How Muslim and Non-Muslim Chaplains Serve Muslim Patients? Does the Interfaith Chaplaincy Model have Room for Muslims’ Experiences?
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- Abu-Ras, W. & Laird, L. J Relig Health (2011) 50: 46. doi:10.1007/s10943-010-9357-4
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Chaplaincy is typically practiced within the contexts of the Jewish and Christian traditions, and little attention has been paid to the influence of the Islamic perspective of nursing and caring. Therefore, many Muslim patients might not receive appropriate care for their religious and spiritual needs, especially as they relate to daily religious practices and worship, medical ethics, and end-of-life treatment choices. This study examined Muslim and non-Muslim chaplains’ approaches to pastoral care used with Muslim patients in New York City hospitals. The study used in-depth interviews with 33 Muslim and non-Muslim chaplains. The results indicate areas of both convergence and divergence.
KeywordsHealth careChaplaincySpiritual careReligionNYC hospitalsMuslimsInterfaith approach
The role of chaplaincy in providing support to hospitalized patients and in helping patients cope with physical illness has been well documented (Emblen and Pesut 2001; Gatrad et al. 2004). The literature shows that religious and spiritual beliefs support mental health (Koenig et al. 1992, 1999; Pargament 1997) and physical health (Koenig et al. 1988, 1991, 1998, 2001; Luskin 2000; Powell et al. 2003), support the prevention of illness and provide psychological benefits and social resources across divergent religious communities (Koenig et al. 1991; Koenig 2008, 2009; McNichol 1996). For hospitalized patients in various parts of the United States, 90% indicate they use religion to cope with illness, and more than 40% say it is the most important factor that keeps them going (Koenig et al. 2001; Koenig 2008). However, one study states that only 42% of hospitalized patients could identify a spiritual counselor to whom they could turn (Sivan et al. 1996).
As more hospitals and other health care institutions acknowledge the importance of spiritual care, there is increasing demand for chaplains and clergy members who can meet patients’ spiritual and religious needs (McClung et al. 2006). Persons who provide spiritual care in health care settings are referred to as chaplains and/or spiritual care providers. According to VandeCreek and Burton (2001), some people might focus their spirituality outside their traditional religious communities, while others attend to their spirituality using their traditional practices that reflect the cumulative traditions of their religious faith, beliefs, and values (VandeCreek and Burton 2001, p. 82). Most chaplains in hospitals are clergy; however, many clergy are not trained in pastoral care skills such as providing spiritual assessment, interfaith conversation, and grief counseling to non-Christian patients. A study of 72 National Hospitals conducted in England and Wales revealed that 93.3 and 91.4% of the full-time and part-time chaplains, respectively, were Christians, and 6.7% of the full-time chaplains were Muslims (Sheikh et al. 2004). This study also shows the disadvantage of access to chaplaincy services and to quality care to non-Christian patients. This disadvantage is similar in the United States.
In the United States, not all chaplains are fully established and integrated members of hospital staff (Norwood 2006). Many of them are well trained to function as integrated hospital staff members and perform different functions such as attending patient rounds, leading in-services on spiritual care, and participating in ethics committees (VandeCreek and Burton 2001). In the hospital context, chaplains are often perceived as “neutral figures, outside the usual staffing hierarchies,” where they function as accessible sources of support and who do not experience negative consequences for their help (Sheikh et al. 2004, p. 94). Whether chaplains are fully or partly integrated in the health care system, their role is important in supporting and strengthening patients’ religious and spiritual beliefs and practices, particularly in the recovery process (Fogg et al. 2004; VandeCreek and Lyon 1997; VandeCreek et al. 2001).
In the United States and in some European countries, historically chaplains have been predominantly Christian, which has benefited mostly the dominant Christian population. During the twentieth century, a new wave of religious leaders started to advocate for an interfaith approach to multiethnic chaplaincy care that would be a more pragmatic model in addressing and supporting the spiritual and religious needs of people from diverse religious and cultural backgrounds (Gatrad et al. 2003). One of the major aims of this model was to engage a variety of individuals to use the pastoral concept as a way to work for the common good (Owens 2001). However, Gatrad et al. (2003, p. 748) argue that in applying this generic approach, some chaplains might not worship with patients of a different faith, or use the spiritual methods of a particular faith to meet the needs of patients, “such as Muslim supplication or absolution for a Christian—to restore a sense of balance, wellbeing, and to give strength.” This notion has been supported by Carey’s and Davoren’s (2008) recent study in which the majority of Christian chaplains reported that their own faith was challenged by regularly ministering to people of different philosophies and beliefs. Based on their results, 60% of chaplains indicated that their faith had been challenged by learning about different ways to God (Carey and Davoren 2008, p.29)
On the other hand, some argue that chaplaincy care in hospitals should be based on a faith-specific chaplaincy approach. Although this approach might address some of the cultural, linguistic, and religious barriers, it may not be practical as it would necessitate employing a high number of unqualified religious leaders, untrained clergy, and denominational chaplains (Gatrad et al. 2003, p. 748). Therefore, neither the use of the interfaith nor the faith-specific chaplaincy approach would always address the specific needs of all patients, especially non-Christian patients.
