The Use of Sacred Story in a Psychiatry Spirituality Group

R o b e r t A. K i d d , M.Div. Sr. Staff Chaplain, Spintual Care ? Education; Virginia Maripolsky, M.S.W., R.N.. Nursing Director, Psychiatry Unit; Patricia R Smith, M.A. Sr. Staff Chaplain, Spintual Care f Education; The Methodist Hospital 6565 Fannin Street Houston, TX 77030 Describes the philosophy and methodology for using sacred stories from several religious traditions with psychiatric patients. Notes how chaplains are integrated into a psychiatric unit's interdisciplinary team. Details how sacred stories are selected for use in a spirituality group, how patients are screened for participation, and how the group is facilitated. Demonstrates the benefit and value patients and staff derive from a spirituality group on a psychiatric unit.

hroughout human history, stories have called people into community. Humanity seems to have learned that stories can be medicine for the soul, a medicine "similar to listening to the ocean or gazing at sunrises. Stories flow where needed, acting like an antibiotic that finds the source of infection and concentrates there." 1

The Psychiatric Unit

The subject of this article, known simply as "The Spirituality Group," is held on the Psychiatric Unit of The Methodist Hospital, a full service, 900 bed private hospital located in the Texas Medical Center in Houston. The hospital serves as the primary teaching facility for The Baylor College of Medicine and draws patients from around the world. The hospital's 30 bed psychiatric unit admits only adults for both general psychiatric and chemical dependency diagnoses. Patient ages range from 18 to 96 with an average age of 55 years. Though the average length of stay for inpatients is 10 days, stays vary depending on the complexity of the case. Patients in the partial hospitalization (out-patient) program attend most groups along with inpatients. The Buddhist story cited below, "The Mustard Seed," is frequently utilized in the Spirituality Group. This story suggests a foundational element of the unit's treatment philosophy: health is found not in isolation, but community.2

The Journal of Pastoral Care, Winter 2001, Vol. 55, No. 4

'Charles and Anne Simkinson, Sacred Stories: A Celebration of the Power of Stones to Transform and Heal (San Francisco, CA: Harper, 1993), p. 6. 2 Marilyn McFarlane, Sacred Myths: Stones of World Religions (Portland, OR: Sibyl Publications, Inc., 1996), p. 10 353

The Mustard Seed

The Buddha was walking on a dusty county road one day when he stopped at the edge of a river to splash cooling water on his face. When he finished washing, he looked up and saw an old woman kneeling beside him. Her clothes were ragged and her face was worn. Her arms were covered with sores. 'Oh, Master, " she wailed. "I suffer so. Please help me. " "What troubles you?" the Buddha asked, looking at her with compassion in his eyes. "Look at me! See my sad lot!" She touched her rags, and she pointed with skinny fingers to her blistered arms. "I am poor, my clothes are torn, I am ill. Once I was prosperous, with a farm and now I am old and have only a bowl of rice to eat. Won't you heal me and bring back my riches ?" "You have described life as it is, " the Buddha answered. "We are all born to suffering. " The old woman shook her head, weeping. "No, no, I won Y listen. I was not born to suffer. " The Buddha saw that she could not understand. "Very well, I will help you, " he said. "You must do as I say. " "Anything, anything!" she gasped. "Then bring me a mustard seed. " She stared in astonishment. "Only a mustard seed?" "Yes, but the seed must come from a house that has never known sorrow, trouble, or suffering. I will take the seed and use it to banish all your misery. " "I will do as you say. Thank you, Master, thank you!" The old woman hobbled away, her barefeet shuffling m the dust. She was on her way to find a house without sorrow. The Buddha continued down the road. Weeks later, he returned along the same road and came to the same place by the river, and there he saw the old woman again. This time, she was scrubbing clothes m the river water and spreading them on rocks to dry in the sun. While she washed, she sang a tune. "Greetings, " the Buddha said. "Have you found the mustard seed?" "No, blessed One. Every house I visited had far more troubles than I have. " "So, are you still seeking the seed I sent for?" "No, I'll do that later. You see, I have met so many people who are less fortunate than I, I have to stop and help them. Right now, Tm washing clothes for a poorfamily with sick children. " Gently, she placed a wet piece of cloth on a rock. The Buddha smiled. He said, "I see, then, that you no longer need the mustard seed. Helping others is a great virtue. You are now on the road to becoming a Buddha yourself. "
Repnnted by permission of Sibyl Publications, Ine 800 240-8566

