We All Cry Salt Water and Bleed Red: Spiritual Care in a Time of Crisis

Podcast Transcript

Adrienne Boissy:  Welcome to the first episode of Studies in Empathy: A Cleveland Clinic Podcast exploring empathy and the patient experience. I'm your host, Dr. Adrienne Boissy, Chief Experience Officer here at the Cleveland Clinic in Cleveland, Ohio. I'm very pleased to have Dr. Amy Greene here who is master of all spiritual care here at the Cleveland Clinic. Welcome to Studies in Empathy, Amy. Thanks for joining us.

Amy Greene:  Thank you.

Adrienne Boissy:  Tell me about who you are and your roles both here and nationally.

Amy Greene:  I'm director of spiritual care here, which is a broad term here, meaning I'm in charge of the chaplains as well as healing services which includes holistic nurses and also the chaplains are part of that. Then we also have family liaisons who are the “what’s next people” at the point of death. They cover the paperwork and help families take the next steps. As soon as they've lost a loved one, they often don't know literally, what do we do next so that's the “what’s next team.”

Adrienne Boissy:  You also have this healing services program, we'll talk a little bit more about. Then you have an interesting role nationally that our audience might be interested in hearing about, tell me about.

Amy Greene:  Right. I'm currently the Board Chair of ACPE, which is a 50 year old organization that is the standard bearer for spiritual care and education. It's the organization that has been mostly responsible for the training that chaplains do in the institutional setting. Chaplains are clergy people by and large, not entirely, not exclusively, but mostly clergy people who have selected to work in institutional settings rather than in congregational settings and therefore they need clinical training. The Association for Clinical Pastoral Education is the oldest and most widely known of the training groups and I'm Board Chair of that right now. I'm very honored to be in that position.

Adrienne Boissy:  It's like a whole new world to learn about.

Amy Greene:  Yes.

Adrienne Boissy:  Tell me, a lot of people I think get confused and I appreciate your definition about what a chaplain does and who they are. Tell me a little bit more about their training so that people understand how they play in healthcare systems and what's a typical day like, what do they actually do?

Amy Greene:  It's a great question because a lot of people don't understand that we're part of the healthcare team. We're full-time employees and we are specially trained to be working in the healthcare setting and sometimes another institutional settings, but largely hospitals and hospices use a lot of chaplains. We're ministers, but we always say that we're ministers whose faith is our motivation but it's not our agenda. We're different from congregational ministers and that we're not trying to bring more people into the fold. We're there to meet people where they are to help them find their way of coping. You may not even be religious. More and more people refer to themselves as spiritual but not religious and many people still refer to themselves as both to some degree. When people have questions of meaning and purpose and faith and hope, and some of the more ineffable categories that very much get impacted by illness and loss and death and very much get brought to the forefront of their minds when they're in crisis.

They want someone whose job it is and whose training it is, and whose vocabulary is familiar to them to help them make sense of what's happening to them, to pray with them sometimes, or just to talk to them and listen to them while they make their own way back to courage. We're not there to give them our answers. We're there to listen to them while they remember or come up with some of their own new answers or new guideposts. If I'm a patient and I'm of Jewish faith or I'm a Catholic or however you identify, I'm a Muslim. Can I call spiritual care in a hospital or do I need a special person to come see me? How do you meet that? Absolutely. In most hospitals now I would say that have professional chaplains, and depending on how well their training embedded, they should be able to send a person to care for anyone of any denomination without expecting any sort of proselytizing or imposition of their own religious beliefs.

Adrienne Boissy:  Don't use those big words with me.

Amy Greene:  Okay, not trying to turn you into a Catholic. If I send you the priest, it's because you wanted a priest.

Adrienne Boissy:  Got It.

Amy Greene:  If I send you a rabbi it's because you wanted a rabbi.

Adrienne Boissy:  Okay.

Amy Greene:  For the most part, people don't really care what our religious preferences. We do have here at the clinic, lots of people on staff. We have Jewish folks on staff, we have a Muslim chaplain now. We have Catholic priests available to us at the will of the diocese. It's wonderful for us when people do have a specific sort of ritual need. They will call for that and we will do everything in our power to get it to happen. We have local clergy. I'd like to say we have a black book with everyone from the Amish to the Zoroastrians. We have had people call and say, "I really want to talk to a Zoroastrian because that's our religious tradition."

Adrienne Boissy:  What is a Zoroastrian?