Chaplaincy Care to Muslim Patients
Despite the various approaches to chaplaincy care services, whether using an interfaith or specific-faith approach, little attention has been paid to the Islamic perspective of nursing and caring. Therefore, many Muslims might not receive appropriate care for their religious and spiritual needs (Engelhardt 2003; Rassool 2000). One possible explanation is there might not be as much religious diversity in chaplaincy as needed to serve diverse hospital patient populations. In a recent survey (Abu-Ras, under-review) of 56 hospitals in New York City (NYC) revealed that the number of Christian chaplains had the highest mean of three per hospital, one Jewish chaplain, with Muslim and other faiths lagging behind.
Islam is one of the fastest growing religions in the United States and became the second largest religious group in America after Christians (US Department n.d.). In the urban region of NYC, the Muslim population is estimated to be 600,000 (Abdulatif Cristello and Minnite 2002). Muslim-Americans have distinct spiritual and health care needs, especially as they relate to daily religious practices and worship, medical ethics, and end-of-life treatment choices. Therefore, the ability to clarify the specific values and support needs of Muslim patients with health care staff is critical (Hamza 2007; Rassool 2000). Ethical dilemmas arise regularly in today’s highly technological health care systems. Many Muslim patients draw on Islamic legal tradition and religious scriptures to make health care decisions, such as to continue or withdraw aggressive treatment, participate in family planning, and receive or donate organs (Hamdy 2008). Professional chaplains who are culturally competent in the Muslim traditions may serve as spiritual care liaisons between staff members, who might experience dilemmas between values and beliefs, and patients and their families.
To understand Islamic perspectives of spiritual care, one must understand the religion, cultural beliefs, values, and worldview of Islam. The religious values and beliefs of Muslims are markedly different from those traditionally found in the Western Hemisphere (Luna 2002). Religious Muslims pray five times a day facing east, and only after an extensive ritual body washing with which a sick patient might require assistance (Abdalati 1993). Some challenges to the Muslim patient and hospital staff can include the dietary restrictions specified in Islam and the month-long fast during Ramadan (the fasting month for Muslims). Islam upholds the sanctity of life and views it as a gift or a loan from God (Sarhill et al. 2001). Therefore, suicide among Muslims and “Do Not Resuscitate” orders are rare. When death is imminent, the Muslim lifts a finger toward heaven and recites the Shahada, (the profession of faith made by Muslims, beginning “There is no God but Allah and Muhammad is the prophet of Allah”) or the declaration of faith in the oneness of God (Schmidt and Egler 1998). If the patient is too sick to do this, assistance from a family member or another Muslim might be required. When death takes place, the mouth and the eyes are closed, the head is turned toward Mecca, and the body is ritually washed only by same gender Muslims. Organ transplants are permissible in certain Muslim cultures and under specific circumstances (Sarhill et al. 2001). It is crucial for Western-trained chaplains to be educated in the practice of Islam as it relates to illness and death because it would be unfitting for Muslim patients to receive health care without incorporating spirituality (Rassool 2000). Patients who share a similar ethnic and cultural background with their chaplain are able to establish a trust-based relationship, considering that chaplain as an advocate. Conversely, ethnic and cultural differences between chaplain and patient may impede the relationship and its effectiveness (Hamza 2007). The provision of culturally appropriate spiritual counseling to meet the needs of Muslim patients is integral to their care, enabling them to feel more comfortable using resources that cater to and satisfy their specific spiritual and religious needs.
In this study, we examine the approaches of Muslim and non-Muslim chaplains to providing spiritual and religious care for Muslim patients and how they portray the needs of Muslim patients in NYC hospitals and health care settings in comparison with the needs of non-Muslim patients. The study also focused on the types of culturally appropriate spiritual resources Muslims currently have, and what is needed.
This study is part of a larger research study. This part of the study used a series of in-depth, semi-structured face-to-face interviews with 33 Muslim and non-Muslim chaplains in NYC hospitals and health care settings. Forty hospitals and 33 hospital chaplains were selected from NYC’s five boroughs of Manhattan, Brooklyn, Bronx, Queens, and Staten Island, culling five to six chaplains from each borough, depending on their availability. First we called about 40 hospitals’ Pastoral Care Departments and requested to speak to the directors or to the person in charge. We briefly described the purpose of the study, the type of questions we were planning to ask, and the overall implication for the Muslim patients and to those who serve them. After permission was obtained, meetings were scheduled with the designated chaplains. After all study procedures were fully explained, we obtained a written informed consent from all the face-to-face study participants. Participants completed the interviews with two trained assessors in the form of face-to-face interviews. The primary goal in conducting these face-to-face interviews was to gain in-depth and first-hand information about professional chaplaincy services available in area hospitals and health care settings. In addition to the semi-structured questions, face-to-face interviews were also conducted using open-ended questions. A participant was eligible for the study if he or she met the following criteria: (a) 18 years of age or older; (b) provides spiritual care in a New York City hospital and/or health care settings; (c) speaks the English language; and (d) agrees to sign the consent form. All face-to-face interviews were conducted in English and at the hospital sites. Informed consent and study procedures were reviewed and approved by the Institutional Review Board of Adelphi University.
