A vital approach

Spiritual support for terminally ill patients of all religions is becoming more prevalent, even in hospitals.

Chani Kroizer 311 (photo credit: Marc Israel Sellem)
Chani Kroizer 311
(photo credit: Marc Israel Sellem)
‘ATalmudic saying states that the Divine presence always rests above an invalid’s bed,” says Chani Kroizer, head and founder of the spiritual support program at Shaare Zedek Medical Center. “I once had a Muslim patient, and although I have a bilingual edition of the Koran, I wasn’t sure there was an equivalent of that concept in Islam. He told me of the tradition of a man who said to God on Judgment Day, ‘I was sick, but You didn’t come to visit me.’ That was an excellent opening for me to work with this patient, starting from a mutual belief regarding the condition of the sick,” she says.
But what if the patient is not a believer? Kroizer replies with an example. “I had such a case. I asked the man if he could feel that in a sick person’s room there was an additional presence or feeling, not necessarily a Divine presence but something beyond us. These are the points from which I develop a personal contact to work with terminal or very sick patients, and create a spiritual atmosphere in which to reach them.”
The ultimate stage of life that leads to death is a profound and significant moment, with an obvious advantage for those who have religious beliefs. Modernity and the era of rationalism may have led us to think that this is no longer the case, but for various reasons it seems that the current situation is taking the opposite direction. From chaplaincy in Western armies (especially Britain and the US) through New Age theories, and now, connected to the Jewish renaissance witnessed in Israel, death is no longer merely a tumultuous or inevitable situation but rather a spiritual experience for the one who is dying, as well as for the family.
Whether it comes from some modest realization that modern medicine doesn’t hold all the answers or a genuine need that our post-modern epoch gives expression to, spiritual support for terminally ill patients has become much more than a trend. Be it rendered to the medical staff, the patients or their families, it is gaining more and more prominence in our society, Jewish as well as non-Jewish.
Spiritual support is a versatile phenomenon. It can be verbal, textual, artistic or simply shared silence. It allows the patients – critically ill or at the terminal stage – to experience a controlled but candid openness to issues that have been repressed for a long time.
“We don’t approach the patient with a set agenda; we are totally open and ready to be led wherever the patient needs to go, but with our support,” explains Nomi Miller, a spiritual supporter at Shaare Zedek.
“There is no therapy room. Sometimes I sit at the edge of the patient’s bed – mostly at a lower level or even at the same level, but I am never higher than the patient. That is a basic requirement.”
Miller, a psychotherapist, says her intervention can range from a moment of silence together to poetry reading, singing or reading and interpreting a text.
“Sometimes we do exercises together in breathing and meditation, holding hands, hugging – anything that I feel my patient needs.”
Chani Kroizer was a young mother of three, moderating study groups at the Elul pluralistic beit midrash for years. “It was in the early 2000s that I started to work with a group of advanced students in Jewish texts,” she recalls. “The topic was ‘sickness and recovery,’ which in Hebrew come from the same grammatical root. The aim was to produce written texts out of our studying. In this group we had psychologists, doctors, a criminologist, a philosopher. It was a very intensive program for two years, and before it ended it became clear to me that I had reached the point where I wanted to go beyond the beit midrash, which had become a kind of a laboratory for me, to touch real life, to encounter the deep and serious issues we learned about in the group. I first went to volunteer at the Hadassah Hospice on Mount Scopus – a place I hadn’t heard about until then. And I began to get closer to the issue of terminal patients’ needs, beyond the medical care given.”
AT ABOUT the same time (in 2004), Jonathan Hudnick, a rabbinical student at the Schechter Institute of Jewish Studies, who came to Jerusalem from Kansas City, introduced the idea of spiritual support at Shaare Zedek, which, though a totally unfamiliar concept here, was welcomed by Dr. Nathan Cherny, director of the cancer pain and palliative care service in the hospital’s Oncology Department.
Cherny immediately recommended that a training course be offered in house, based on the model of clinical pastoral education (CPE) being implemented in the US. According to the Association of Clinical Pastoral Education, the method is interfaith professional education that brings theological students and ministers of all faiths into supervised encounter with persons in crisis.