As in the above story, the patients on the hospital's psychiatric unit are called on to move beyond preoccupation with their own illnesses and into enhanced community with others. Such refocusing of attention is not seen as a way of neglecting or minimizing patients' problems, but rather as a way of dealing with them both inter- and intra-personally. The Spirituality Group described in this paper has proved a viable element in accomplishing this team goal. Skillfully utilized, sacred stories help individuals move out of isolation into community.

What is Spirituality?
Before meaningful reflection can be done on the usefulness of a spirituality group in a psychiatric setting, several definitions must be established. First, what is meant by spirituality? The Group's working definition is this: Spintuality is a set of beliefs or attitudes which lead the believer to greater peace, courage, hope, faith and more significant, satisfying relationships with self, others and the Divine. Stated another way, it is "the thoughts, feelings, and actions of any person who is stretching to grow
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beyond the bounds of isolated ego in the direction ofncher relatedness, deeper matunty, and an enhanced sense of vitality and meaning. "3 This is not religion; religion is spirituality that has become codified. While all do not profess a specific religion, the group leaders' core assumption is that all are spiritual beings. Spirituality is what calls us beyond ourselves and into relationship with others as well as the Transcendent Other. Spirituality is defined by what it accomplishes, not so much by the specific beliefs it contains. Sacred stories with beginning, middle, and end accomplish this as mystery unavailable by reason alone. Kindred spirit listeners become potential beholders of ancient truths. The spirit of storytelling is to move listeners into places where imagination is utilized and memories of other times and places are possible. Sacred stories arrive as gifts to be opened by listener and teller alike. They present themselves to all who participate in spirituality groups.

Why Spirituality Groups?

The primary rationale for including spirituality groups in this psychiatric treatment milieu lies in The Methodist Hospital's mission statement which calls all the hospital's caregivers "to provide high-quality, cost effective healthcare... in a spiritual environment." 4 The Methodist Hospital is obviously part of a church-related hospital system. Accordingly, a public commitment has been made to meet the spiritual needs of patients during their hospitalization believing that such holistic care is part of the hospital employees' collective calling to ministry. Therefore, the establishment of a psychiatric spirituality group is a partial fulfillment of the hospital's mission. Secondly, inclusion of intentionally spiritual components of treatment seems to be the best clinical practice. The Public Health Service has defined culture as "the shared values, norms, traditions, customs, arts, history, folklore and institutions of a group of people." 5 This cultural heritage and worldview are inextricably woven together to give meaning to life events, including mental health issues. An appreciation of these cultural elements is a prerequisite to understanding and interpreting patterns of behavior.678 The success of Alcoholics Anonymous is a notable example. Indeed, ethnicity, culture, and spirituality are intertwined in the patient's personality and become a part of both mental illness and recovery. The Methodist Hospital, deep in the Bible Belt of the South, brings together in the interests of healing and wholeness, people of diverse economic, educational, and emotional health levels. Moreover, most have vast lived-experience resources. If ignored, the extent to which these values and beliefs affect treatment may never be discovered. The Group leaders' assumption
Mary Louise Bringle, "Soul-Dye and Salt: Integrating Spiritual and Medical Understandings of Depression" The Journal of Pastoral Care, 1996, Vol. 50, No. 4, p. 332. 4 The Methodist Hospital System Mission Statement, Houston, TX. 5 F.A. Carnevale, R.N. "Toward a Cultural Conception of the Self," Journal of Psychosocial Nursing, 1999 (August), pp. 26-31. 6 U.S. Department of Health and Human Services, Public Health Service, Cultural Competency for Evaluators, pp. vi-23. 7 A.M. and Diego L. Collins, "Mental Health Promotion and Protection," Journal of Psychosocial Nursing, 2000 (January), pp. 27-31. 8 H.I. Kaplan and B.J. Sadock, "Synopsis of Psychiatry," Behavioral Sciences/Clinical Psychiatry, 8th d. (Baltimore, MD: Williams and Wilkins, 1998), pp 27-31.
3