The semi-structured questionnaire was developed by the principal investigator for the purpose of this study. It included closed- and open-ended questions. The semi-structured questionnaire was reviewed by researchers from Muslim Mental Health, Inc.1 before piloting the questionnaire with five health care settings and chaplains. The questions were revised and finalized based on the comments we received from the subjects and the Muslim Mental Health professional team. The closed-ended questions focused on chaplains’ socio-demographic information, while the open-ended questions focused on: (a) what experience Muslim and non-Muslim chaplains have in caring for Muslim patients, (b) their assessments of Muslim patients’ needs; (c) their approaches to pastoral care with Muslim patients; (d) what spiritual resources Muslims currently have; and (e) what measures should be taken to address Muslim patients’ needs.
Descriptive analysis was used to analyze the socio-demographic data. For the qualitative part, we employed a grounded thematic approach to analyze transcripts of all interviews using the computer-assisted qualitative data analysis software package ATLAS.ti. (2009). Both authors reviewed and coded the interviews, reviewed each transcript, and developed research categories through continuous comparison across interviews. Based on the grounded thematic findings of the interviews, we compared and contrasted between all participant’s responses.
Chaplains represented a broad range of religious affiliation, including Christian (48.5%, n = 16), Jewish (21.2%, n = 7), and approximately one-third (30.3%, n = 10) Muslim. Most chaplains (34%, n = 11) in this study work in Manhattan hospitals and in Brooklyn (21%, n = 7). The majority of chaplains (70%, n = 23) were male, and 66% of the participants held an M.A. degree or above and had a mean age of approximately 57 years. About 70% (n = 23) of chaplains served in general hospitals, and the vast majority in non-profit institutions. About half (48%, n = 11) of the non-Muslim chaplains (four female and seven male) were board-certified.2 Among the 10 Muslim participants, one was a board-certified chaplain. The vast majority (91%, n = 21) of the non-Muslim chaplains are employed full-time and are directly paid by their hospitals, while two out of 10 Muslim chaplains are employed full-time but are directly paid by the state of New York; 50% (n = 5) identified themselves as imams but work as part-time chaplains, one Muslim imam (chaplain) works as a volunteer, and one as an intern under training.
Assessment of Muslim Patients’ Spiritual Needs
Seventeen of the 33 chaplains reported that Muslim patients ask for one or more of the following: an imam, a Qur’an, literature about Islam, a prayer mat, someone to pray for them, instructions on how to say their prayers, special meal schedules for Ramadan, ablution space, and halal food (food that can be eaten and permissible under Islamic law and also on the proper method of slaughtering an animal for consumption). On the other hand, fourteen participants, including one Muslim chaplain, reported that to their knowledge, Muslim patients have never asked for one or more of the following: an imam, prayer, Qur’an, halal food, prayer mat, gender-matched care, or use of the chapel. A Muslim chaplain reported being asked to explain to the hospital staff the beliefs of Muslim patient regarding fasting during Ramadan and taking medications. Another reported talking with patients about the meaning of their illness. A non-Muslim chaplain reported a patient consulting an imam about organ donation. One Muslim chaplain reported that he had never been asked to consult on the permissibility of organ donation or autopsies for Muslim patients. The varied experiences of the chaplains with Muslim patients’ needs were not determined by their level of professional qualifications.
When the 23 non-Muslim chaplains were asked how they perceived Muslim patients’ need for chaplaincy services, most suggested that the Muslim patient population is low and that the existing Muslim patients do not request an imam or a substitute in their absence. Another comment that appears twice is that: “The Muslim patients do not have the same needs in a hospital as, say, Catholic patients (sacraments or last rites, anointing the sick) or Jewish patients (kosher food, Sabbath accommodations)—nothing that specifically requires seeing an imam.” Two Christian chaplains agreed that most of the Muslims [in their hospitals] are secularized and do not require [an imam]. A Christian chaplain suggested that Muslim patients’ “needs seem to be met by the family or community.” A Jewish chaplain extended this to Muslim staff: “There is usually no need [for an imam], since many Muslim doctors are very religious, and act as imams. When a person dies, Muslims do not need an imam, the family takes care of all the needs.”
