’s
To illustrate the clinical application of Spiritual AIM,
diverse faith traditions at the bedside. In addition,
three cases based on actual patient encounters are
chaplains are specifically trained to understand the
described below. Based on the assessment of the
nuances of providing ritual—including when to refer
patient’s primary identified core spiritual need, the
to other spiritual caregivers or faith leaders. Cha-
chaplain sought to intervene to help the patient
plains also create rituals for nonreligious patients,
move further along the path toward spiritual health,
family, and staff who need to mark profound oc-
with desired outcomes conceptualized and evaluated
casions and times of transition (e.g., birth and
in relation to the identified core spiritual need.
death) using nonreligious materials such as poetry
and music.
Analogous to physicians identifying improved Meaning and Direction
function in an organic system or in a given set of Background
laboratory parameters, chaplains who employ Spiri-
tual AIM identify what improvements along the Mr. X, a 70-year-old man, is suffering from signifi-
path of spiritual health and wholeness would look cant complications from a gastrointestinal cancer.
like. Based on each patient’s identified core spiritual He is in a loving, supportive relationship with his
need, the chaplain strategically intervenes to walk partner. Although he does not affiliate with any par-
with the patient toward greater wholeness and health. ticular religious practice, he was raised Mormon
While the desired outcomes described in Table 1 and has a very positive relationship with family
may appear ambitious, clinical experience provides members who still practice this religion. He was re-
many examples of patients who have achieved sig- ferred to the chaplain by his primary care physician
nificant healing of their spiritual needs. For example, to discuss some of the patient’s questions about the
a dying 70-year-old mother, after talking with the end of life.
chaplain, was able to express to her children her con-
clusion about the meaning of her life: “The best thing Assessment
I ever did was having you two kids.” In another case,
a chaplain was working with a patient with a history The patient tells the chaplain that, due to his ill-
of childhood trauma who was now coping with ad- ness, he can no longer work at his job in the hospital-
vanced cancer. The chaplain assessed the patient’s ity industry. The patient tells the chaplain that he
core spiritual need as reconciliation. Although this had previously felt a great sense of meaning and
patient did not believe in God (but attended a church purpose in his employment. He is wrestling with
for many years), the chaplain’s embodiment as truth- two questions related to meaning and purpose.
teller helped the patient, through their relationship, Since his work had been a big part of his identity
to learn to look at her part in relationships, to be and he could no longer work, he tells the chaplain
more vulnerable with her husband, and to take that he wonders about the meaning of his life and
responsibility for what she could do to heal relation- what his legacy will be. Additionally, he tells the
ships. Interestingly, she described an epiphany— chaplain that he is afraid of facing the finality of
which occurred in church at Christmas—involving the end of his life because, having left the Mormon
a release of shame and misery and the adoption of a faith, he has no belief in an afterlife. The patient is
new sense of enjoyment of life. also agonizing about the right time of year to visit
As illustrated by the above examples, Spiritual his family and friends. On the one hand, he knows
AIM seeks attainable outcomes that are observable that his death is drawing near and wants to have
or reportable by chaplain or patient (Lucas, 2001). quality time with them; on the other, he wants to
As Peery stated, “Outcomes are simply the observa- do this during spring or summer, when the weather
ble results of our care” (2012, p. 351). Outcomes- is nicer.
oriented models, such as Spiritual AIM, have several
research implications, addressed further in the Dis- Chaplain’s Awareness
cussion section. With regard to outcomes, Spiritual The chaplain is puzzled by the patient’s feeling stuck
AIM postulates that core spiritual needs are univer- and the lack of action about when to visit his beloved
sal; Spiritual AIM does not presuppose belief in friends and family, especially given his lucid under-
God or any other religious belief. Thus, Table 1 ident- standing of his prognosis.
ifies seeking and experiencing “forgiveness from oth-
ers and God” as one possible desired or proposed
Plan For Embodiment
outcome, but other outcomes involving reconciliation
are equally desirable. The chaplain seeks to embody a guide for the patient.84 Shields et al.
Intervention ries about whether she is following the diet correctly.
