Health Care Analysis 10: 339–356, 2002.© 2003 Kluwer Academic Publishers. Printed in the Netherlands.In a Secular Spirit: Strategies of Clinical PastoralEducationSIMON J. CRADDOCK LEEJoint Program in Medical Anthropology, University of California, San F rancisco andBerkeley (E-mail: [email protected])Abstract. The Clinical Pastoral Education (CPE) model for the provision of spiritual carerepresents the emergence of a secularized professional practice from a religiously-based theo-logical practice of chaplaincy. The transformation of hospital chaplaincy into “spiritual careservices” is one means by which religious healthcare ministry negotiates modernity, in theparticular forms of the secular realm of biomedicine and the pluralism of the contemporaryUnited States healthcare marketplace. “Spiritual” is a label strategically deployed to extend therealm of relevance to any patient’s “belief system,” regardless of his or her religious affiliation.“Theological” language is recast as a tool for conceptualizing the “spiritual lens.” Such movestransform chaplaincy from a peripheral service, applicable only to the few “religious” patients,into an integral element of patient care for all. Such a secularized professional practice isnecessary to demonstrate the relevance and utility of spiritual care for all hospital patients inan era of cost-containment priorities and managed care economics.Key words: chaplaincy, professionalization, professional ethics, religious pluralism, secular-ization, theologyIntroductionIn this article, I argue that Clinical Pastoral Education (CPE), a training modelfor the provision of spiritual care in medical centers, represents the emer-gence of a secularized professional practice from a more religiously-basedtheological practice of chaplaincy. Further, I argue that the transformationof hospital chaplaincy into “spiritual care services” is one means by whichreligious healthcare ministry negotiates the secular realm of biomedicineand the pluralism of the contemporary United States healthcare marketplace.“Spiritual” is a label strategically deployed to extend the realm of relevanceto any patient’s “belief system,” regardless of his or her religious affiliation(or lack thereof). “Theological” language is recast as a tool useful herefor conceptualizing the “spiritual lens,” itself similar to the psycho-socialformulations of social work. These moves transform chaplaincy from a peri-pheral service, applicable only to the few “religious” patients, into an integral340element of patient care for all. In an era of constrained healthcare resources,US hospitals have been severely affected by the cost-containment priorities ofmanaged care economics (Enthoven and Singer, 1996; Shortell et al., 1994).Consequently, a secularized professional practice is necessary to demonstratethe relevance and utility of spiritual care for all hospital patients, rather thanrestricting their applicability to explicitly religious patients.Amidst the increase in biomedical knowledge and the accompanyingadvances of medical technology in the 20th century, one might well ques-tion the place of religion and spirituality in medical centers and the care ofpatients. Fundamental to the argument advanced in this article is a recognitionof the history of the hospital-as-social institution that evolved from housesof Christian charity of early Byzantium, only assuming its identity as the“medical center” in the recent past.Until the late Middle Ages, religious personnel remained in leadershippositions, staging ceremonies and participating in care giving. Spiritualcare remained in the hands of priests, while physical nurturing becamemostly the responsibility of religious and lay women because of theperceived domestic roots of these tasks. A medical presence in hospitalsoccurred only gradually, from consultants to salaried staff membersduring the Renaissance. (Risse, 1999, p. 7)1The hospital began as a “house of God” – it is not spiritual concernsthat are the new development there, but rather science and biomedicine. AsFoucault demonstrated, in the West the birth of the clinic is rooted in thetransforming power of sign and symptom and the accompanying conceptionsof the individual and social body that made possible increasingly effectivemedical intervention (Foucault, 1973).2Only after the eighteenth centurycould hospitals become the “houses of Science” we know today as tertiarycare medical centers.Christian women expanded their healthcare ministry to the New World,following the waves of European migrants. As first settlements then citiessprang up, Christian hospices, clinics and later hospitals were established toserve the sick and the poor (Risse, 1999, p. 339).In 1994, City Physicians Hospital,3a secular community-based non-profit facility in Northern California, was driven by the economic pressuresof managed care to become part of a large, religiously-sponsored hospitalmanagement system (Robinson, 1996). While retaining some autonomy andits identity as a secular community hospital, City Physicians began operatingin conversation with its counterparts in that system throughout the state. Oneof those institutional siblings was Incarnation Hospital, one of the earliestreligiously-sponsored facilities in California dating back to the gold rush,operating only a few miles from City Physicians Hospital. As a Catholic341hospital, Incarnation has had Catholic chaplains as part of the hospital stafffor many years and is considered a leader in chaplaincy training. At CityPhysicians, on the other hand, local clergy had visited patients as needed butthe hospital has no tradition of chaplains on staff. In 1998 the CPE programat Incarnation was expanded to include City Physicians Hospital. This articleemerges as part of a sustained ethnographic engagement with this hospitalsystem.Pastoral Care and Clinical SettingsThe history of pastoral theology as an applied discipline follows the changingdemographics and consequent sociopolitical developments of the US at theturn of the century that challenged the early understanding of “a Puritannation founded on Christian [Protestant] principles” (Hemenway, 1996). Thenew professionalization of law and medicine helped to elicit concerns in the1920s about what skills beyond liturgical practice were imparted in divinityschools that would equip ministers for their work with the faithful. As thefields of