When asked how they approach Muslim patients, most chaplains explained that they approach Muslim patients in the same manner they approach all other patients. Some abbreviate their task to “providing religious services” or “offering scripture or prayer,” while others ask more generally “if they need anything from their faith” or “offer encouragement to the patient to practice faith.” Some spoke of assessing emotional and spiritual needs, “meeting [patients] where they are,” “making them feel secure,” and “welcomed and embraced spiritually.” Others attempt to build trust by “listening” and “being available,” so that patients can “talk about their problems.” In a description of a typical visit, two chaplains report they introduce themselves, engage in conversation, ask the patient if he or she has any emotional or spiritual needs with which they may be able to help, and then offer a prayer. According to these chaplains, some Muslim patients are open to having a prayer read by a non-Muslim priest, while others will refuse. The chaplains are trained to make a visit by offering spiritual support in a way that is sensitive to the patient’s spiritual and emotional needs. A chaplain shares the way he identifies the spiritual object that is helping the patient and how they are able to cope with the suffering: “You have to ask if you can visit (chaplains are the only ones who can be thrown out). It’s a process and takes years of training. You do not just ask for prayer right away. My CPE (Clinical Pastoral Education) training supervisor would say that if you leap to prayer too quickly, you haven’t gone far enough. This is a non-CPE approach. You’re trying to help people with struggles they’re going through. God comes out in the hospital. You’re suffering in the hospital. Everyone wants to talk about pain. Sometimes Muslims will talk to me about their illness… how [they’re] feeling, what’s going on.” A Muslim chaplain likewise explains that he learned this “pastoral care” approach in CPE: “CPE educates you regardless of faith tradition. When you are an imam, you know how to minister to Muslim patients only. When you do [the] CPE course, you learn how to minister without being of the same faith as the patient. The motto of CPE is ‘without having the same faith, [you] can minister to the patient [for the] spiritual healing of that person.’ CPE educates the chaplain to minister to the patient in his or her faith. One faith education. Spiritually, many patients are distressed. You should not abandon a patient [but rather] give encouragement to the patient to practice faith. Some people do not practice any faith, but believe in a spiritual power.”
Though this interfaith model of pastoral care for all patients across religious boundaries is the dominant form for most chaplains interviewed, several identified some limitations. For instance, one Jewish chaplain says that: “When specific requests are made for a religious ritual or culture-specific prayer …chaplains are always referring patients to each other when specific religious needs cannot be met. When in need of an imam in a life-or-death situation, I often call for an imam at the large mosque almost 8 blocks away.”
Barriers for Non-Muslim Chaplains
The non-Muslim chaplain faces specific barriers in serving Muslim patients, such as sensitivities around gender and politics. Twenty-nine chaplains mentioned the need to respect standards of modesty and male–female interaction when interacting with Muslim patients. Five non-Muslim chaplains said that they were somewhat hesitant and very careful when visiting a Muslim patient of the opposite sex, or their visits could be rejected. One Christian chaplain admitted that seeing a [Muslim] woman in a full face veil “gives you a funny feeling” and that she finds it “repressive and oppressive.” A Jewish chaplain commented that he always avoided discussing any political subjects with Muslim staff and patients, though he is “on friendly terms” with them.
What Should be Done to Meet the Needs of Muslim Patients?
Consistent with the range of ideas about what Muslim patients need, chaplains articulated a range of strategies to address these needs. Four chaplains (Protestant, Catholic, and Jewish; board-certified and non-board-certified) agreed that Muslims ask for very little or something as basic as prayer beads or a Qur’an. Two of these chaplains indicated that they had access to prayer beads or a Qur’an. A Catholic, non-certified chaplain said that Muslims do not need any ministering and say “we’re okay on our own.” A board-certified Jewish chaplain suggested that most Muslim patients were foreign-born, did not request anything, and likely wanted to break away from their traditions.
A second group of six chaplains, diverse by religious affiliation and certification, were ambivalent toward the needs of Muslims and suggested that an imam would be better able to assess their needs. A Jewish chaplain remarked, “Muslims, like Catholics, do not usually want to talk to a rabbi.” A Catholic chaplain wondered how Muslims viewed pastoral care, and another chaplain wondered how he would get a Qur’an if someone asked, and whether there were special Muslim prayers for the sick. The other two chaplains admitted that they did not know what Muslim patients needed. One board-certified Jewish chaplain said: “Muslims are ‘normal patients’ [who] have problems just like everyone else; they should not be singled out with questions about their unique needs.”
A third group of six non-Muslim chaplains suggested that Muslim patients should be treated as individuals with specific needs. The two Jewish chaplains recommended assessing a Muslim patients’ need for prayer, support, a pastoral visit, or a consultation with an imam on medical decisions, and making any reasonable accommodations for them. Four Christian chaplains in this group report talking to Muslims about their faith and what helps them. For instance, one female chaplain said: “My job is to rally for them while they’re here, and in treatment. What is happening during is what I’m interested in. It’s a process of assessment, where is one spiritually and theologically? What will help them, so their beliefs and values will help them and not work against them? Clergy often come in assuming that the patient knows doctrine—not true! Most people have a shallow knowledge of their faith.”