She also misses her friends.
The chaplain reflects back to the patient her obser-
vation that the patient is struggling with the decision
Chaplain’s Awareness
about when to take a final trip to the community
where he grew up to say his goodbyes. She asks the The chaplain notices that the patient seems very in-
patient, “When was a previous time or place in your terested in the chaplain’s personal life. He feels sad-
life when you sought an answer and you came to ness about the patient’s extreme behavior to please
some certitude about a decision you needed to her husband and thinks that it detracts from her do-
make? How did you decide?” This reminds the patient ing what she enjoys.
of his own inner wisdom and ability to make a good
decision. The patient commits to living one day, hav- Plan for Embodiment
ing made the decision to visit immediately, and the
The chaplain seeks to embody a valuer and commu-
next day imagining he has made the decision to
nity with the patient.
wait until the spring to visit his birthplace. The cha-
plain also names for the patient that he is wondering Interventions
about his legacy and the meaning of his life, particu-
larly given his ambivalence about there being some The chaplain begins by attentively listening to the
kind of existence after death. The chaplain guides patient and affirming her desire and efforts to stay
the patient as he articulates a strengthening belief well. He acknowledges the patient’s loneliness and
that his loving and long-lasting relationships are his her worry about the diet regimen. He surfaces her
legacy and will continue in some form after he dies. old belief that she must take a lot of vitamins and
The chaplain names, and helps the patient process, be strict with herself to be worthy in her husband’s
his sadness related to the loss of these relationships. eyes. The chaplain’s interventions are informed by
the theology that he and the patient share in com-
Outcomes mon—that the patient is a beloved child of God and
that God is calling her to recognize this. Her old belief
The patient decides to wait until the spring to visit is that she needs to be engaged in this challenging re-
his hometown and expresses feelings of serenity gimen to be in community with her husband. In rea-
and acceptance that he may die before he can take lity, she is inherently deserving of nurturing at this
the trip. The patient enrolls in hospice, and, at the re- point in her life. The chaplain explores her anger
quest of the patient, the chaplain marks this decision with God, indicating to her that she is worthy and al-
with a blessing. While he is in hospice, the patient lowed to feel anger. He also explores the multiple fa-
and chaplain speak regularly. Even as the patient cets of the patient’s grief—at feeling lonely, at letting
becomes more somnolent and quiet, he affirms his go of her old beliefs and practices, at her sadness that
legacy as an excellent and loyal friend. her life is coming to an end. The chaplain affirms and
coaches the patient in self-advocacy, and in doing so
Self-Worth and Belonging to Community the patient finds her voice to express her true feelings
to her husband.
Background
Ms. Y is a woman in her sixties with a life-threaten- Outcomes
ing cancer. She is in a loving and supportive relation-
The patient acknowledges that she is feeling angry
ship with her husband. She was raised as a Catholic
with God. This anger energizes her to claim her voice.
and currently worships at a nondenominational
She makes a decision for a new life, where she will
Christian church. Her palliative care nurse prac-
ask for what she needs and do things she enjoys,
titioner referred her to the chaplain.
such as spending time in the garden, with friends,
and camping. She begins to feel more able to advocate
Assessment for herself in relationships and treatment decisions.
The patient reveals that she has been keeping herself
on a strict diet and has been using an enormous Reconciliation and the Need to Love/Be
amount of supplements and vitamins because she Loved
wants to stay alive as long as possible for her hus-
Background
band. She expresses worry about her husband’s
well-being after she dies. She focuses on an arduous Mr. Z, a 58-year-old man, is brought to the emergency
dieting regimen to the neglect of her own pleasurable department with acute chest pain and is diagnosed
activities, such as gardening and camping. She wor- with a myocardial infarction. The chaplain is calledSpiritual assessment and intervention model 85
into the emergency department to meet with the ful changes in his life. After several weeks and
patient. When the chaplain arrives, the patient is months of changed behavior, the patient is able to ac-
working on his laptop, is on his cellphone, and has cess self-forgiveness and receives forgiveness from
an assistant by his side. The nurse enters, tells the his wife for his part in their estrangement.
patient to “stop all of that” and announces that the
chaplain is here to see him.