Amy Greene:  It's out of Iran, formerly Persia. It's an old, old religion. That's a very cool religion. I'll send you some stuff about it.

Adrienne Boissy:  Great. See, I'm learning.

Amy Greene:  Wonderful people, but for the most part they don't really mind. They just want us there to be with them in their crisis and speak with them respectfully.

Adrienne Boissy:  Let's talk about that. I want to incite into your brain a little bit to understand how similar or different are the needs of people who you're serving.

Amy Greene:  That's a great question because I think they're really overwhelmingly similar. I often say we all cry saltwater and we all bleed red. Regardless of the other differences that we have, when we have losses, when we have pain, when we have fear, when we have anxiety about our health or someone else's health, our loved ones, the unknown. These things come as interruptions to our life and we feel put upon. Some people feel punished by God, some feel punished by the universe. Some feel just angry, confused. Why me? I don't want to digress too much, but I think Buddhism has a lot more to say about just the general reality of suffering so that there's not as much surprise about suffering. It's more seen as a reality and part of life.

Adrienne Boissy:  I'm going to interrupt you there. There was this great moment in, "When Breath Becomes Air," this book with Paul and Lucy Kalanithi about suffering occurs when there's an expectation that it won't occur.

Amy Greene:  Exactly.

Adrienne Boissy:  Then when it does, that tension creates that moral distress and that suffering.

Amy Greene:  That's exactly right, and it's very Buddhist. We actually cause ourselves more pain when we say, "Oh, you know, this rock fell on my head. Why did the rock fall on my head?" Well, rocks fall and we have heads and sometimes rocks and heads collide. We always are looking for a deeper meaning or deeper purpose for why the rock fell on my head.

Adrienne Boissy:  I hear that from patients all the time.

Amy Greene:  Yes, I know.

Adrienne Boissy:  Do I have MS now because I-

Amy Greene:  Did something wrong.

Adrienne Boissy:  Didn't behave when I was in high school or I get hit in football. There's that constant searching to attach meaning to it or a deeper understanding.

Amy Greene:  So much of the time religion really is to blame. I mean, people don't like me saying that since I am the reverend doctor.

Adrienne Boissy:  You're the most irreverend.

Amy Greene:  The most irreverend doctor, that's true. I am, but I'm also deeply rooted in my own Christian faith tradition. We have misinterpreted a lot of things that caused people to take on self-blame for things that we're trying to teach children to behave and we taught them to be fearful and self-blaming instead. I think religion, you know, it can be used for good or ill just like anything. Anything that we have that has a potential to do good also has a potential to do harm. Many of us who gravitated toward chaplaincy I think have experienced some of the harmful effects of religion sometimes. I think that stands out to a lot of us. We find that in common, that we still love it and still want it to be used for good but we know there are plenty of stories. We're very sympathetic when people have negative feelings about religion. We're sort of like, "Yeah, call us because we will understand that and we'll let you work through that and talk about that."

Possibly give you a different spin on even your own faith tradition that you might not remember as much about the good stuff as you're remembering the more painful, maybe misinterpreted things that have contributed to your pain and contributed to that sense of the kind of suffering that again, the Buddhist call the optional part of suffering. The inevitable is the rock falls out of the sky. The optional part of that is why me, why did that rock, you know. Then just take it so personally. That's how we continue our own suffering and prolong it.

Adrienne Boissy:  You're making me think of a story that I heard that isn't on our list, but I want to ask you about anyway. I heard this story once from one of your colleagues about how they led a church and there was a shooting in that church family. The church was trying to heal and he was trying to stand up for the first time and talk about how you do that. How do you think people begin to move forward after horrific tragedy and moments like that? How do you even stand up there? What do you say?

Amy Greene:  It's a good question. I think we often start by just acknowledging the difficulty of words in a time like that. I think as a general rule, we're more comfortable with that excruciating silence. I think that's maybe one of the things about our training that people don't necessarily recognize, jokingly called it the Amycratic oath like first say nothing stupid to make things worse, which would be do no harm. The second part is try really hard not to run away. The trying really hard not to run away part, I think that's where real compassion is because we want to run away. We don't want to see it. We don't want to be there. We don't want to have it happening to us or to anyone else. Just the willingness, the sheer spine that it takes to just tolerate it lets people know they're not alone in the suffering, that we're going through it together, and that we don't know the answers. We're probably going to have more questions than answers maybe indefinitely, but that no one will have to be alone in that process. You know, I was really inspired by the story. I think I even tweeted it, that came out about the Jewish nurse.