Muslim chaplains assist Muslim patients with needs that are often unaddressed in hospitals. Two Muslim chaplains suggested that they bring to Muslim patients a theological perspective on illness, framing the experience in terms of a personal jihad: “A personal jihad is to persevere, to struggle, to push on through a crisis. It’s a struggle with the soul to push through something. Illness is a part of personal jihad—to push through.” They speak of illness as a test or an opportunity for purification and forgiveness and contrast this with non-Muslim perspectives on illness which might include punishment or existential crises about God’s justice. All of the Muslim chaplains report that they pray and recite the Qur’an with patients, and two say they offered literature available in a patient’s language. Two pointed out that they do not have adequate funds or supplies relative to other chaplains and provide their own resources if patients request reading materials. As one chaplain says: “Other chaplains get a lot of material—a supply of Bibles, and so forth, I do not.” One Muslim chaplain advises Muslim patients on alternative forms of performing ritual worship when disabled by illness or constrained by medical devices. All the Muslim chaplains report that Muslim patients are happy to see them, find them a familiar presence, and want to talk.
Only Muslim chaplains spoke of certain chaplaincy roles in regard to Muslim patients. These included the rituals of reciting specific prayers at birth, participating in male circumcisions, and reciting a surah (verse) of the Qur’an while someone is dying. Muslim chaplains also articulate their role as providing both spiritual guidance and education about faith and practice to Muslim patients, and some also serve as Friday preachers. Muslim staff members and patients’ families are the primary beneficiaries of the latter service because most of the patients themselves cannot physically get to the chapel.
Accommodating and Supporting Muslim Religious Practices
Both Muslim and non-Muslim chaplains frequently state that their role in the hospital is to educate staff about Muslim patient concerns and needs and to ensure that the hospital respects them. For most, such support involves institutional and clinical “accommodation.” Chaplains serving in Veteran’s Administration or state psychiatric facilities point to the government’s obligation to provide patients with “access” to their religious practices. Two Jewish chaplains emphasized the accommodation of Ramadan dietary shifts and special iftar (fast-breaking) meals. Three Christian chaplains mentioned that some sick patients are exempt from fasting during Ramadan, but one saw her role as an advocate: “You have a Muslim patient here during Ramadan and they refuse to take their medication. It is your job to intervene on behalf of the patient, and become their advocate. You can get the doctor to prescribe the medication twice a day, so they can take it before and after the fast. You can give it intravenously.”
Three Christian chaplains also mentioned special foods for iftar and the provision of halal meat. Three Muslim chaplains suggested that most patients are exempt from Ramadan fasting, though one indicated that he helps patients fast appropriately. Two Muslim chaplains indicated that their hospital supports or holds Eid (Islamic holiday) gatherings at the end of Ramadan, one providing a kosher meal for iftar.
One Christian chaplain said “that in the Catholic hospital, staff takes down the crosses in the bedrooms if it’s a Muslim, and put up a crescent.” Two Christian chaplains also mentioned helping patients find the direction of prayer and trying to adjust beds to face Mecca. Muslim and Christian chaplains mentioned a shortage of Qur’ans and the reliance on donations from mosques or Muslim staff, while some indicated that patients often bring their own.
Accommodating and Offering Prayer
The most common form of religious practice mentioned in the interviews was prayer. Four Jewish chaplains mentioned offering prayer mats to patients, and two indicated that Muslim staff members pray daily in the hospital chapel. Likewise, nine Christian chaplains emphasized that Muslim staff pray in designated spaces in the hospital, most furnished with prayer mats. One chaplain asserted that Muslims were getting special treatment by having their own space, while two others indicated that their hospitals have inadequate accommodations for Muslim staff prayer. Several indicate that families of patients perform the five daily prayers either at the bedside or in a chapel.
Christian chaplains were more likely than their Jewish counterparts to report praying with or for a Muslim patient. Although one Catholic chaplain admits to not “being well-versed in Muslim prayers for healing,” he often tells patients that he will keep them in his prayers. An Episcopal chaplain asks permission to pray in the name of Christ. Three others reported that they either remain present while a patient offers a prayer in their own language; asking to pray with the patient using the patient’s own language for God; or asking Allah to be merciful, and to give peace of mind and spirit. One Jewish chaplain recounted a story of praying with a Muslim patient after a challenging pastoral visit with a conservative Muslim: “At the end of the pastoral visit, I (the Jewish chaplain) asked him: ‘would you like me to pray for you?’ He said yes. He asked, ‘Are you going to pray for me with all your strength, coming from your soul?’ Nobody has ever said this; this was a very intense encounter. He asked after if I was certain I gave it my all, then he felt satisfied.”
Muslim Chaplains for Muslim Patients: The Problem with Imams
Some chaplains argued that Muslim patients need more adequate spiritual and religious care by local imams and perhaps Muslim chaplains. Even when non-Muslim chaplains seek an imam to visit Muslim patients, many reported that local imams are not trained in pastoral care, do not seem to visit the sick, and do not volunteer to provide for patient needs. One Christian chaplain said: “I would love to have an imam who could come, but nobody wants to volunteer their services… I should not need to ask. I would think an Imam would be sensitive to his people. They could inquire.” Another Christian chaplain suspected that the concept of pastoral care is foreign to them. “Yet if you ask Imams about this, they will say, ‘Of course we visit the Muslim patients.’ But it doesn’t seem as if they have expectation of clergy visits as the Christians do. The relationship structure is different.” A Jewish chaplain expressed a frustration that was echoed by others: “The Muslim community should be sensitive to the ritual needs of patients. They should set up a chaplaincy program to provide pastoral care. They should set up a central number to call for an Imam to come and provide pastoral care.”