Less than a year later, the first pilot training course was launched at Shaare Zedek, with four students – two rabbinical students from Schechter, one from Hebrew Union College and Kroizer. The course, which lasted one year, included practical work with the hospital patients. Today, it is a two-year course that includes practical training and personal consulting.
The current course, which began in September, is the sixth course and has six students. The program is codirected by Kroizer and Dr. Noa Bar-Shalom.
Today, various forms of training courses in spiritual support are given at Shaare Zedek, the only in-house course of this kind given at a hospital, as well as courses at Hebrew Union College, the Schechter Institute and, recently, Herzog Hospital.
“While the original idea derives from the chaplaincy known in the West, we have adapted it to our needs and to the Israeli voice and character,” says Kroizer. “After all, hospitals are a kind of ‘ex patria,’ and we do not work from a religious set of values but rather with a human attitude and approach, looking at every person as simply a human being. For example, in my private life I wouldn’t pray with a non- Jewish person; but here, as a spiritual supporter, I can pray with a Muslim or a Christian patient because it is part of something different, and the prayer is not the kind of prayer we say in our respective faiths.”
“We focus on helping the patients find meaning in their life as they approach its end,” says Miller.
“Sometimes it is a work of reparation, and sometimes it is aimed at helping them renew family ties.
Sometimes it allows the patients to say things they had never the opportunity or the courage to say before. In some cases, they will ask for me to be present because it gives them strength to do what they feel is the right thing at that moment. I would say it is a tailor-made support because we work on a very individual track. We look for what the patient needs at that particular moment; it has nothing to do with therapy, which takes much longer. Here, it might be a one-time encounter.”
One of the questions raised by this new approach is the issue of training or who is eligible or entitled to be a spiritual supporter. Despite the fact that she is a professional psychotherapist, Miller says that such a background is not necessary.
“In spiritual support training, one gets the tools needed to administer spiritual support, which is not psychological support. It uses a totally different approach. You learn to accompany someone, not to heal through therapy,” she points out.
IN ONE of the cases she worked on, Miller met a woman with cancer. “She was flanked by her daughter and her husband, and I offered my services. That is how we always proceed. The husband and the daughter went out, and the woman and I were left alone in her room. She told me about her life and said that as a devout believer, she felt confident she would get better.”
The second meeting took place two weeks later, Miller recounts. The doctors decided to start a series of chemotherapy treatments, which caused the woman’s physical condition to deteriorate. Miller remarked that in spite of her pain, the woman asked Miller how she was feeling. In response, Miller asked the woman where she got her strength from.
“I am used to helping others but not so much to care for myself,” the woman admitted, adding, “I can hear my mother’s voice telling me that everything will be fine. She used to speak to me by using old sayings and proverbs, and now they are all coming back to me.”
Miller decided to use that as a thread to go further and asked the woman if it was like old melodies from childhood memories. When the woman said it was, Miller took another step forward and suggested that they read a prayer text together that she probably also remembered from childhood. It was during the days of slihot preceding the High Holy Days. Miller pulled out a sheet of paper and, holding hands, they began to read together the prayer of the sick asking to be healed.
The woman asked Miller, “How did you know that it was exactly what I needed right now? I grew up in a religious family, but over the years strayed from it, and our daughters went to secular schools. No one but me still remembers these things at home today.”
At that moment, the daughter came into the room, and the woman invited her to join them in reciting the prayer, which the girl was evidently doing for the first time. Miller discreetly stepped out of the room to let the two experience that moving moment together.
“It is, in fact, chemotherapy for the soul,” says Miller.
She admits that after three years of working as a spiritual supporter she sometimes feels emotionally drained, and is grateful to have the opportunity “to give back some of the treasures I have received from life.”
Rahel Attoun created the Mazorim program at HUC through the HaveRuth organization, named after her daughter Ruth, who died of cystic fibrosis when she was 11 years old. Attoun’s program is not aimed at supporters but to provide tools to help the caregivers in various disciplines.