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is that for many patients, a satisfying, helpful spiritual life has predated their psychiatric illness and thus is often part of their memory of wellness. Giving patients an opportunity to remember these helpful elements of their history enhances their sense of wholeness. Third, several regulating agencies monitor the hospital's psychiatric services. The Joint Commission on Accreditation of Healthcare Organizations (JGAHO) expects that psycho-social assessments of patients will include information about their spirituality and that the resultant treatment plans will identify types of care and services which will meet those needs. 9 This Spirituality Group complies with JCAHO's standards for Patient Rights and Patient Education by insuring that these religious needs are assessed, addressed, and documented in the medical record.10 Additionally, both the Texas Department of Health and the Texas Commission on Alcoholism and Drug Addiction recommend a holistic approach to mental health which includes assessment of spirituality needs followed by attempts to meet those needs.11

Inclusion of Chaplains on the Interdisciplinary Team

The initiative for including chaplains in the psychiatric interdisciplinary team began with the Department of Spiritual Care and Education. After several meetings with the psychiatric medical director, nurse manager, clinical supervisor, and other team leaders, a plan was agreed upon for the regular offering of a Spirituality Group on the unit. This alone, however, did not establish the chaplains as functional team members. Strengthened relationships with nursing leadership has been the key to the ultimate inclusion of chaplains as real, day-to-day players on the interdisciplinary team. Although the Department of Spiritual Care and Education had always been available to this unit, it was the growing, collgial, chaplain/nurse relationship which truly solidified the chaplains' presence on the psychiatric care team. Nursing standards also played a role in carving out a place for chaplaincy services on the unit. Including a Spirituality Group on a psychiatric unit has allowed the hospital to be in compliance with American Nursing Associations' Standard IX for Interdisciplinary Collaboration.12 In The Methodist Hospital's psychiatric unit, the interdisciplinary team concept is a foundational care philosophy. Chaplains, then, cannot minister in isolation. For therapeutic and operational reasons, chaplains are called on to be radically interdependent with other psychiatric staff persons. This new alliance with Spiritual Care has fostered a revisiting of values, attitudes, prejudices, and perceptions by all members of the psychiatric care team, chaplains included.

Joint Commission on Accreditation of Healthcare Organizations, 1999-2000 Standards for Behavioral Health Care (Oakbrook Terrace, 1999, PE.1.7.1.3)pp. 169-175. 10 JCAHO 2000, RI 1.2.6, p52. n Texas Department of Health Title 25: Health Services, Chapter 133: Hospital Licensing Subchapter D: Special Service Requirements; Section 133.54: Standards for Hospitals Providing Comprehensive Medical Rehabilitation, Mental Health, or Chemical Dependency Services. 12 American Nurses Association, "Standards of Nursing Practice Publication Code No-41,10M 1:77," (Kansas City, MO, 1991.)

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What Stories are Sacred?

