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Doing the Splits:
The professional identity of the spiritual counselor
in contemporary Dutch health care1

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Hetty Zock
University of Groningen, Netherlands

This paper is about the changing professional identity of spiritual caregivers in Dutch institutions of healthcare. I will go into the dilemma’s spiritual caregivers in the Netherlands are faced with at the moment and make a comparison with the situation in the USA.

A blurred image

What image comes to mind when hearing the term ‘chaplain’ or ‘spiritual counselor’2? Is it that of a minister, a priest or an imam – a religious officeholder, fulfilling ritual functions and offering counsel from a religious perspective? Or is it rather that of a specific health care professional – a counselor with whom you can freely talk about how you are feeling, and how you are making sense of what is happening to you as a patient? At the moment, the profile of spiritual care is not clear at all in the Netherlands, neither for the Dutch population, nor the spiritual counselors themselves. Spiritual care is a profession in transformation. To understand this, we have to look first at the religious situation in the Netherlands. The changes in spiritual care as a profession must be understood against the background of the secularization, the pluralization and above all the individualization of religion and worldview in the Netherlands.

Religious context

The Netherlands is one of the most secularized countries in the world – the second most secularized country in Europe, after Sweden. A recent research report of the Social and Cultural Planning Office shows that at this moment, 36 % of the population has a religious affiliation (and that is included the 6% Muslims!; there are about one million Muslims in the Netherlands on a population of 16.000.000), and it is expected that in 15 years this percentage will have decreased to 28% (Becker & De Hart 2006). However, the scores on religious belief and participation are higher than that on church membership, and there is a great interest in free-floating religion - in ‘spirituality’, worldview issues, meaning-giving and existential questions. People are doing ‘bricolage’, picking from all kinds of worldviews and religions available, without the guiding of a particular religious tradition or institution. So religion is highly individualized and de-institutionalized. This now has huge consequences for how people search for meaning and life-orientation, and how they handle existential issues when getting sick, old, or disabled, and have to be admitted to a health care facility.

Therefore, care institutions in the Netherlands try to have as broad a team of spiritual counselors as possible, with open-minded counselors from various religious backgrounds. And, in practice, the spiritual counselor is more and more becoming a healthcare professional responsible for the spiritual dimension of care –that is the domain of search for (existential) meaning and life-orientation. So instead of ‘pastors’ they are becoming ‘existential counselors’. This situation, however, is not reflected yet in the organization of spiritual care. According to Dutch law (article 6 of the Dutch constitution, which guarantees freedom of religion and worldview; and article 3 of the law regulating the quality standards and quality care for health care institutions) every person who is staying in a health care facility for more than 24 hours is entitled to spiritual care by a counselor of his/her own religion or worldview.3 Spiritual caregivers, therefore, traditionally are representatives of a particular religious or worldview institution (Christian churches, the Humanistic Alliance, Muslim groups, etc.), and hence religious officeholders who are entitled to fulfill ritual functions. Therefore, the legal position of a spiritual counselor is twofold: s/he is an employee of the health care institution, but most of the time s/he has as well what is called a ‘mission’ – an official relationship with a church or other worldview institution. It is not obligatory to have such a mission, but the care facilities (even if they are public institutions) often require that spiritual counselors do have one.

And here we have the splits the current spiritual counselors in health care facilities are doing. Most of them were trained as pastors and are official representatives of a religious or worldview institutions, but in actual practice they are acting more and more as existential counselors who are available for all patients/residents and who have to define the specificity of their domain with regard to other health care professionals such as psychologists, social workers and nurses. Recent research on the opinions of spiritual caregivers on quality of spiritual care shows, that spiritual caregivers value their ministry, but are ambivalent about its role in relation to patients (Smeets 2006, pp. 94-98).

