Pastoral Contracting and the Hospital Chaplain

by David B. Pettett

In pastoral care training we are taught the importance of contracting. This means setting up clear boundaries and expectations for the caregiving relationship. Where we know that the pastoral care relationship will cover several sessions over weeks, or months or even a year, we can see the value of contracting and we will even spend the whole of our first pastoral session in contracting. But for a hospital chaplain visiting a patient who they are unlikely to see again, is contracting so important?

 

The simple answer is, “Yes, contracting is always important.” The nature of the pastoral session will determine how contracting is done but it is just as important for a hospital chaplain to contract as it is for the pastoral carer who expects to have weekly sessions over the next 12 months.

 

Contracting is the process that ensures both parties understand the purpose, scope, and limits of the relationship. Understanding these three aspects of the pastoral encounter promotes trust and mutual respect. For a chaplain at the bedside of a person in hospital who expects a short-, five-, ten- or 15-minute conversation this process of contracting can happen within the first few sentences of the pastoral encounter. Altogether there are seven steps any pastoral care giver must take when contracting and these apply to a long-term situation or a short encounter to a greater or lesser degree. We will only have space in this blog-post to discuss the first of these steps.

 

The first thing in all contracting is to clarify the purpose and goals of the pastoral encounter. When I was a hospital chaplain, I began by introducing myself and saying, “I’ve just come to see how you are.” These simply words stated my purpose and implied my goal or the limits of our conversation.

 

Within this first step in a long-term pastoral encounter you will discuss intentions. As the pastoral carer you will want to understand the reasons the care receiver is seeking pastoral care. Is it for spiritual guidance, emotional support, or a specific issue? This allows the person seeking pastoral care to clearly state their intentions and hoped for outcomes.

 

For the hospital chaplain who is simply visiting patients as part of the hospital’s care program there is no intention on the patient’s behalf and the visit by the chaplain may be a surprise. This is where, in the contracting process I listened/watched very carefully for the patient’s response to my introductory statement of purpose. The patient’s response, either verbally or in body language, gave me an understanding of whether my visit was welcomed or not. A simple response of, “That’s very kind of you. I’m doing fine,” could mean either, “I’m fine. Go away,” or it could mean, “Yes, I’m open to talking with you.” Body language, a smile, a frown or tone of voice usually alerted to which response was meant. The point is, in these few words the patient and the chaplain have entered a contract. “I’ve come to see how you’re doing.” “That’s kind,” said with a relaxed voice and warm smile. The contract is established and the conversation can proceed. The chaplain had stated his intentions (“to see how you are”) and the patient has stated his or her intentions by indicating, “It’s nice of you to come. I’m open to some conversation.”

 

Part of the process of contracting is to set boundaries.  This clarifies the caregiver's role. In my opening words these boundaries were set by the words, “I’ve come to see how you are.” I had not come to help the patient to think about rehabilitation options for example. Yet, if the patient said something like, “I’m so pleased you’ve come. I have to go to rehab and am anxious about what that will look like,” the patient is renegotiating the contract. He or she is saying to us, “I’m glad you’ve come to see how I am but I want to push the boundary out a bit to talk about my anxiety about going to rehab.” The chaplain needs to respond to this renegotiation of contract by the patient by agreeing they are willing to talk about this (and if they’re not willing, why on earth are they involved in hospital chaplaincy?) and resetting the boundaries. These may include the chaplain’s lack of professional competence in rehabilitation. The chaplain is not qualified to explain the technicalities of what rehabilitation will and will not involve. But the chaplain will be able to listen to the patient’s anxiety and facilitate the patient’s discovery of a more relaxed attitude. In renegotiating this contract the chaplain could say something like, “I don’t know what they will do for you in rehab, but tell me more about being anxious.” A new contract has been set and the conversation can proceed with both the chaplain and the patient clear on how the conversation will proceed.

 

The major point to note here is that we don’t just set a contract in place at the beginning of a pastoral conversation and let it sit. As the conversation proceeds and turns we will need to be constantly recontracting. This may seem tedious and the over simplified examples I’ve used in illustration might seem to be an ordinary part of normal conversations, and indeed they are normal. What the pastoral carer needs to keep in mind with these quite normal parts of conversation is that we are establishing a contract, setting the boundaries, notifying intentions and advising hoped for outcomes.

The importance of contracting is in its demonstration of a true respect for the person seeking pastoral care. If somehow the conversation turns in a direction the person being cared for did not expect, the pastoral carer could actually cause harm rather than give support. The conversation could also end abruptly leaving the person in greater distress than when the conversation started. When a pastoral conversation crosses a boundary into an area not contracted, the pastoral carer must be aware of that crossed boundary and take the time in the conversation to renegotiate the contract. For example, if the patient and chaplain have agreed to talk about the patient’s anxiety with rehab and the patient then begins speaking about the abuse their alcoholic husband gives them, the chaplain needs to renegotiate these boundaries by saying something like, “we began by talking about being anxious about rehab. Are you comfortable to tell me more about your husband?” Of course the patient’s anxiety about rehab may be closely tied with the husband’s abuse and the chaplain may see the introduction of the abuse into the conversation as coming within the boundaries of the anxiety already agreed upon. The point is the chaplain needs to be on their toes. They need to be asking the question, “Are we still in the contract originally negotiated or have we crossed that boundary and need to renegotiate?”

 

Proper contracting is one of the many things pastoral carers need to do well to make sure the person is well cared for. Hospital chaplains need to be aware that they are not exempt from the necessity to contract and must remain vigilant that they stay within the contracted boundaries or renegotiate when those boundaries are crossed.

 

We have not discussed the other six elements of contracting here but hope to consider them in further posts. This first element of contracting is probably the most important and something even a chaplain on an unexpected and limited pastoral visit is not exempt from doing.