Because The Methodist Hospital's patient base is international and its commitment is to ecumenical ministry, it was determined that sacred stories for this group should be from a variety of religious traditions. As previously mentioned, Houston, Texas becomes an international community by virtue of business, educational , travel, and climate dynamics. This broad-based approach not only relieved fears that any hint of religious coercion would be present but also insured that patients could feel as free as possible to express their spiritual inclinations in any way that seemed to fit them. Using a variety of traditions in story selection had the additional benefit of increasing the field of ideas which could be broached in a spiritual context. Yet this commitment to ecumenicity made the group leaders realize that an agreement had to be reached on the definition of a sacred story. Not really wanting to get into the task of deciding what was sacred and what was not, the group leaders chose a pragmatic approach for discerning stories' sacredness. Sacred stories are defined as narratives found in currently active religious traditions which are utilized by present-day religious adherents to offer inspiration and instruction. This definition included but was not limited to Buddhist, Hasidic, Hindu, Native American, Muslim, and Judeo-Christian traditions. It did, however, exclude illuminating stories such as Aesop's Fables, which might, in another setting, with another group of facilitators, be used with spiritual benefit. Here, it can be argued, why not use those stories that most likely reflect stories most familiar to the members of the group? Why, indeed, would one purposely introduce foreign and new materials to a group whose make-up is mostly of over-stressed patients? Our experience has given us two basic supportive tenents to do so: The Use of the Overfamiliar We would argue that for the religiously resourced patient, familiar stories are often too familiar to catch our attention. We have heard how this story comes out. Too often we have heard sermons and lessons about that story that just explain it away and leave us with some well-ascribed ethic we are to follow. Again, we are careful not to read too closely to ascribing to a code of conduct or convincing others of a point of view. In the Judea-Christian tradition, we trust that the Maker of the story continues to pursue the present listener with a call to wholeness as the nature of stories to heal unfolds. Many Images of God are Already Present Whether we are conscious of it or not, we believe that images of God are always present in the back of our minds. "Such imagistic symbols are part of the long-neglected language of the soul, part of our heart's accumulated repertoir of responses to God's constant presence. They come from a lifetime of impressions of what God is like. Mostly, these images remain hidden, helping or hindering our growth in grace, until we intentionally bring them to the foreground." 13 Further, Robert C. Morris suggests claiming such authentic God-images is the beginning of adult spirituality. Such images are part of what Baron
13

Robert C. Morris, "Face to Face," Weavings, Afournal of the Christian Spintual Life, 1997 (January/February).

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von Hgel, the great turn-of-the-century spiritual director, called our own personal attrait, or way of being attracted to God. Morris claims that out of a great panoply of symbols, only some connect one's own deepest self to the Divine.14

Why Use Sacred Stories as a Modality?

Of all the options open to the group leaders, it seemed more therapeutically effective to engage patients around spiritual concerns if these issues were presented a bit obliquely, even paradoxically. Stories seemed to do this especially well. Historically, shamans, holy leaders, preachers, and teachers have used stories to offer comfort, guidance and counsel. Sacred stories offer rich and symbolic images to trigger memory and imagination of both individuals and groups. Each symbolic image in sacred stories stands as a container for numinous energies, packed away until triggered into recall. Introducing images allows imagination to awaken. Like prayer, the use of the imagination allows us to hope in a new way. A kind of hoping has begun in stories of struggle and sacrifice and where the intervention of the Transcendent is sought. Often it is in the very presence of hopelessness that hope becomes alive. Patients are quick to give a name to their hopelessness, for it is often this very desperation that brought them to hospital admission. Sacred stories help patients communicate and change. Stories' concrete images give shape to the highly subjective and nuanced aspects of individuals' spirituality which may otherwise defy clear verbal expression. Issues such as forgiveness, courage, faith, hope, joy, purpose in life, and the meaning of community are intensely personal and can be hard to articulate. When the energies of the images in stories are released in story telling, hearers can recognize their own experience and where landmarks for them might point toward change . Finally, using sacred stories seemed the path of least resistance for discussing with psychiatric patients their spiritual issues. The use of spirituality as a therapeutic modality in any medical/scientific setting frequently raises questions among many health care professionals and not a few patients. This is especially true in psychiatric settings. In consultation with the interdisciplinary team, it was agreed that using sacred stories as a vehicle for spiritual discourse was relatively unlikely to exacerbate patients with spiritual concerns. The group leaders believed that if suggested through stories, spiritual issues would be more likely broached at the patients' initiative, met with less resistance, and therefore be more freely dealt with.