Historical background: Pillarization

The contemporary Dutch situation of spiritual care can only be understood against the background of pillarization: the organization of Dutch society in ‘pillars’ on the basis of religion or philosophy of life. In short, it means that as a Catholic, one bought bread at the Catholic bakery, went to a Catholic school, played tennis at the Catholic tennis club, voted for the Catholic party and, when falling ill, went to a Catholic hospital. Since the 1950s, this system gradually collapsed against the background of the fast secularization of the Netherlands. Catholic and Protestant hospitals merged with public institutions, and concordingly the traditional role of the hospital chaplains and priests changed.

A typical product of Dutch pillarization is the introduction of the humanistic counselor in the 1980s. Humanistic counselors were appointed in health care facilities because humanism was considered as a ‘pillar’ and under the condition that humanistic counselors got a ‘mission’ by the Humanistic Alliance in the Netherlands. Here we have a paradoxical situation: In the beginning (since the 1970s), the humanistic counselors claimed that their counseling was aimed at all non-churchgoing persons; but they could only be integrated in the chaplaincy system by becoming a ‘pillar’. A remarkable fact is that the Humanistic Alliance has only very few official members (12.000) – a very small pillar indeed.

More recently, Muslim and Hindu spiritual counselors have been appointed. They often have a problem with their ‘mission’, because there are many Islamic and Hindu groups in the Netherlands, and it is difficult to find a representative group to ‘send’ them.

The VGVZ: The Netherlands Association for Spiritual Counselors in Care Institutions

It is this doing the splits that divides the official organization for spiritual counselors in the Netherlands, the VGVZ (see www.vgvz.nl). The association has about 850 members (=75 % of the spiritual counselors working in health care). It was founded in 1992 (a precursor in 1971). Under its auspices a handbook of spiritual care appeared (Doolaard 20062) giving an overview of the history, the specific settings and the worldview identities of spiritual caregivers. Since 1998 the VGVZ has a journal (Tijdschrift Geestelijke Verzorging [Journal of Spiritual Care]). In 2002 the VGVZ published a Professional Standard (Professional Standard 2005 [Beroepsstandaard 2002]). At the moment, the association is developing a professional register, in order to come to a certification of the profession.

The changes in the profile of spiritual care in the Netherlands as sketched above is reflected in the name of the profession. Until recently, the chaplains in Dutch care facilities were called ‘pastors’. The VGVZ has introduced the term ‘Geestelijk verzorgers’. ‘Geestelijk’ is hard to translate in English: the Dutch term is ambivalent, meaning both ‘mental’ and ‘spiritual’ (a ‘geestelijke’, for instance, is a clergyman) thus referring both to the world of mental health and to the clerical world. ‘Verzorgers’ means ‘caregivers’ – which situates spiritual care among the health care disciplines. And this is exactly the dilemma contemporary spiritual counselors are stuck in – between clergy and health care profession. The term ‘geestelijk verzorgers’ is translated by the Association as ‘spiritual counselors’ (Professional Standard 2005). The term ‘spiritual’ is used to broaden the term ‘pastoral’, including in principle diverse religious and worldview traditions, as well as non-institutional forms of religiosity.  The term ‘counselor’ might be confusing in an American context, indicating there, if I am well-informed, chaplains/pastors who have specialized in pastoral counseling. This kind of specialization does not exist in the Netherlands. The work ‘spiritual counselors’ are in fact doing is, however, very similar to that of hospital chaplains in the USA.

We may conclude that on the one hand, the VGVZ is working hard at the professional level, intending to develop ‘spiritual care’ as a health care profession (the term ‘spiritual’ indicating the broader, general function of what spiritual counselors in actual practice are doing). But on the other hand, the VGVZ requires that their member have this so-called ‘mission’ – an official relationship with a church or other religious or worldview organization.4 The definition of spiritual care in the Professional Standard tries to combine these two aspects:

“the professional and official guidance of and caregiving to people in the process of seeking meaning for their existence, from and on the basis of religious and existential convictions…”5 (Professional Standard 2005; italics mine, HZ)

So according to the VGVZ spiritual care is a profession, focusing on the search for (existential) meaning and the role of religious/existential convictions hereby; but this is done from an official perspective (that is: bound to a worldview association). There is a lot of discussion about the interpretation of the phrase ‘from and on the basis of religious and existential convictions’: whose convictions – those of the patient or those of the counselor? And what does this mean in practice?

