by Gordon J. Hilsman

If we had to choose only one spiritual care intervention from among all those listed in published taxonomies, curriculum summaries, certification competencies and research articles, it would have to be conveying empathy. To astound a patient with clear indication that another person grasps their primary emotions in that always unique predicament is a goal of every spiritual care effort. That is because decades of chaplaincy experience have shown it, and, as Harvard psychiatrist Greg Fricchione has documented scientifically (Fricchione 2011), personal isolation is the first deep experience of serious health issues, one that yearns for healing by loving care. In short, nobody understands what it is like to be that specific person in that unique life situation. Some level of felt loneliness is almost always involved, whether it shows or not. Genuine empathy conveyed well dispels that loneliness, albeit temporarily, like nothing else.

But as the phenomenon of long-term systemic racism in the United States has shown, empathy is often not enough. Personal presence can be powerfully caring. But it can also be an excuse for inexperienced passivity or even fearful petrification. As one young ICU patient’s irate mother once said crisply to a neophyte chaplain, “Well, aren’t you going to say anything. All I’m seeing is a lot of standing around and shifting from one foot to another!”

Genuine empathy cries out for action, if only to promote more disclosure. Empathy without something else does little more than Charlie Brown telling Snoopy, shivering in the snow, “Be joyful and well fed”, and walking away. A piece of that action called for after conveying empathy is sometimes the depth of quiet presence. But sometimes it is the face-to-face courageous truth of confrontation.

Ralph L Underwood (2002) offers a concise way of understanding the partnership between empathy and confrontation. As a Christian theologian, Underwood writes with the traditional language of that perspective, yet captures the human relationship succinctly:
“In empathic listening, the pastor’s own viewpoint is held in check to ensure accurate and caring understanding of the other person. In confrontation a perspective other than the parishioner’s own is introduced… Even when understanding is advanced through empathy, the stimulation of an additional approach may be immensely useful. On the other hand, confrontation that presumes to proceed without empathy often misses the mark as well as provoking unnecessary opposition and defensiveness (Underwood p. 89).”

A mild and kind form of confrontation promotes further disclosure by most patients. Gaining access to the inner world of people for their own benefit has long been a basic function of spiritual caregiving. Chaplains and pastoral counselors facilitate sharing from the depths of a person, from the patient’s own point of view. The traditional disciplines of medicine and nursing, for which hospitals were designed, have a primary need of diagnostic listening. Chaplains on the other hand excel at personal listening. Since the beginning of the clinical ministry movement in the mid-1920s, spiritual care (then, and sometimes now, known as pastoral care) has been incorporating the perspectives of other caregiving disciplines into its practice.

That newer, clinical style of spiritual care, as notably described succinctly by Howard Clinebell (1984) , uses four types of interventions, empathy, questions, interpretations, and support to establish rapport and then uses that initial relationship to facilitate further disclosures and emotions. That basic framework has been a top tool in evaluating pastoral care conversations of clinical pastoral education (CPE) students ever since. Clinebell did not champion confrontation centrally in that book. He did however, mention it briefly there and addresses it effectively in his books on care of alcoholics. And confrontation now needs to be seen far more broadly.

The confrontation intervention can be seen as either an addition to Clinebell’s four as a distinct fifth element, or preferably, as in a class of its own that can take the form of any of the others, except support. Better yet, it can be seen as the partner of conveyed empathy, used as either a question, a reflective comment, or an interpretation, that invites a person to another level of depth of disclosure and conversation. Here are three personal examples of confrontations in the form of an astute emotional reflection, a sharp intuitive interpretation, and a savvy, pointed question.

Confrontation as Emotional Reflection

In my third unit of CPE I was once talking in group ever more openly than I had anticipated. At one point a peer simply said gently, “It sounds like you’ve been lonely most of your life.” As a celibate priest at 31 I was hit by that like the proverbial ton of bricks. I’d never seen myself as lonely but rather successful, compelling, inward, and inhibited. I had however, chronically recognized a vague, unnamed feeling of awkward sadness as quite familiar. My peer was calling it correctly. It was so true and clear, so pointed and insightful, it made me shiver and I could not ignore it. I didn’t cry then, sitting in my stunned silence, but I sure did later that day. That was a confrontation in the shape of an empathic reflection.

Confrontation as an Interpretation
After that third CPE unit I met a committee for consultation requesting what was then called “advanced standing” in the ACPE. In the consultation group of six, as I followed the lines of inquiry and responded as openly as I could, one consultant leaned forward, looked me in the eye with a smile, and said, “Sounds like what you really want is to be celibate one day a week, married one day a week, and single five days a week!”. Everyone laughed but me. That was one of those “funny but not funny” comments that invites one into a different perspective entirely, exactly what confrontation always attempts to do.

It was an interpretation, an adding of insight to a situation that will hopefully crack it open. That one did, for me.