Adrienne Boissy:  You tweeted.

Amy Greene:  I tweeted. I know, my boss made me. I sent out the story of the Jewish nurse who treated the shooter at the synagogue. I was so moved by that story because he just said, "It's just who I am and what I'm supposed to do, as a Jew and as a nurse and as a human being. It's what I'm supposed to do." It was so powerful to me because I don't think most of us could do that. In healthcare, we have to care for everyone. We don't usually have it that starkly right in our face that we're having to care for someone who has declared himself our enemy, has said very blankly he would like us to be dead, which because of an identifying mark that we wear. That was a story for me of just incredible inspiration that I think tapping into that depth of mercy for the whole person rather than just seeing what they did, this bad-

Adrienne Boissy:  One piece of-

Amy Greene:  One piece of who they are, yeah, but often we try to say very little and listen more than we speak. I'm not doing that right now.

Adrienne Boissy:  I'm hearing sometimes there are no words.

Amy Greene:  Yes.

Adrienne Boissy:  This Amycratic oath, I'm in love with that phrase now, is don't say anything and definitely don't say anything that will make it worse.

Amy Greene:  Yeah.

Adrienne Boissy:  You told this great blessing speech that I heard recently at an event celebrating our nurses and your mom was a nurse?

Amy Greene:  Yes.

Adrienne Boissy:  You had this beautiful memory of watching her. Can you talk to me about that?

Amy Greene:  Sure. Thank you.

Adrienne Boissy:  If you're willing.

Amy Greene:  Yeah, my mom came out of the Appalachian Mountains. She was born in 1930 and was raised in a log cabin literally. Came out of just deep poverty but came up from a wonderful family that worked so hard and knew how to love and work and have faith. Those were the most important things. She was the first one in the family that anyone knew of to leave the mountains and come down to the city and become a nurse. She trained in Knoxville, Tennessee. My earliest memories of her, she worked the night shift often so that she could be home with us, I guess, and my dad could go off to work. I loved seeing her all dressed up in her starched white uniform and her white stockings with the seams up the back. That's a big, strong memory of mine. Her white polished shoes and her hat that she pin on her hair. I just loved seeing her like that because I thought it was a superhero costume and turns out it was. Yes, turns out it was.

Adrienne Boissy:  That's just it.

Amy Greene:  It is. I was just thinking of her on the day of blessing all the nurses because I'm always grateful for them. I always think when I cross the street from the parking lot to my building and the flood of night nurses is getting off and I'm walking through them coming the other ... There's a current of nurses just flooding in the opposite direction and I just say a prayer for each one of them and I'm so grateful for them. I think of my mom who's been gone for a while, but I think of her all the time.

Adrienne Boissy:  Speaking of our caregivers for a second, I want to talk about, we're seeing more challenges for all caregivers in healthcare. People who are working in our EDs or even in places we wouldn't expect to see things like violence or abuse of our people from patients. Can you talk to me about as you've had to stand in some of those ERs or you've had to stand with some of those teams after these events have happened? For people who are trying to provide amazing care and bring their full selves and empathize and then they're at the receiving end of that, what can we learn from how to support them more effectively?

Amy Greene:  That's a great question. I think that what we try to do as chaplains and as fellow caregivers is to show up for our teammates as often as we can when something horrible has happened. We're not as glued to one bedside as many of them are. We have both the freedom and the responsibility to be moving about. When something happens in a unit in particular that is just people are stuck. We have to go back to the same route.

Adrienne Boissy:  You got to go back the next-

Amy Greene:  You got to go back and back and back to the same spot where whatever that trauma or difficulty happen. We have this Code Lavenders that we've been doing for about 10 years now. Just a combination of the chaplains and a few holistic nurses just pooling our resources for those who know the Christian scriptures. I always call it like the loaves and fishes. We had a couple of this and a couple of that and we try to feed the 5,000 with it and it's been working. It's been wonderful because we just go to the units and say, "We're here for you. You know, we're part of your team and we're here for you now." Mainly to listen, let people. Some people really need to talk about what happened. We now know that not everybody does. Not everybody needs a crisis debriefing in the same way. Some people, talking about it will just re-traumatize them. For other people, talking about it will let them put it down, but either way, they need to know they're not alone, that we're there to support them and listen.