This doing the splits is turning into a breaking point, because care institutions increasingly appoint spiritual counselors who do not have an official ‘mission’  - and hence cannot become a member of the VGVZ. At the moment, about 15-20 % of the spiritual counselors in healthcare do not have an office in a worldview association (Smeets 2006, p. 159). Further, more and more students who want to become a spiritual counselor have no fixed religious/worldview affiliation themselves, and if they do, they do not want to have an official mission – even if they consider themselves as anchored in the Christian tradition and are members of the church. The last five years, training programs arise that focus on the professional aspects of spiritual care, irrespective of a religious or worldview affiliation. These training programs attract a lot of students. See for instance the Master Program in Groningen I am in charge with (see: www.rug.nl/theology/education/maprogrammes/pastoralcare). I even owe my professorship to these new developments.

A short comparison with the situation in the USA6, as far as I can judge from the other side of the ocean. We see a similar development in the sense that the profession is ‘broadened’. This is reflected in speaking about ‘spiritual care’ instead of pastoral care. I am thinking of the discussion on ‘generic chaplaincy’ (Engelhardt 1998), and especially of the ‘White Paper’ by Vandecreek & Burton (2001). The White Paper also uses a broad description of ‘spiritual care’, comparable to that of the VGVZ (although that of the VGVZ is still broader). Equally, just like the VGVZ, the certification as a professional chaplain requires ‘endorsement by a faith group or a demonstrated connection to a recognized religious community’ (Vandecreek & Burton 2001, p. 7). I wonder to what extent this is a point of debate in American chaplaincy associations as well.

The debate on the religious affiliation of the spiritual counselor

At the moment, the spiritual counselors in the Netherlands are deeply divided on the subject of the religious affiliation. A fierce debate is going on about pros and cons. To what extent does the worldview identity of the spiritual caregiver determine the content of his/her work? Is an (official) religious/worldview affiliation of the spiritual caregiver a prerequisite for the profession? What is the role of the so-called ‘sanctuary position’ (‘vrijplaats’ in Dutch – literally: a free place), which implies, first, the freedom of patients to speak confidentially with a spiritual caregiver and second, the (partial) exemption of accountability of the spiritual caregiver towards the healthcare institution?

As I argued earlier the changing religious situation in the Netherlands is a relevant factor here. But the immediate cause of the debate is the proposition of the board of the VGVZ to drop the requirement of having a religious/worldview affiliation for spiritual counselors in the professional register which is in the make. If this proposal is accepted, the situation may arise that a spiritual counselor who is working in a care facility may register as a spiritual counselor, although s/he is not allowed to become a member of the VGVZ (for which an affiliation remains required). This way, the board of the VGVZ is trying to bridge the gap between the established spiritual counselors who do have a ‘mission’ and the increasing number of spiritual counselors who do not.

The debate on the religious affiliation threatens to split the VGVZ, and all kinds of ‘splitting’ mechanisms can be seen; the discussion in journals and at conferences is very polarized, and both camps are guilty of stereotypical representations of the other. A splitting of the VGVZ will have negative consequences for the profession as a whole, because as a small country with few spiritual counselors we cannot afford a diversity in associations for spiritual care. We need to stick together to plead for decent spiritual care in a situation of budgetary cutbacks and health care reform (cf. the situation in the USA, see Vandecreek 2000). A new system of financing spiritual care is in the make, based more on the demand of the patient and less on the ‘presence’ of spiritual caregivers, freely offering their services to patients). The increasing ‘extramuralization’ of care (treatment in outpatients clinics, etc.) is an important factor hereby, because the presence of spiritual caregivers was guaranteed by the freedom of religion/worldview (see above). In this context, Dutch spiritual counselors are asked to define what their specific contribution to care consists of, to describe their ‘products’, and to account for the effect and the quality of their work in an evidenced-based and  protocolized way - just like the other health care professionals. Now the crucial question that divides the spiritual counselors is: Is it possible to determine the professional identity of spiritual care in this way, or does this violate the essence of the profession? To what extent is spiritual care radically ‘different’ from the other care disciplines, bringing along other methods and to be measured with different standards? We see that the discussion on the profile/domain of spiritual care brings along a discussion on method. It is not surprising that the point of view on the religious affiliation plays a crucial role in this discussion. Those who consider spiritual care as a health-care profession focusing on existential meaning-giving are more inclined to think about spiritual in terms of health care quality standards than those who consider spiritual care as primarily religious/worldview care from a specific religious/worldview background and institution.