Confrontation as a Question
Later, after final educator certification, I was still stuck in ambivalence for months over leaving the priesthood. I was involved with a woman but functioning publicly as a celibate, putting off the most painful decision of my life. As I shared my situation openly with a brilliant friend and author two years younger than me, he asked, “Can’t you find a way to be both sexual and celibate?” Wham. My reflexive response betrayed the deeper truth. “Dan, I’ve got to get some integrity back into my life.” “No” blared clearly now in my mind. That question suggested something loathsome to me. I knew priests who had fathered children and were still functioning as priests. I simply couldn’t even consider it. It was immediately clear that I had only one direction that would get me whole. I followed through with the process of Laicization soon after.

That was a confrontation in the form of a simple question.

We humans are not open books. Sometimes we need help turning that front cover over to see our own pages and begin perusing deep inside.
Humans are rarely direct in dealing with our serious needs. We do display some of our serious concerns to all the world, especially when we feel like we must do so for a little longer survival, or for a manipulative edge in tight situations. We sometimes intentionally hide what bothers us most for the sake of managing our image or protecting people we love from the truth. But most often we curiously have many concerns hidden from ourselves by variously named unconscious processes of which we are not in charge. Self-deceit still abounds at this stage of the evolution of humanity.

Like the world’s rivers to our human ancestors, there are natural barriers to our moving freely into personal openness; and like the fences we ourselves build for protection, there are unique ways we shield ourselves from feeling the stark truths of our difficulties too vividly. We keep some distance from our own souls…until we don’t.

At times we need bridges over our natural river barriers, and gateways through our self-constructed fences into our own radical self-awareness. Spiritual caregivers sometimes need to use those gateways to really hear troubled peoples’ pains and respond creatively to them. Prime among those gateways is the remarkable skill of confrontation in its innumerable forms.

Of course, not all confrontive interventions are dramatic or obviously transformational.

Consider, for example, this male patient experiencing prior grief, the common, even universal awakening of feelings of sadness, regret, warmth, and malaise relative to remembering a major loss long after it happened. The vague feelings of major loss lay there, maybe unpredictably felt often, and are brought near the surface of consciousness by the experience of hospitalization. A chaplain visits a man for the first time.

In a common spiritual care conversation in a hospital room, the male patient is talking briefly about himself. He mentions:
“…then, just after my wife died….” He finishes the sentence and moves on. A moment later, as he pauses, the chaplain simply asks,
“Wait. Did you say your wife died?”
The man, “Yeah. She passed away right here in this hospital.” (Pause) “My son lives just over in Fremont.”
Chaplain, quietly: “How did she die?”
Man: “Oh, she got cancer and was gone in three months.” (pause) My sister died last year too, up in Montana”.
Chaplain, with brief silences: “Your wife died quickly.” (pause) “I’m sorry.” (pause) She was pretty young.”
Man: “Yeah. We thought we’d have a lot more time.”
Chaplain, patiently: “Sad.” (pause) “Disappointing.” (pause) “Think about her a lot?”
Man: “Oh God yeah. All the time. Every day. We had our differences, but she was a wonderful woman.”
Chaplain: “Lots of memories flood you I bet, sometimes.”
Man, looking out the window, becomes teary: (pause.) I cry sometimes when I remember. Cry hard sometimes. (pause) I remember….” (He begins to reminisce, not looking at the chaplain.)

At least twice here, the chaplain confronts the patient in a gently empathic, but quietly firm way. Both times she “goes against” the prevailing thinking process in the man and draws his attention to his wife and the grief the chaplain believes lies in wait, ready to be shared, again, in the process of the man’s underlying grieving experience. The conversation may have brought the man to his covert grief without the mild confrontation, but probably not. It is possible too, that there was something else the man needed to talk about that was missed by the chaplain turning the conversation to the prior grief. But not much could have been more important. Reminiscing about his wife, which now may take 15 or 20 minutes, probably contributes positively to his spirit this day and his potential ability to cope and heal in this hospitalization.

There may be controversy about whether reminiscing can be harmful to some people with trauma histories, and thus not advisable in the short window of time with which chaplains work. But such highly sensitized patients are generally recognizable by facial vulnerability, shaky demeanor, and pace of speaking. We can assume that the experienced chaplain proceeds to explore the grieving after quickly making that appraisal – this soul is ready to reminisce.
Even very experienced caregivers may not have interrupted the man’s flow of disclosure. That said, confrontation most always includes the possibility of failure. Courage to proceed judiciously with the willingness to apologize gracefully, if necessary, is a skill to be developed by all chaplains.

Hospitalized people fairly-often regress. When placed in that vulnerable personal place many of us take refuge in ways of coping we don’t normally use, becoming more like children, even toddlers. Adults crying, bickering, opposing, demanding, and insulting are fairly common in hospitals. In that vein spiritual care is sometimes more like parenting a toddler than an infant. Rather than needing total support and warmth, like an infant, conflict is natural for a toddler. Two-year-old children demand it, insist on it, force it. They will not survive without it. Mild or sharp confrontation, in rare cases even physical restraint forms an integral part of their care. And their development. Some patients in particular situations are like that. Consciously or unconsciously, they will not feel the care deeply, or find themselves anew, without a strong, observant voice gently directing them.

