hindsight-02Qualitative Values in a Quantitative World:

Changing My Mind (A Little)

by Mark E. Jensen, Ph.D.

Introduction

The editors have asked some of us to say, in a relatively short space, some things that are on our minds as we are "mid-career." I heard a fine address by Maxine Glaz a couple of years ago, as she was looking at retirement, the title of which included the phrase "Making Up My Mind". Her focused topic (psychopathology) was quite different than these reflections, but there is a similar theme. I want to offer some comments about how my mind continues to be made up on one aspect of the intersections of religion and medicine.

If I've learned anything since I left graduate school, it is the pervasiveness of social location and context on the concerns one has, and the ways they get framed and worked out. While no one wants their ideas to be accounted for (or minimized) simply by a set of categories (white, male, etc.), perhaps no one should be writing without a word to readers about some of the important contexts which shape and inform them. When I wrote my dissertation, I was interested in how people came to sense of purpose, or vocation, in the world. Academically, I was interested in how pastoral theology and theological ethics might have a more fruitful dialogue, particularly through the exploration of narrative. The clinical context in which I was working then was as a chaplain to a cancer unit. I was convinced that the context of terminal illness (or a diagnosis that often symbolized terminal illness) was not "unique," but perhaps epistemologically privileged: these persons had a lot to teach the rest of us if we knew how to listen.

My day to day professional life today is as an educator, a clinician, and an occasional researcher/writer. I help supervise students in a large Clinical Pastoral Education program at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. I teach in a new Divinity School and an old Religion Department, both at Wake Forest University. I do some pastoral counseling, and I do some collaborative research with interdisciplinary colleagues (physicians, psychologists, public health academics) at the Medical Center. Related to the research portion of my work, I serve on the Institutional Review Board for the medical center, a group responsible for reviewing research involving human subjects. I do education at the crossroads of science and the humanities, graduate and undergraduate curricula, academic and professional curricula. I am married to an educator (a public school master teacher of learning disabled students). We are parents to two daughters, ages 15 and 12, whose headlong investment in the world gives us pause, joy, and high mileage.

While I was born and reared a Southern Baptist, the denominational wars that began in the late 1970s eventually gave me the gift of my leaving that denomination to wander in the creative wilderness of liberal baptist dissenters.

Now, about those things on my mind.

Researching Religion and Health
in an Academic Medical Center

Most of my training and many of my instincts, both academic and clinical, in the conversation between ethics, psychology, religion, and things medical, are in the conversation between Christian theology and the depth psychologies, the humanistic psychologies, the transpersonal psychologies, and the contemplative Christian tradition. In the last dozen years or so, a lively literature, both popular and academic, has sprung up purporting to combine religion, or spirituality, and medicine. Some of the "early" wave of this literature (around 1990) came from epidemiological research and literature reviews that set out to demonstrate: 1) that religion (later broadened to spirituality) had been left out and/or maligned in the medical literature; 2) that religion (briefly and variously defined) showed some positive health effects. Following and alongside this literature came a movement to educate physicians not to ignore the religion of their patients. This movement held that physicians should know how important religious resources were to their patients. Some wanted physicians to know how to listen to spiritual concerns that affected medical treatment. Some wanted religious histories to be part of the standard medical interview. Some wanted physicians to be able and willing to utilize religious resources (such as prayer) with their patients.

Although I was on an interdisciplinary team that won early funding from the Templeton Foundation to address these issues in medical school curriculum, for several reasons I sometimes found myself in a curmudgeonly mode in these discussions. First, I thought the ways in which "religion" was measured in the epidemiological studies had little depth, texture, or sophistication. Second, I feared that physicians would go from neglect of the topic to a kind of triumphalism that would lead them to believe they could master or had mastered subtle assessments related to their patients' inner worlds. Third, I found discussions of the ethics of physician-patient relationship, particularly the issues of professional or role-based power, absent or glossed in the rush to have physicians attend to their patients' spiritual needs. Fourth, my clinical work put me in immediate touch with persons whose experiences with religion had been abusive or conflicted; I knew the methods of the epidemiological studies were not yielding those findings, and the zealots "rehabilitating" the image of religion in the medical world didn't want to hear it. Fifth, the literature that was emerging evidenced almost no knowledge of or concern with the history and contributions of the psychology of religion. Finally, currents in pastoral theology, with the help of feminist and liberationist critical theologies, were moving to radical understandings of the socially constructed nature of all linguistic systems. Pastoral theology was composing in a postmodern key, and few things partake of modernist paradigms more than the canons of medical research (whether in epidemiology or clinical trials).

But didn't I say I wanted to describe how my mind was changing? Well, here's how. I'm realizing that few people in an academic medical center care to engage discussions about postmodern epistemologies (even if they are affected by them--witness the boom in complementary therapies), the unconscious, or splits in God and self-representations. I decided that being more conversant and involved in empirical (modernist) efforts to explore the relationship between spirituality, religion, and health, was the best way to influence the discussion in this context.