Detailed Methodology
The matter of hearing a sacred story and reflecting on it as a group sounds to some like simple work, and to some extent, it truly is simple. But before a group of psychiatric patients can be assisted through such an activity, a good bit of thoughtful ground work must be done by the group leaders as well as other members of the interdisciplinary team. Story selection, group process plans and patient screening are all components of this critical presession groundwork.
u

Ibid., p. 30

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Selecting the Stories The day before each meeting, the group leaders confer about the following day's story selection. Truly, there were times when the group leaders were unsure whether they chose the story, or the story chose them. Occasionally, the real appropriateness of a story did not reveal itself until the group process was well along. As experience with the groups increased, there was more intentionality about the types of stories utilized given the needs of a particular group of patients. For example, the more highly functioning the group, the more metaphorical the story could be. Though it was a vague criterion, intuition played an important role in story selection as well. As stated earlier, a commitment was made to the rest of the psychiatric team to be inter-faith in approach. Members of the psychiatric team, (particularly those from less familiar religious traditions) were enlisted to share their sacred stories. Additionally, interested staff persons pointed out books which often contained additional stories. All this heightened staff interest and ownership of the group. Stories are selected by several criteria. First, a story must simply be interesting. It must have all the traditional elements of any good story: an exposition, a complication, a climax and a denouement. A selected story must have sharply drawn figures which have a good chance of eliciting some helpful emotional response from the patients. Finally, the story must be brief, with no more than five hundred words. Attempts were made to select stories which generally point toward issues of hope, strength, courage and enhanced relationships. These are, after all, the key elements in the leaders' working definition of a helpful spirituality. Care is taken to avoid, as far as possible, stories which might exacerbate patients. Nursing and medical staff were consulted about such stories when in doubt. In general, stories were avoided that were disturbingly violent and those that simply seemed bland. For example, the story of Abraham nearly slaughtering his own son, or ofJephtha sacrificing his daughter, were both ruled out. Also avoided were stories presenting only male champions. Interestingly, as already pointed out, it seemed that the non-Christian stories worked better in this setting than Christian ones. Apparently, using more unfamiliar stories allowed everyone in the group (facilitators included) a larger measure of playfulness, objectivity and creativity in interpreting the sacred stories. New stories presented us with a cleaner slate to draw upon and set the stage for the element of surprise. Crafting the Questions After selecting the story for the day, work is done crafting questions which will be asked after the story is read. Consideration was given to the idea of not planning any questions at all and letting the conversation flow free. While this might work in other settings, it has seemed ill-advised on this psychiatric unit since many of the patients need the focusing power of direct questions to help them "stay with the story." The structured discussion format also provides them a level of comfort that would be missing in a more free-form setting. Though the questions asked are scripted and focused, group facilitators nevertheless feel free to digress into unplanned topics, depending on the functioning level of that day's group. Group leaders begin by generating a larger number of questions before 359

the meeting than thought necessary, ranking them according to their potential importance and impact. Then, as the group process unfolds, the facilitators decide in the moment which questions to ask and which to skip. This offers the facilitators more freedom and increases their ability to match questions to the needs of the group. Group questions tend to fall into two types: those which are closed ended and serve mainly to assist patients in paying attention to the details of the story itself; and questions which are more thought-provoking and open-ended, designed to help patients grapple with the personal meaning they find in the stories. When the Buddhist story, "The Mustard Seed," is used (referenced earlier) , the following may be asked: "With whom did you most identify in the story? Have you ever seen a mustard seed before?" These closed-ended questions focus the patients' attention on the details of the story. Leaders also ask thought-provoking, open ended questions that illuminate patients' sense of meaning and existential states. These are questions like, "Is there anything about this story that troubles you?" "What is the good news of this story for you?" and, "How does this story give you hope?" The chaplains are very careful not to intentionally superimpose their own meanings onto the stories. Because of this, patients' interpretations of the stories can be quite unexpected and fresh. The story of "Joshua and the Wall of Jericho" was a particularly arresting example. To a number of that day's patients, Joshua came across as the villain in this story, pulling down the walls of people who'd really done nothing to provoke this behavior. That particular session unfolded into a dialogue about the function of participants' personal walls: "What are they for? What do they look like? Who do we let in and who do we keep out?" The Muslim story, "Hajar and the Miraculous Well," is a story where Hajar and her baby son are abandoned in the desert and an angel miraculously provides them with life-sustaining water. This session featured conversations about dealing with betrayal and abandonment. It also produced conversations about maintaining faith in God even in times of desperation. A very popular Native American story, "How the Coyote Got His Name,"15 focuses on how various animals sought the help of the Spirit Chief to find a name and role for themselves in the world. Here, questions arose about Who/What each person's Spirit Chief, or guiding life force, was. The group also talked about favorite nicknames and how they represented parts of participants' personhood. Also, as an outgrowth of this story, participants talked about inherent personality traits which were somehow useful in day-to-day community life. Over time, two closing questions have been designed to help patients summarize their reflections and assist them in thinking about life after discharge. These questions are: "What is this story really about?" and, "What will you take home with you from this story?" Sometimes, patients are disappointed and maybe a little frustrated that the leaders do not take a more doctrinal, "tell it like it is" approach in group questioning. It seems that this is what some patients have come to expect in spiritual settings. Still, it was believed that a more open-ended, questioning approach leads not only to more honest dialogue, but also
15