In sum, the professional identity of the spiritual caregiver in Dutch health care is at stake. There is a great need for a theoretical foundation of spiritual care as it is arising in practice. How can this be done?

The Psychology of meaning-giving: A theoretical foundation of spiritual care.

Spiritual caregivers are looking for a theoretical foundation in the psychology of meaning-giving and coping. The VGVZ speaks about ‘the domain of spiritual care as ‘seeking meaning for existence’ (Professional Standard VGVZ 2005) and the White paper speaks about helping people to ‘cope with illnesses, traumas, losses, life transitions’ (White Paper, p. 2). Those opposed to determine the domain of spiritual care as that of the ‘search for meaning’ argue that this way the boundaries between psychological and spiritual care is blurring. The difference between spiritual counselors and psychotherapists are blurring. They are very much afraid of reducing religion/worldview to psychic functioning and of instrumentalizing religion as a coping function. The spiritual counselor, they argue, is different: s/he is not in the service of the goals of the care institution. Hence it is impossible to measure the ‘effects’ and quality of spiritual care. The spiritual counselor does not objectify, is no ‘expert professional’ who is delivering a ‘product’ to a client, but a fellow human being, engaged in a mutual relationship. Religion is more than ‘coping’ and spiritual counselors are radically different from the other care professionals.

     On the whole, pastors and spiritual counselors in the Netherlands are very suspicious of using psychological language and tools. The huge theological influence of Karl Barth undoubtedly plays a role here. Anchoring religion in anthropological needs and infrastructure is suspicious. And here we have a big difference with the situation in the USA. In reading the White paper, it struck me that it freely talks about ‘the benefits, the effects of spiritual care’, about ‘needs’ that have to be attended to, problem solving, ‘coping with a crisis’. Here we might have the influence of an American optimistic belief in self-made man, who has to grasp the opportunities and can ‘make’ his/her own life. In general, American pastoral theologians seem to use psychological tools much more freely (see f.i. Dykstra 2005). Valerie DeMarinis’ will speak in this session about: ‘the psychological need of spiritual care in post-modernized context’. A lot of spiritual counselors and pastoral counselors in the Netherlands would be horrified… 

Not me. As a psychologist of religion, I am on the side of those who opt for a new description of the domain of spiritual care as a health care profession in terms of ‘the search for existential meaning’. In a postmodern context as the Netherlands, where religion is to a great degree individualized and de-institutionalized, there is no other solution. Moreover, from a strategic point of view, I don’t think playing the ‘we are different’ card is very wise. Yet I do see some dangers here. There is, first, the danger of a reduced view on meaning-giving and religion. We do not want ready made ‘drive-thru’ spiritual care. Second, there is the danger of a blurring of professions, and the concomitant danger of getting marginalized. Many psychologists in the Netherlands are suspicious of spiritual caregivers, and argue that they are the taking care of meaning-giving in a better way. For instance, in a recent advisory report on the financing of spiritual care it is argued that there is no evidence-based proof that spiritual care effects coping functions. Care facilities, however, may decide themselves if a social worker, a psychologist or spiritual counselor is asked to assist in this respect.