Perhaps such a stance reflects less a change in mind as a change in strategy. But just as the personal is always political, so the political becomes personal. I have become involved in several modest research initiatives across the medical center exploring this "new" old frontier. In each case, our team is exploring some question via measurement through surveys of attitudes, religious coping styles, religiosity/spirituality. In two of the three cases, these measures of something religious are being correlated with a health outcome of one type or another. In the one case where health outcomes are not measured, we are seeking to find when and how religious/spiritual ideas, practices, or values come into play in end of life decisions in an intensive care setting. In all three of the projects in which I am involved, important clinical questions are being pursued.

What am I learning? First, I am learning that the involvement across disciplines in a joint project is more important than the particular research method being used. That said, my ticket to a seat on these teams comes only in part from my being a minister/chaplain interested in these matters. It comes from being conversant (notice I did not say expert) in the methods of empirical correlational research methods. That has required some brushing up on matters of design and statistical analysis. In the doing of these projects, connections are made that transcend either method or finding of the particular study. When that happens, professionals, disciplines, and ultimately persons entrusted to our care benefit.

Second, I've rediscovered that a rigorous statistical analysis often has a capacity not only to lead us to accept or reject the null hypothesis, but to present surprises (often first seen as "anomalies" or "outliers") that confront our biases, and lead us to look again. While in some ways quite different from my clinical involvements, I keep experiencing a remarkable parallel to my love of the intrapersonal and interpersonal surprises that emerge in pastoral conversation, tapping us on the shoulder with an impish grin or threatening grimace.

Does that mean that chaplaincy is becoming or should become, as Larry Vandecreek suggests, an evidence-based profession instead of a tradition-based profession? Larry and I have lively conversations about this, and I have to give him enormous credit for framing the question this way. I still find myself somewhat uneasy with that proposal (subject for another essay on another day), but I will agree that we have not yet begun to see half of the benefit from utilizing empirical, correlational methods in our theory building and work with other professionals. Being bi-lingual gives one credibility beyond the "safer" approach of remaining smugly tucked in our methodological compounds wishing the world would come see what we have to offer.

As the current discussion in medical literature about spirituality and health is beginning to enter a more sophisticated phase, here is the main lesson for me. The most effective "intervention" (a phrase which, in my most curmudgeonly and postmodern mode I object to) is the one that has physician, social scientist, chaplain, and pastoral theologian struggling together to answer tough questions. We find common ground in our most compassionate humanism, not in our ideological or methodological commitments. My search for an all-embracing theory (better than mere modernist empiricism) is my problem, or hobby, or idiosyncrasy, and need not be inflicted on persons not so inclined.

And no, I don't have to leave behind my other favorite theories or concerns. My old interest in ethics, narrative, theology, and illness lives. Standing behind and alongside some of the research in which I am now involved is a profound appreciation for the work of Arthur Frank in his book The Wounded Storyteller. Frank writes with both wonderful style and an intellect and consciousness quite conversant with postmodern insights and conundrums. He sees the body as gift, medium, and problem (and implicitly challenges medicine and theology to come to grips more clearly with these realities). With appreciation for the achievements of modernist medicine, he eloquently documents the dilemmas of persons constructing identity in and through illness. Their plight is often "narrative wreckage." The wreckage occurs not only because of the interruption and devastation that illness can cause, but because modernist medicine becomes the sole author of the story--the ill person gets deprived of voice. The "restitution narrative" is the form of the story most preferred by medicine, culture, and patients seeking relief. Here's the rub: it doesn't always work, and it is a story written entirely by medicine. The only possible role for the patient in such a story is compliance. What happens when cure is not possible? Frank documents and argues for the existence of two other narrative forms: the chaos narrative and the quest narrative.

Lest I convert this into a review of Frank's book, I will return to the point it helps me make. He gives language to intuitions and realities many of us see and work with. His wonderfully textured argument cannot be translated or reduced to a logistic regression analysis, or can it? Of course it cannot, but the consciousness sensitized by methods, insights, and narratives like his can inform one or more of the persons at the table working on clinical problems, even if they are working on them in a modernist empirical mode.

After all, data only has meaningful life when woven into theory. The difference between useful theory and good narrative is less than meets the eye, and our culture needs clinicians in whose eyes, hearts, and minds narrative, theory, and data can have a useful meeting.

 

Author:

Dr. Mark Jensen is Chaplain Supervisor at the Wake Forest University Baptist Medical Center, Adjunct Professor in the WFU Religion Department, and Adjunct Professor of Pastoral Care for the WFU Divinity School. He is also currently the Chair of the Mid-Atlantic Region of the Association for Clinical Pastoral Education. His doctoral dissertation, completed in 1988, is titled "A Pastoral Theological Study of Vocation.”

Must Reading

Arthur Frank, The Wounded Storyteller: Body, Illness, and Ethics. University of Chicago Press, 1997.

Barbara Kingsolver, Poisonwood Bible. Harper, 1999.

Kenneth Pargament, The Psychology of Religion and Coping; Theory, Research, and Practice. Guilford Press, 1997.