Ibid., pp. 72-73

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models an acceptance of others which is foundational for good mental and spiritual health. Screening Patients for Participation Care clearly needs to be taken in determining who should be actively encouraged to attend the spirituality group and who might be adversely affected. The issue of screening patients for participation in the Spirituality Group is an interdisciplinary matter on the unit and takes place on many fronts. To accomplish this, a chaplain attends the Multi-disciplinary Treatment Conference each week to solicit feedback from other team members regarding specific patients' Spirituality Group attendance. A chaplain also attends the weekly Community Meetings (which all patients and staff attend) to assess patients' interactions with others in a group setting. This observation helps a great deal in judging their appropriateness for Spirituality Group participation. Also, a chaplain attends occupational therapy sessions three times a week and another co-facilitates one of the patients' twice-weekly focus groups. In the Occupational Therapy Clinic, patients and chaplains get to know one another in a low stress environment. Such face-to-face encounters not only assist the chaplains in screening for the Spirituality Group, but also help some patients feel more comfortable risking group attendance by virtue of their heightened familiarity with one of the group leaders. Since patient attendance at all meetings is ultimately voluntary, intentional efforts are made to help patients self-screen as much as possible for this group. During the calendar review portion of the Community Meeting on the day of the Spirituality Group, group facilitators provide the name and faith tradition of the day's story. The Group's "commercial" goes something like this:
The spintuality group is at 3:15 this afternoon in Room 722. This is not a worship service, not a prayer service and not a preaching service. No one will attempt to change what you already believe. In this group we take a story from one of several religious traditions and we reflect together on it to find what things give us strength and faith and hope. Today's story is a Native American one called "Grandmother Spider Brings the Sun. "

It was learned that this procedure helps patients make informed decisions about Spirituality Group attendance. As this group has become one of the standard scheduled groups, "word of mouth" by other patients has been instrumental in increasing attendance. On the day of the group, the chaplains meet with the psychiatric clinical supervisor and compare notes about who should attend the group. At this point, the chaplains and clinical supervisor also do some final strategizing around specific patients' needs. Excluding those for whom the group is contraindicated, all patients on the unit are invited to attend. Generally, three quarters of the patient census shows up for the Group. Using the DSM TV,16 an additional screening tool was developed listing diagnoses which could be considered for inclusion in the group. It was decided that patients with the following diagnoses could benefit from the Spirituality Group:

^Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (Washington, DC: American Psychiatric Association, 1994).

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Substance Abuse Related Diagnoses Mood Disorders Anxiety Disorders Somatoform Disorders Sexual and Gender Identity Disorders Eating Disorders Sleep Disorders Personality Disorders Adjustment Disorders (usually found in the out-patient population) Patients with the following diagnoses may benefit from spirituality group, but will require close scrutiny: Thought Disorders/Schizophrenia/Paranoia Borderline Personality Disorder Attention Deficit Disorder However, persons with the following diagnoses are not allowed to attend the Spirituality Group until their status changes: Active psychotic episode Dementia Mania Dissociative Disorder