We might do Reiki or we might do some guided imagery. We might play some music. Just different things to say, "Let me just sit here with you for a little bit and be that kind of community that reminds you of who you are and why you're here and that you're not alone and that you're supported." I will give a little lavender armband to wear to say, "Just remember you took a hit today," like, "Be careful, go easy on yourself." It signals to your colleagues too that maybe take it a little easy on me today. It's been really wonderful because my team was wearing them a few months ago when a colleague of ours who had already moved to another place had died. Several of us were wearing the Code Lavender bands just to remind ourselves, we took a hit. People would say something that says, "Sorry, Jeff. Sorry, you lost somebody." It helps because you're in it together and you feel supported by each other. That's one of the things we love about working in a place like this where people feel very much part of the same team.

Adrienne Boissy:  There's something about just the visibility of suffering or it being acknowledged.

Amy Greene:  Acknowledgement, that's it.

Adrienne Boissy:  Keeps it from growing.

Amy Greene:  That's it. Yeah, that's totally it. We try so hard in the culture we're in to deny pain, deny lost, deny death. We can't even say death. I mean, people are on the radio saying somebody ... The shooting today in California, they guy said they passed. They didn't pass, they die. They were killed. Let's stop putting euphemisms on it because the people that are going through it, they know it was death. The families know they were murdered. Their lives are devastated. Let's stop putting soft fuzzy words around it. I won't let my team say, they know they can't use expired and they can't use passed. They have to say death.

Adrienne Boissy:  That's another Amyism.

Amy Greene:  It's a rule.

Adrienne Boissy:  We have a few minutes left. There are number of things that I know you wanted to talk about. One was about what can we do to take care of ourselves. I know you talk about this concept of compassion or empathy fatigue. Talk to me about what you do to take care of yourself and what you would ask others to do.

Amy Greene:  Yeah. I'm learning a lot about compassion for the self, and I have to say, I didn't know really what it was. I thought I did. Self-compassion and self-care are two different things. Self-care is good and very important and can be very, very useful, but it can also be very selfish and practiced by ... Some of the most selfish people I know do great self-care. Self-compassion on the other hand has more to do with accepting our limitations and our losses, which is so counter cultural like nobody wants to accept limitations. All people want to do with limitations is overcome them, and deny them and push past them. That's okay too. We want to do well, we want to achieve, we want to be our best, but there's a point at which we do hit that wall where something happens to us and we think it must be our fault.

I mean, it's the obvious flip side if we can't have an acceptance of our natural human imperfections, vulnerabilities, adversities, that befall, literally befall out of the sky that are not targeting us but just happen. We torture ourselves with the blame of what we could have done differently. Why didn't I eat right? What did I do? You know, that's not how it works. Suffering falls on everyone. I mean, I hate to be the bearer of bad news, but we're all going to die at some point. Sorry.

Adrienne Boissy:  Top secret.

Amy Greene:  Sorry if this is the first you've heard of it. I hate to ruin your day, but there's a way in which accepting that and knowing that, that we can't do everything, that we can't always be strong. Some of us are going to get sick no matter what we do, no matter how hard we work at it, no matter how healthy, the best health care. We're still going to have things happen. If we could get past blaming ourselves when bad things happen to us, we could get a long way toward feeling better.

Then we could also be more loving and caring of other people who are going through hard times because we wouldn't be looking for what they did to cause it or create it or make it worse. It's just a natural human thing that we do, but it's not very helpful. Although I could say rest and relax and do yoga and all that, which is all fine, everybody has their own basket of choices about what that would look like. I think more and more it has to do with this self-compassion piece, which I have to say I thought I knew about it after 35 years in the ministry. I thought I knew something about compassion and I feel like I'm really just learning.

Adrienne Boissy:  One of the things we discussed was courage to stay, to be present when situations are difficult for patients. In the following segment, Amy shares a pivotal moment in her career that made an impact on her and how she approaches empathy.

Amy Greene: I felt called really young to be a minister and that was unusual. My era, there weren't any female ministers that I knew of. I was actually an adult before I ever saw an ordained female clergy person. I was newly graduated from Union Seminary in New York City. It was one of my very first nights on call. I got the pager and saw the number and it went up to the unit. It was very simple those days. The nurse said, "Full term dead baby in room 302. She wants a priest," and just walked away. I said, okay. I knocked on the door and I opened it. Sitting on the side of the bed with her feet down on the floor was a beautiful young woman about my age. I was in my mid-20s. She had tears streaming down her face, obviously full term. I said, "I'm sorry, there's no priest on duty. I know you wanted a priest. I apologize. There's nobody here but me. I'm Amy. I'm the chaplain." She said to me, "Can you say anything?" Still gets me.