In an age of a new and hopefully vigorous dealing with systemic racism and a growing awareness of the personal and interpersonal wounding of most women and children in their childhood or youth, we caregivers need our confrontation to be done well, with practice, and continuous, courageous trial and error to constantly get better at it (See chapters 5 and 6, e.g.).

Confrontation in spiritual caregiving is leaning into an issue, injecting a tone of intimate connection into a conversation. The moment of confrontation dispenses with congenial social perspectives, formalities, and polite niceties. Confrontation includes the intention to change the way two are meeting to a way that is more direct, engaging and potentially unpleasant, to address important and difficult matters. It is used occasionally by some medical and nursing staff in most every hospital unit and can be employed effectively by chaplains to deepen conversations to a soul-to-soul level while not overwhelming a person with the unavoidable dire tragedy of a situation.

Historically clergy carry that reputation. A special kind of conversation that, in certain circumstances reaches deeper into issues, has always characterized pastoral connection, even before the initiation of the clinical ministry movement began in 1920s America. When one person “levels” with another about serious personal matters in heart-to-heart disclosures and deliberations, souls are reached, relationships altered, and lives are changed. Such interactions often follow the lead of a caregiver who creates an atmosphere for open sharing and authenticity, and then uses it to bring the most difficult disclosures of the patient to the surface. That caregiver shows in the dialogue, by manner and tone, that they have the time, the interest, the earthiness, and the interpersonal courage to stand face to face, willing to be honest in delicate, discouraging, or personally scary matters. That is confrontation in the best sense of the word.

Some spiritual care confrontations are deftly gentle, calmly patient, and carefully direct. Some are much more difficult. For patients who are semi-publicly making racist statements; or showing indication of having a drinking or mental illness problem; or parents clueless about the dire seriousness of their child’s medical situation; or combat veterans at a point of ambivalence about sharing the worst of their war experience; caring confrontation may need skillful expertise necessary to further the care, sometimes towards intricate referral to other forms of care.

The primary purpose of this essay [book] is to illustrate how confrontation can be used in various aspects of health care and its wider culture, and to promote continually learning to confront as a basic tool for the practice of all caregivers.
The phenomenon of caring confrontation isn’t precisely definable in any clearly useful way. We can describe it however, as one person bringing clearly to another, an observed or intuited truth that may be unpleasant but is likely to reduce that person’s self-deception and improve the quality of their self-awareness for care of themselves and other people. The authors will be demonstrating how this can be done effectively and more often in difficult spiritual care conversations.

Usually, one needs to find one’s own soul to confront well. It takes reflection—allowing the situation to affect you; tuning into your intuitive grasp of the situation as a whole; employing your own personal or caregiving history of similar situations; and then finding words and phrases to boldly, succinctly yet kindly and humanly, convey your unique take on it. This seems like a daunting task. It can be. And then again, at times it merely leaps to your mind as a sincere caregiver moved by jarring empathy. Call it the Spirit of God or the mysterious genius of the human personality. Either way it commands the situation and cares for this person, now, on a level that is impossible without addressing the issue directly.

The ordinary, mostly social lubricative interaction that provides pleasant, congenial connections between people in everyday life is musical. It makes life warmer, more pleasant, more connected, and more fun. In small process groups however, and in spiritual care of people in difficult life situations, social comments are less often useful. They can become like music turned into noise, distracting and even annoying. There are times when personally light, supportive efforts at comfort, run the course of their usefulness. Then instead they obstruct interaction that could be more beneficial to all of those involved.

As philosopher/humorist Stendhal wrote in the nineteenth century:
“Oh if only there were a true religion. Fool that I am, I see a Gothic cathedral and venerable stained-glass windows, and my weak heart conjures up the priest to fit the scene. My soul would understand him, my soul has need of him. I only find a nincompoop with dirty hair” Stendhal (1830).

Those times call for a confrontation versus continued superficializing collusion– a statement by one person who sees the relevant deep truth of a situation and finds a sharp but relatively palatable way of expressing it in clear words.
This is deep and soulful human encounter. Soul here means the core of a person, the unique inner depth that motivates humans non-verbally and can be partially seen by observing the spirit, the elan, the excitement or discouragement of the person. Soul is the seat of a person’s values and one’s pursuit of them. What is called spiritual or pastoral care is a soul-to-soul interaction that transcends the social and especially the pedantic instructional.
Understanding and appreciating confrontation belies the fact that confronting is most often interpersonally dangerous. It always carries the likelihood that it will tweak the ire of any or all of those involved, and even, in some cases, interloping bystanders. When one person notices and verbalizes a deeper truth, those around can easily misunderstand. But those who are open and savvy, will see the new perspective and be grateful for it.