Group Process
The group is scheduled weekly in the late afternoon, but well before dinner and is held on the Psychiatric Unit in a large, comfortable group room with a large marking board. The Group process is relatively simple and attendance is voluntary. Chaplains explain the purpose of the group, remind the participants of behavioral ground-rules, facilitate introductions, tell the story and engage the group in the reflective questions pertaining to the day's story. If anyone leaves the group early for any reason, it is the responsibility of one of the chaplains to check with that patient before leaving the unit to ascertain why he or she left the group early. If consultation with the patient is needed, it is arranged at that point and documented. Not infrequently, participants in the group will want to confess something. Confession in this context refers not only to admission of wrongdoing, but also the public statement of some core belief that has been challenged during a time of crisis and now, as a way of affirming its validity, needs to be spoken aloud before others. This is particularly common among chemical dependency patients who need to continue processing hurts they have inflicted on themselves and others as well as affirm the progress they have made so far. Before the patients leave the group, they are asked to complete an evaluation form. This form is useful not only in determining how the patients evaluate the Spirituality Group experience, but also in discerning what specific spiritual issues they find compelling. The Group leaders have found that a short, private debriefing after the group's conclusion is helpful for assessing that day's group and in planning future sessions. They are often joined at this point by the unit's clinical supervisor. During this interchange, energy is usually still high and the
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group leaders feel creative. It is during this debriefing session that the unit's clinical supervisor sometimes gains new insights into the patients' spiritual lives while the information is still fresh. After the group has concluded and after dealing with any individual patient concerns, chaplains document the patients' participation in their individual medical charts. Documentation focuses on the level of the patient's involvement in the group and any pertinent issues which were discussed. Naturally, care is taken to ensure confidentiality. Further, if a patient had a particularly powerful emotional experience or moment of insight, this would be shared with the nursing or physician staff.

Outcomes of the Spirituality Group

Patients report that the Spirituality Group is helpful for them because they feel some competence there. They are not directly taught anything. In addition, it is an occasion in which staff and patients participate in a discussion on a more even footing as opposed to the more common helper/helpee paradigm. Patient benefits of the Spirituality Group are summarized as follows:
The group provides a forum for spirituality to act as a healer. It provides a place for exploration of beliefs, cultures and values in a non-threatening environment. The stories give shape to highly subjective material that might otherwise defy verbal expression. It offers an opportunity for patients to ask for individual spiritual guidance. It facilitates emotional healing by providing patients an opportunity to be in touch with their memories of wellness. It gives patients an additional chance to participate in an interesting, informative, and pleasant group experience.

Adding chaplains more intentionally to the psychiatric milieu has, of course, changed the team's group dynamics. This inclusion has presented the challenge of accepting still more differences and perspectives of other professionals which transfers to the acceptance of the differences of the patient. As well, new modes of conflict resolution and problem solving have been incorporated into the team process now that the chaplains are a routine part of the mix. All of these qualities are necessary to establish a wellbalanced team. As with the patient benefits, team benefits can be summarized in the following way:
The new inclusion of the Spirituality Group and chaplains have helped the psychiatric team embrace the mission statement of the hospital. T h e Spirituality Group allows the Unit to meet the requirements of the Hospital's various regulating agencies. Inclusion of the chaplains has challenged the multi- disciplinary team to negotiate roles with new members. Enhanced partnerships with chaplains has established new professional interaction patterns within the team. Their presence on the team has challenged the chaplains to be more interdep e n d e n t with the team, rather than independent.

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Heightened attention to spirituality issues means that the team now focuses m o r e of its planning on values, beliefs and religious and cultural issues Adding new team members and programs to the present psychiatric milieu has had an energizing effect on the whole team Stones have become, for the group leaders, a place where living souls go to living waters that touch the heart and where the self can become clear and strong again The Group's foundation was this "When at least one soul remains who can tell the story and that soul recounts the tale the greater forces of love, mercy, generosity and strength are continuously called into 17 being in the world" *t Clanssa Pmkola Estes, The Gift of Story A Wise Tale About What is Enough (New York, NY Bal lenirne Books, 1993), 10
17

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