The Need for Muslim Chaplains
Non-Muslim chaplains who have had positive interactions with imams or Muslim chaplains pointed out that although many patients ask for prayer beads or Qur’ans, they shared a general unawareness about the range of services that chaplains provide. One Muslim chaplain also suggested that Muslims need to take responsibility for increasing the supply: “Chaplaincy … This is a real calling. We need to get more clinically trained Muslims—not necessarily imams—, board-certified. They need some clinical training. They need to meet people where they are in their illnesses. They need to leave out biases, and realize the difference between culture and religion. There are different cultures but one religion.”
For many respondents, the role of Muslim chaplains extended beyond the immediate needs of patients. One Jewish chaplain suggested overcoming negative stereotypes about Muslims among staff by increasing the presence of Muslim chaplains to help “counteract how people feel about Muslims post 9/11.” He added: “There’s fear out there about Muslims …Chaplaincy can change this and serve to counterbalance this perception. If you had an Imam sitting in the CPE group, people would get to know him. If he made rounds, people would see that Muslims are not so bad.”
In the United States, chaplaincy services are designed and practiced according to a paradigm of pastoral care or “spiritual care” for all, regardless of religious affiliation. Chaplains are often trained, paid, and credentialed by specific denominational institutions; nevertheless, they frequently serve outside the boundaries of religious affiliation. Accordingly, many of the non-Muslim chaplains argued that “we do alright on our own” serving Muslim patients. Explicitly and implicitly, they argued that Muslim chaplains are not necessary because Muslims have the sameneeds as everyone else: there is an existential similarity to all human suffering and a common religious response to that suffering. From our data, the “one size fits all” approach to chaplaincy suggests that non-Muslim chaplains approach Muslim patients in much the same way they approach other patients and that the strategies used to satisfy Muslim patients’ needs are deemed sufficient. This approach also suggests that chaplains and Muslim patients should be “open” to each other. It also involves self-restraint on the part of the chaplain, a “boundary”- to avoid imposing the chaplain’s own faith on the patient. The approach simultaneously involves the boundary-leaping ability to interchange names for “God” or modes of prayer between religious traditions. The goal of interfaith chaplaincy is to be open, embracing, welcoming, supportive, and comforting to people of all faiths and none.
The late-twentieth century phenomenon of contextualizing generic spirituality as an inclusive term that transcends a single religious tradition has had profound influence on pastoral care provision in the United States during the past few decades. For instance, Schmidt and Egler (1998) examine the shift within German Protestant pastoral care from conceiving chaplaincy as a ministry of “proclamation” to the American Clinical Pastoral Education (CPE) model, which addresses the “spiritual dimension” of patient care. Although religious patients might express their spirituality through traditional rituals, chaplaincy educators argue that non-religious patients also seek to make their lives meaningful in the face of their adversity (VandeCreek 2001). Muldoon and King (1995) define spirituality as a search for value and meaning in one’s life, and it is this non-denominational framework and the accompanying challenges to traditional pastoral care which has given rise to the concept of CPE. The use of CPE as a means of ministering to any patient also helped initiate the clinical use of spiritual needs assessment tools by hospitals and the subsequent financial justification for services provided to patients (Lee 2002).
Despite the evolution of pastoral care from a religious-based service to one of universal appeal, it has clear limitations when used with Muslim patients. In this study, non-Muslim chaplains recognized a need for an imam when Muslim patients needed a specific ritual, or in “life and death” situations. Within the NYC hospitals, where birth and death rituals are recognized across religions and cultures, we thus recognize a shortcoming of the interfaith model of chaplaincy in relation to Muslim patients where it is limited in the ritual aspect of religious life, particularly at the boundary markers of life and death.
Many scholars describe the interfaith chaplaincy/CPE model as an expansion or adaptation of a Protestant-based chaplaincy model (De Vries et al. 2008; Lee 2002; Mohrmann 2008; Schmidt and Egler 1998). Schmidt and Egler (1998) suggest that end-of-life discussions, rituals, and prayer with Muslim patients require specific religious knowledge of Islam. They suggest that chaplains must go beyond generic services that are based on “formal” common ground, but that often lack the “content” required or requested by Muslim patients (Schmidt and Egler 1998). Other scholars argue that the separation of individual “spirituality” from religious community and religious practices is not possible within an Islamic framework (Rassool 2000; Stoll and Stoll 1989). Furthermore, the sick patient’s perception of illness and death is the conventional Islamic response of acceptance and understanding of God’s will, whereas general spiritual counseling focuses on the challenges facing individuals. Although Muslims are expected to seek appropriate care and treatment for their illness, Athar (1993, 1998) points to the Islamic belief that illness atones for sins and that death is part of the journey of life.