I said, "No, I really can't." I said, "I can't think of anything harder than what you've got to do right now." I didn't tell her, but my baby was home safe and sound with my husband. I said, "I don't know anything harder than this, but I'll stay with you if you want me to." She nodded and I stayed. Honestly, I don't remember. It was several hours. I don't remember saying much else. I think I took her a cup of water from time to time. Her husband came. She was a nurse at a different hospital. He was a fellow in that same hospital that I was working.

We were all here, a doctor, and nurse, and a chaplain all in our 20s dealing with this death of a baby. The morning came, one of my colleagues came who was a nun and she took the pager and took over. I went home utterly devastated and feeling like I can't do this. I couldn't do anything. I had this great theological training and yet I had nothing, you know. I got called upon to do something very real and important and I couldn't do anything. I couldn't even say anything. Fast forward, a few weeks, and I'm actually about to quit the program.

I'm so convinced I can't do the work that I'm thinking, I just don't think this is for me. The office of pastoral care gets a note and it's from this couple. It has a small check inside and it says, the presence of the chaplains help to mitigate their suffering and their friends wanted to send a gift of thanks to the department. I really couldn't believe it. I mean, I really thought that can't be but then I also thought I don't have the right to make that done. This is their story and they say it helped. I'm like, really? I just couldn't believe it. I left the training program and I didn't actually come back to chaplaincy for a while because I was raising my kids and I wasn't sure at all that I was going back into chaplaincy. All those years later, that was the thing that I remembered. It was one of the most impactful experiences I'd had as a chaplain and really the thing that made me want to go back.

Fast forward to this past January and for some reason I'm digging through my attic looking at old papers and I come across a xerox copy of that note that I didn't know I had. I just couldn't believe it. There were their names. I thought, you know what, I'm going to look them up. I wrote a letter and I said, "I really apologize if I've interrupted your life, but I'm wondering if you're the people that I'm looking for." On a night 32 years ago, I was on call as a chaplain. I said, "You know, I apologize if I've upset you. I apologize if I've gotten the wrong person. I really apologize if this was just a terrible idea. But if you are those same people, I need you to know ... “Sorry, I wasn't going to do this… "I need you to know how much impact your little note of thanks had on me." It's probably not too much to say that it may have salvaged my career as a chaplain because I was so early in the process and it was so devastating to me to feel so helpless and yet your note told me that it was the one thing that it helped. It just never went away. It was always there in my mind.

I would tell new students about it. I would say never be sure that you didn't help because you just don't know. I didn't hear, I didn't hear and I didn't hear and then about two months later I got this letter. Their names are on the return. I take it into my assistant's office. I said I have to read this with someone because I'm scared to death to open it. I opened the letter and she says, "Dear Amy Green, I want to thank you for reaching out to us after 31 years. We were very moved to hear that we had changed the course of your ministry." She goes on to say that evening was the most painful moment of our lives. Sorry. "Medicine could not create a miracle and I knew that I needed God's help to get through. I will tell you that I felt very alone in my pain and overwhelmed. My husband was equally in pain and at a loss of how to be helpful. It felt like everyone was running out of the room away from us because they did not want to witness or deal with the tragedy.

We could not blame them. We would have left if we could have. You helped me survive by having the courage to stay with us during that painful time. I will be forever grateful for your courage and kindness." I love that they said they would have left too if they could have. I mean, they're just so wise and generous to say that because they were not resentful of the people that kept running out of the room but I think staying put is so hard. It seems like you're doing nothing and it's actually the hardest thing we can do is just stay put and be willing to feel what the other person is feeling but not get overwhelmed by it, and not run away, and not be so caught up in our own thoughts and our own worries that we abandon people who are suffering, to just sit still so that this person knows they're not alone. That's the takeaway, I think, and it's so much harder than it looks.

Adrienne Boissy:  This concludes Studies in Empathy Podcasts. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcast. Subscribe to Studies in Empathy Podcast on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcasts. Thank you for listening. Please join us again. Thank you so much, Amy.

Amy Greene:  Thank you.