“For a long time, the spiritual dimension had been avoided in Israel because of the religious context,” she says. “So we take the pastoral structure and give it an authentic Israeli voice to enable patients and caregivers to approach the spirituality that lies in all of us – sick and healthy.”
In fact, Attoun says that a spiritual approach to life should be the aim of everyone, not only patients and therapists.
“Israeli society is not yet ready to overcome stereotypes on the spiritual issue or to accept that there is a need for such support.
However, we can see some first signs. For instance, in a study group I moderate at [beit midrash] Kolot called Crisis and Tikkun, we train people who are in the caregivers circles. The number of participants is increasing all the time, so I can say that the awareness is growing.”
CRITICISM OF the profession may come from various directions.
Besides the reservations expressed by medical staff to what is perceived as an expression of New Age – something all those involved categorically reject – there is serious concern about the lack of academic therapeutic training of these spiritual supporters.
“We are absolutely not connected with New Age theories,” says Kroizer. “Nevertheless, it is clear that these new winds have prepared the atmosphere for what we propose. In this context, we have certainly arrived at the right moment, when people are ripe to listen to what we propose.”
Regarding the concern about the lack of academic training, Kroizer explains: “We do not require a therapeutic background from our students simply because our aim is not to heal or to offer therapy of any kind. We are here to accompany, to support, to give strength through spirituality – and that is very different.”
Dr. Inbar Cohen, a psycho-oncologist, is trained to work with the terminally ill. Although she is not opposed to rendering spiritual support and personally knows and respects most of the people involved in spiritual support, she says she still doesn’t really understand what it means.
“The palliative aspect is indeed growing. We can see that in the different attitude toward pain or discomfort of the terminally patients,” says Cohen. “Following Elisabeth Kubler-Ross’s writings on these issues in the late 1960s, medical circles have completely changed their approach regarding the appropriate way to accompany people who are close to death. The discipline of psycho-oncology was born there, including a transcendental look at imminent death, the way to prepare people to die, the search for meaning, the need to clean the slate before departing.
We all are fully aware of the changes in society and in the medical profession toward these aspects. But still, the whole issue came to us through the chaplaincy, which is a religious, Christian, Catholic perspective on life and death, though we are aware that it has reached the Jewish communities in America.
“In the early 2000s, it reached us in Israel,” she continues. “In psychology we work with the patient through the issues that concern him, regarding his life that is reaching its end – what bothers him and what needs to be done, as well the relationship of the dying person with his family members. As I understand it, spiritual support does the same but mainly through texts. But the major problem, in my view, is that not all the spiritual supporters have a therapeutic background, even if they don’t use it for the work they do. As a psychologist, I am concerned by those who don’t have such training. What happens if a [difficult] situation develops? What tools would they use to handle it? I don’t know.”
Cherny says that spiritual support is an inseparable part of the palliative treatment used today in most hospitals and care centers.
It includes the emotional, spiritual and social aspects of the patient’s condition and that of his family. “It requires special tools and knowledge, especially when facing patients who are suffering from incurable illnesses.”
Cherny says that in his opinion, there is no way to separate the medical aspect of the treatment – surgery or any other medical procedure – from the attention paid to the spiritual and emotional needs of the patient. “What we have here is a multidisciplinary department that decides upon a specific comprehensive treatment for each patient, adapted to his or her specific condition and needs. Sometimes there is more focus on the spiritual aspect, and other times we emphasize the physical issues, but they are all different aspects of the same medical approach.”
Today this is part of an international attitude in medicine, according to Cherny. Last year, the Health Ministry issued a ruling inviting all hospitals to create their own paramedical department within four years, and soon the same will apply to the health funds.
“You can heal a person, but if you don’t pay attention to his will to live, if you don’t find ways to restore meaning to the life that has just been saved by medicine, then what have you accomplished?” Perhaps Miller puts it best: “We work on small hopes, small achievements – how to overcome a bad moment, how to enjoy a favorite dish when the digestive system isn’t functioning at its best. That is not therapy, that is the essence of being there for someone who needs it at a very special moment in his life.”