DISCUSSION
Assessment Spiritual AIM is one of the few well-articulated spiri-
The patient almost immediately, and with minimal tual assessment and intervention models to describe
prompting, confesses to the chaplain that he is cur- not only assessment, but also corresponding inter-
rently having an affair. He says that he believes ventions and desired outcomes. Moreover, unlike
that the affair is a great cause of stress and, ulti- the vast majority of existing models, it clearly articu-
mately, the cause of his heart attack. He expresses lates its underlying psychological and theological un-
guilt and a desire to end the affair and repair his mar- derpinnings.
riage. The patient expresses anger at the nurse for Although there is no established, widely-agreed-
taking away his laptop and cellphone and sending upon standard for evaluating spiritual assessment
his assistant out. Prior to this medical event, the models, Fitchett’s framework is the most comprehen-
patient was not taking responsibility for his part in sive for this purpose (Fitchett, 2002). Spiritual AIM
the brokenness of his marriage. does address the various criteria of this framework.
For example, Spiritual AIM operates from a “holistic
Chaplain’s Awareness context”—that is, it recognizes the relationship be-
tween religion and other aspects of human life as-
The chaplain notes her internal trepidation (her “gut sumed and expressed in the model—for example,
reaction”) that the patient might be challenging to culture, personality, family, and health—rather
create rapport with, based on the observed inter- than just focusing narrowly on religion.
action with the nurse as well as his appearance of Spiritual AIM is characterized by a number of
wanting to remain in control, even during a health unique features. First, it is based on a definition of
crisis. Therefore, the chaplain is relieved when the spirituality that includes—yet is broader than—
patient readily acknowledges his stress and his part questions of meaning. This is important because we
in his broken relationship with his wife. have discovered through clinical practice that many
individuals define spirituality through other
Plan for Embodiment terms—including love, relationships, community,
The chaplain seeks to act as a “truthteller” by reflect- and belonging. While some might argue that these
ing back the patient’s honesty about his feelings of terms are in themselves dimensions of meaning,
guilt, the stress this has created for him, and his Spiritual AIM does not conceive of “meaning” as the
need for forgiveness and reconciliation. overarching core need of each individual (expressed
through different domains) but rather as one of three
Interventions potential core spiritual needs that can be rapidly
identified.
The chaplain asks questions to encourage the patient Furthermore, Spiritual AIM was developed as a
to confess his part in creating brokenness in his life process to occur in the context of the relationship
and marriage. The chaplain asks the patient to ac- between the chaplain and patient, a criterion also
knowledge his impact on others. The chaplain also as- suggested by Lewis (2002). In addition, through its
sesses whether the patient is contrite. The chaplain use of commonly used language (rather than restrict-
acknowledges the patient’s guilt and asks him to talk ing the model to theological language), Spiritual
more about it, which encourages him to express contri- AIM translates effectively to the interdisciplinary
tion and remorse. Once the patient expresses true re- team. In contrast, some models use exclusively
gret, the chaplain holds the patient accountable to theological language (LaRocca-Pitts, 2012; Pruyser,
identify and commit to new behaviors and make 1976), which may be challenging for healthcare pro-
amends to his wife. She asks the patient to state how fessionals from other disciplines to relate to. Never-
he will end the affair and what he will do to take specific theless, Spiritual AIM is grounded in a specific
responsibility for the brokenness in the marriage. theological perspective that is inclusive of several
faith traditions and based on commonly held values.