A “one size fits all” approach to chaplaincy as generic interfaith spiritual care based on implicit contemporary Protestant values might present challenges for many Muslim patients. Though two of the Muslim chaplains interviewed felt that they could operate within the interfaith model, the majority expressed that Muslims had specific types of needs that would remain unaddressed by interfaith chaplaincy services. As a corollary to the argument that interfaith chaplains can “cover” Muslim patient spiritual needs, several chaplains offer another rationale for the lack of Muslim chaplains: Muslims do not have the same needs as Jews and Christians. This response would at first glance appear to be based on knowledge of what Muslim patients do need. The non-Muslim chaplains would appear to be well-educated about Islam and Muslims—their cultural, theological, spiritual, ethical, and legal approaches to illness, health maintenance, medicines, healing, death and dying—and based on that knowledge decided that Muslim patients do not need any additional professional care providers other than the existing staff chaplains to assist or accompany them. In our sample, chaplains identify a wide range of possible needs among Muslim patients, from basic accommodations like Qur’ans and prayer mats to the more systematic recognition of modesty, fasting regimens, and decisions pertaining to end-of-life.
On the other hand, non-Muslim chaplains may not have extensive knowledge of Islam and Muslims, which can contribute to the lack of awareness of Muslim patients and the lack of available services for them. We recognize this argument in chaplains’ comments that Muslims do not have the same rituals as Jews or the same sacraments or ordinances as Catholics and Protestants. In contrast, Muslim chaplains mention specific birth and death rituals, prayers and recitations from the Qur’an, and words of comfort drawn from Islamic theology, while some non-Muslim chaplains recognize that they are “not well-versed” in the particulars of Muslim healing practices. The particularities of Muslim prayer and ritual, as Schmidt and Egler (1998) illustrate, should cause Protestant and other non-Muslim chaplains to consider the limits of their participation in prayer for and with Muslim patients. The Jewish chaplain’s intense encounter with her Muslim patient’s insistence on praying “with all her soul” in order for him to be “satisfied” illustrates this point well.
Furthermore, the assumption that chaplains are primarily clergy who perform rituals for patients truncates the diverse range of roles and services that chaplains identify for themselves. Other denominationally appointed/trained/supported chaplains do not exist solely to perform tradition-specific rituals. Chaplains in our survey identified the primary roles of chaplaincy as prayer, providing emotional support, and providing end-of-life support. Muslim chaplains, on the other hand, additionally provide Qur’an recitation, advocacy on behalf of Muslim patients, religious advice on adapting ritual requirements to a hospital setting, and a theological perspective that others cannot (sometimes through proclamation). One wonders whether Protestant, Catholic, or Jewish patients must ask for Bibles, prayers, worship services, or kosher food before the hospital begins making them available. This study supports the argument that there is a lack of attention to the ritual needs of Muslims in comparison with Christians and Jewish patients. Perspectives on illness, healing, emotions, and end of the life care that Muslims share are overlooked in this argument. When assessing the need for Muslim chaplains, the range of Muslim needs from the patients’ perspective and the chaplaincy roles from the provider perspective need to be considered.
To justify the provision of Muslim chaplaincy services, it is necessary to articulate Muslim patient and staff needs. These specific needs include theological perspectives and counseling about illnesses, ethical and legal advice regarding ritual obligations as well as medical decisions, ritual prayer and Qur’an recitation, and Friday sermons. The dimensions of proclamation, ritual, and theologically informed counseling and legal advice might resonate with more traditional Protestant, Catholic, and Jewish practices, but not necessarily with contemporary interfaith chaplaincy practice. This first limitation of the “one size fits all” model is not without precedent in the history of United States hospital chaplaincy and serves as a reminder of boundaries that might not be fully erased or transcended.
This boundary needs careful attention in light of the second limitation on the interfaith chaplains’ success in meeting Muslim patient needs which often rests on the ability to access appropriate local Muslim religious leaders. Many chaplains identified the need for increased pastoral care and chaplaincy training in the Muslim community. The non-Muslim chaplains indicate that the “relationship structure” of imams is different than that of Protestant ministers or Catholic priests to their parishioners. The roles and definitions of “professional” clergy in relation to congregations and to public institutions (including government and hospitals) in the United States have been highly contested and richly varied; the “pastoral care provider” or “chaplain” is only one among many roles for Christian clergy (Holifield 2007), much less for those of other faiths. Although several of the chaplains in our study indicate that the Muslim community has the responsibility for producing chaplains, the implication is that Muslim chaplains might be able to provide more culturally and spiritually sensitive services to Muslim patients. Investigating how Muslims currently in chaplaincy training programs negotiate the integration of the interfaith CPE model with Islamic religious traditions might provide greater insight into the barriers and challenges to increasing the availability of professional Muslim hospital chaplains.