What I am working at is an anthropological-psychological theoretical underpinning of spiritual functioning in terms of the search for meaning, which is not a reductionistic one. What we need is a theory of meaning that has a sensitivity for existential, ultimate layers of experience; for that what cannot be ‘made’ – for surrender and devotion; for receptive as wel as active capacities; for allocentric next to autocentric attitudes; for the human being as an autonomous as well as a relational being; for the guiding role of values, beliefs and traditions; for that was has intrinsic value next to extrinsic functions. An inspiring figure for me is the Dutch psychologist of religion Jan van der Lans (1996). He argues that the scope of ‘religion’ must be broadened into the sphere of ‘ultimate meaning’. The importance of ultimate meaning, he states, constitutes the core of identity, because meaning giving implicates evaluation: ‘the central goals which give direction and positive thrust to one’s life’ (1996). Van der Lans shows how meaning giving in this sense is intricately linked with psychological and spiritual well-being and coping.

With this kind of frame, it can be made clear that spiritual counselors focus on the patient in a different way than psychologists do, and can contribute to the coping process from a specific perspective: that of worldview, religion and existential meaning-giving. This does not imply splitting, however. Spiritual and psychological care have different domains, although there definitely is common ground - as becomes clear in the PCR group.

Conclusion

Doing the splits: it may lead to falling apart or to a gracious dance. I am convinced that contemporary spiritual care is evolving into a health care discipline with a proper, specific profile, which differs from the other health care disciplines in bringing in the existential perspective on the search for meaning and the role of worldview and religious traditions thereby.

The Dutch situation may after all be not that different from the American situation. We see a similar tendency of broadening the domain of spiritual care. Differences are the degree of secularization and individualization of religion; the amount of non-denominational working spiritual counselors; the emergence of non-faith trans-denominational or non-denominational based training programs. In the Spring semester 2008 I will have a sabbatical leave, and I am planning a stay in the USA to do further comparative research on spiritual care.

Literature

Becker, Jos & Joep de Hart (2006). Godsdienstige veranderingen in Nederland [Religious Changes in the Netherlands]. Report of the Social and Cultural Planning Office, www.scp.nl/publicaties/boeken/.

Doolaard, A. (20062). Nieuw Handboek Geestelijke Verzorging [New Handbook Spiritual Care], Kampen: Kok.

Dykstra, Robert C. (2005). Images of Pastoral Care. Classic Readings, St. Louis, Missouri: Chalice Press.

Engelhardt, H. Tristram (ed.) (1998). Generic Chaplaincy: Providing Spiritual Care in a Post-Christian Age. Christian Bioethics: Non-Ecumenical Studies in Medical Morality, 4(3).

KSGV [Study Center for the Relation between Religion and Mental Health], see: www.ksgv.nl/.

Professional Standard of the Netherlands Association for Spiritual Counselors in Care Institutions (2005), www.vgvz.nl/Professional%20Standard%20Spiritual%20Counsellors%202005.pdf

Smeets, W. (2006). Spiritual Care in a Hospital Setting. An Empirical-theological Exploration, Nijmegen: Radboud Universiteit Nijmegen.

VandeCreek, L. (ed.) (2000). Professional Chaplaincy: What Is Happening to It During Health Care Reform?, New York etc.: Haworth, (=Journal of Health Care Chaplaincy, 10, nr. 1).

VandeCreek, L. & L. Burton (eds.) (2001). Professional Chaplaincy: Its Role and Importance in Healthcare, A White Paper (also published in The Journal of Pastoral care, 55, nr. 1).

Van der Lans, Jan (1996). “Religion as a Meaning System. A Conceptual Model for Research and Counseling’, in: Halina Grzymala-Moszczynska & Benjamin Beit-Hallhami, Religion, Psychology and Coping, Amsterdam: Rodopi, 1996, pp. 95-105.

VGVZ (Netherlands Association for Spiritual Counselors in Care Institutions), www.vgvz.nl