Outcomes
Few models identify desired outcomes of spiritual
The patient expresses his emotions and sheds tears. care interventions (Lucas, 2001; Peery, 2012). Art
The patient makes a commitment to make meaning- Lucas, Sue Wintz, and Brent Peery have been86 Shields et al. teaching outcome-oriented chaplaincy for years. Yet, yet have a different theological basis for doing so. the use of this type of chaplaincy has not been widely The key point, however, is that chaplains should be adopted by professional chaplains. However, in our able to articulate a spiritual assessment model, apply view, just as every field of medicine must identify tar- it appropriately in the clinical setting with the full gets of interventions in order to measure effective- range of patients, and communicate it effectively to ness, chaplaincy needs to identify specific outcomes the interdisciplinary teams with whom they work. that can be assessed. The next steps for chaplaincy A related criticism is that Spiritual AIM’s Chris- are therefore to develop reliable and valid assess- tian origin may limit its effectiveness and adaptabi- ment tools, to define and implement specific inter- lity with patients of certain non-Christian religious ventions targeted at specific spiritual needs, and to backgrounds, or with patients with no faith/religious evaluate the outcomes of these interventions system- background or practice. However, in several places, atically. Spiritual AIM offers an open template that can be It is important to note a number of critiques of filled in according to a patient’s background. For Spiritual AIM. First, some chaplains—as well as example, a patient with a core spiritual need for other healthcare professionals—may react to the self-worth may demonstrate the outcome of “reports model’s assessment of one “core spiritual need” as greater sense of belonging to community” (see “labeling” or “putting people in a box.” At least two re- Table 1) by joining a completely secular illness- sponses can be made to this critique. To begin with, related support group, or a spiritually focused, the model emphasizes the importance of making an though not religious, mindfulness or guided medita- assessment of one primary spiritual need in the ser- tion group. Or a chaplain may make an intervention vice of designing and implementing specific interven- marking an important decision made by a patient tions. In other disciplines, this is analogous to the with a core spiritual need of meaning and direction importance of making a presumptive diagnosis or by offering a blessing or ritual that is appropriate case formulation in order to design and implement to that patient’s religious background (Table 1). a treatment plan. In plain terms, one must “put Moreover, it is our belief that chaplains can be groun- one’s nickel down” in order to try to make progress ded in their own philosophical and/or theological fra- in meeting the patient’s needs. As noted previously, mework and yet also learn and use frameworks and the patient’s responses to the initial assessment methods that originate from different belief systems and intervention may lead to a reassessment and or philosophies. For example, chaplains already do new intervention based on a different core spiritual this when they utilize a psychological theory or tactic need. This is part of the process, just as other disci- adapted to their specific role. In addition, chaplains plines must remain open to new information that regularly, and often with great skill, enter into may shift the clinician’s diagnostic thinking and illu- patients’ unique worldviews and belief systems, in- minate other potential treatment options. Second, all cluding when those views or beliefs differ signifi- healthcare disciplines categorize patients; this is cantly from those of the chaplain. This is akin to nothing new. What may appear novel is the notion physicians learning the “biomedical model” for pro- that even chaplains categorize patients. The model viding care, while still needing to respect patients’ proposes a parsimonious categorization scheme individual beliefs about health and medicine. We en- based not only on years of experience working with courage chaplains encountering Spiritual AIM, or this model and noting its utility, but also on the prac- any spiritual assessment model that is new to them tical need to get to work in helping patients, rather and emanates from a theological framework different than spinning one’s wheels in making an assess- from their own, to draw on these aspects of their pro- ment. Indeed, one strength of the model is the fessional training. straightforward classification into three core spiri- Another criticism is related to the lack of systema- tual needs; experienced chaplains can often make tic evaluation of Spiritual AIM against extant an initial assessment within minutes of meeting a theories and frameworks for providing culturally patient. competent pastoral and clinical care. Spiritual AIM A second criticism of the model has been leveled on was developed while ministering in multiple geo- the basis of its apparent reference to primarily Ju- graphic areas and to diverse populations with regard deo-Christian or Western faith traditions. Some cha- to race, ethnicity, religion, culture, sexual orien- plains may not wish to “translate” the model into tation, religion, etc. (11 years in North Carolina, their own faith tradition. However, chaplains should 3 years in Southern California, 18 years in be encouraged to claim their experience, theology, San Francisco). However, it has not yet been evalu- and spiritual practice, and to apply the model ated in terms of frameworks and best practices for through that lens, with a critical eye. Chaplains can cultural humility in pastoral care and counseling adopt the model’s categories and interventions and (Visions Inc., 2013; Augsberger, 1986; Sue & David,
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