A third limitation of interfaith chaplaincy that emerged from our data is unacknowledged prejudice and discrimination against Muslim patients. Several chaplains acknowledged their unawareness of Islam, doubts about their ability to discern Muslim needs, and their prejudices about “seeing heavily veiled women.” Some spoke of the “political tension” around Jewish-Muslim relations with regard to Israel/Palestine as an obstacle to open relationships.
Several non-Muslim chaplains said that Muslim patients tended to refuse, reject, or mistrust services that they offer. These chaplains attribute such rejection and mistrust to the “foreignness” of some Muslim families or to the fear of “being proselytized by non-Muslim chaplains.” Non-Muslim chaplains might interpret such refusal to mean that Muslims do not need or want chaplaincy services at all. Muslim patients’ resistance might be a response to negative racial, political, and/or religion-based discrimination in other contexts or to perception of discrimination by providers. Several studies demonstrate that minority patients perceived higher levels of discrimination in health care than non-minorities (LaVeist et al. 2000; Lillie-Blanton and Hudman 2001; Smedley et al. 2003). Other studies document the prevalence of such suspicious attitudes among Muslims, particularly post 9/11 (Abu-Ras and Abu-Bader 2008, 2009; Abu-Ras et al. 2008; Ali et al. 2005). Even when these attitudes are acknowledged, health care providers (including chaplains) might provide unequal care to religious minorities. Schmidt and Egler (1998) suggest that Christian chaplains need to reexamine the theological grounds on which they base their pastoral care ministry with Muslims. We suggest that non-Muslim chaplains also need to take a measure of their gut reactions to Muslim patients in an Islamophobic social environment and how this environment influences their Muslim patients’ responses to them.
This study cannot be generalized based on the limitations of the sample size as well as the method of recruitment. The study was conducted only in English and thus excludes non-English-speaking chaplains. Future studies on Muslim spiritual needs should also include the perspective of patients and community- or mosque-based imams. The qualitative interviews were conducted with a small, non-random sample of chaplains. Although the interviewer’s verbatim notes were coded by both authors involved in this study, helping to reduce the possibility of individual subjective bias in interpreting the data, a more in-depth analysis of chaplains’ discourse about Muslim patients would be possible with electronically recorded interview data. Through constant comparison between transcripts and grounded thematic analysis, we were able to identify repeating themes that portray attitudes toward, experiences with, and approaches to Muslim patients. Because the Muslim community is culturally and religiously diverse, future studies should better control for ethnicity and other individual backgrounds. In addition, factors such as size and composition of the health care system, chaplaincy staffing, and Muslim patient population might be considered unique to NYC. These limitations constrain the authors from making generalizations based on the findings because the data might not be representative of other subject populations. A more comprehensive national study could illuminate these factors more clearly.
Conclusion and Implications
Special consideration must be given to the differences and similarities between Muslim and non-Muslim patients’ needs. To increase the use of spiritual care services among Muslim patients, chaplains and hospitals must identify barriers and develop approaches to remove them. One means is through coherent and comprehensive chaplaincy training for Muslim chaplains, community-based imams, and interfaith CPE residents in training.
All health professionals need to recognize varying perceptions of health shared by people from different religious, cultural, and linguistic backgrounds and strive to deliver culturally sensitive health care. The results from this study could help inform chaplaincy providers and health service planners to improve the appropriateness, relevancy, and effectiveness of services for Muslim patients. Furthermore, the training of Muslim chaplains to meet the needs of Muslim patients will need to account for the ways that Muslim religious leadership differs from Christian and Jewish models, as well as the internal diversity of Muslim-American communities. The current challenge within the NYC hospital setting is that there is one active out of the two board-certified Muslim chaplains in NYC, while other Muslim chaplains serve as local imams with very minimal training in chaplaincy services. Therefore, Muslim chaplains generally lack the knowledge required by chaplaincy departments. Although suggesting that the professional training and certification of Muslim chaplains is important, we also recognize that self-educated lay activists may exercise as much or more leadership and authority in the broader Muslim community as traditionally educated imams and jurists. A number of institutions are currently evolving to address the increased need for indigenously trained Muslim religious leaders in the United States.
Muslim Mental Health, Inc. is an organization committed to promoting research and educational activities, introducing Muslim mental health concepts and advancing culturally sensitive therapeutic approaches (www.MuslimMentalHealth.com).
Board Certified Chaplain (BCC) "A person who has demonstrated professional excellence as a chaplain, meeting all eligibility requirements including a Bachelor’s Degree, a 72 semester credit graduate theological degree from an accredited school, four units of clinical pastoral education (CPE) ordination or commissioning to function in a ministry of pastoral care, and ecclesiastical endorsement by a recognized faith group, is recommended by a Certification Committee, approved by the commission on Certification, and ratified by the Board of Chaplaincy Certification Inc. Board of Directors." (Association of Professional Chaplains, retrieved from www.professionalchaplains.org).