Pastoral Care

Abstract

Pastoral care is a form of counseling in which chaplains, clergy, and other spiritual-care providers attend to the emotional, existential, and spiritual needs of people facing illness, loss, and crisis. Distinct from religious ministry narrowly conceived, contemporary pastoral care in health settings is an interdisciplinary practice: it assesses a patient's sources of meaning and support, addresses spiritual distress, and works alongside the medical team as part of whole-person care. This article sets out what pastoral care is, the clinical-pastoral-education movement that professionalized it, the tools used to take a spiritual history, the psychology of religious coping, and the growing body of evidence linking attention to spiritual needs to patient-reported and end-of-life outcomes. Three demonstrations let the reader build a structured spiritual history, trace how spiritual support relates to end-of-life care, and balance positive against negative religious coping.

Keywords: pastoral care, chaplaincy, spiritual care, religious coping, counseling

Pastoral care is among the oldest helping practices and, in its modern hospital form, among the youngest of the clinical professions. For most of its history it was the province of clergy offering comfort from within a religious tradition; over the past century it has become a trained, credentialed discipline that serves patients of any faith or none, embedded in hospitals, hospices, and the military. The shift reflects a broader recognition in medicine that serious illness raises questions — about meaning, guilt, hope, and mortality — that are not reducible to symptoms and that shape how patients cope and decide (Koenig, 2012). This article treats pastoral care as psychology treats it: as a form of counseling with a distinctive focus on the spiritual dimension of coping and care.

What Pastoral Care Is

Pastoral care is the provision of emotional and spiritual support to people confronting the hard passages of life — serious illness, bereavement, moral injury, and dying. Because MeSH files it beneath counseling, its parent descriptor, it is worth marking what kind of counseling it is: not the correction of behaviour or the treatment of a disorder, but the accompaniment of a person through suffering, oriented toward meaning rather than cure. Its practitioners — hospital chaplains, clergy, and trained spiritual-care providers — work with a patient's own framework of belief and value, whether that framework is religious, secular, or uncertain (Puchalski & Romer, 2000). A 2009 consensus conference gave the field its working definition, framing spirituality as the dynamic dimension of human life relating to the way people seek meaning, purpose, and transcendence and experience their connection to the moment, to self, others, nature, and the significant or sacred — a deliberately broad formulation that encompasses the non-religious as well as the religious (Puchalski et al., 2009).

Figure 1

Three features distinguish pastoral care from adjacent practices. It is patient-led in its content, taking the person's own beliefs and values as the material to work with rather than importing the provider's. It is non-directive in the counseling sense, aiming to help patients find and mobilize their own resources of meaning rather than prescribing a course of action. And it is increasingly integrated, delivered as one component of a care team's shared responsibility for the whole person rather than as an optional extra summoned only at the very end (Steinhauser et al., 2017).

History and Clinical Pastoral Education

The modern profession dates to the 1920s and to two Americans who insisted that clergy be trained at the bedside rather than only in the seminary. Anton Boisen, a chaplain who had himself been hospitalized for psychosis, argued that patients were “living human documents” from whom theology students should learn directly, and in 1925 he placed the first group of students in a mental hospital for supervised clinical work. The physician Richard Cabot, a pioneer of medical social work at Harvard, had called that same year for a “clinical year” in theological education. Together their programmes became the clinical pastoral education (CPE) movement, which established the model still used today: supervised practice, case presentation, and reflection on the encounter between provider and patient.

CPE turned pastoral care from unstructured religious visitation into a clinical discipline with standards of training and accountability. Contemporary board-certified chaplains complete graduate theological education and multiple units of supervised CPE, and they are credentialed to practise across faith traditions and with the non-religious. This professionalization is what allows pastoral care to be studied and evaluated as a health-care intervention rather than treated as a purely private religious matter (Fitchett, 2017). The historical detail of Boisen's and Cabot's founding programmes is drawn from standard histories of the field rather than from the empirical literature cited here.

Spiritual Assessment and the Spiritual History

Just as a clinician takes a medical history, a spiritual-care provider takes a spiritual history: a structured inquiry into the beliefs, practices, and communities that give a patient meaning and support. The best-known tool is the FICA framework, which organizes the inquiry into four domains — Faith and belief, the Importance of that faith in the person's life, the Community the person belongs to, and how the person wishes clinicians to Address these concerns in care. A brief, structured history of this kind lets clinicians understand patients more fully and identify those in spiritual distress who might benefit from a chaplain's involvement (Puchalski & Romer, 2000).

The purpose of assessment is to distinguish the patient whose faith is a resource from the one for whom illness has provoked a crisis of meaning. A spiritual history is not an attempt to change what a person believes; it is a way of learning what they believe so that care can be aligned with it — ensuring, for instance, that treatment decisions respect a patient's framework, and that spiritual distress is recognized rather than mistaken for depression or non-compliance (Balboni et al., 2022). The first demonstration lets the reader assemble a spiritual history from the four FICA domains and see how coverage builds.

Religious Coping and Spiritual Distress

Psychology's most productive contribution to this field is the study of religious coping — the ways people draw on belief to make sense of and manage stress. The central finding, established through the RCOPE measure, is that religious coping is not uniformly helpful: it divides into positive forms — seeking spiritual connection, benevolent religious reappraisal, collaborative coping with a benevolent higher power — and negative forms, sometimes called spiritual struggle, such as feeling punished or abandoned by God, or wrestling with religious doubt. Positive religious coping is associated with better adjustment; negative religious coping predicts poorer mental-health and, in medical patients, worse outcomes (Pargament et al., 2000).

This distinction is what makes assessment clinically consequential rather than merely descriptive. A patient in spiritual struggle is at elevated risk, and identifying that struggle is a principal reason to involve pastoral care. The broader literature relating religion and spirituality to health, while methodologically uneven, converges on the conclusion that the quality of a person's spiritual life — whether it is a source of comfort or of conflict — matters more for well-being than religious affiliation or attendance as such (Koenig, 2012). The third demonstration lets the reader weigh positive against negative religious coping and read off the net direction of adjustment.

Spiritual Care and Health Outcomes

The strongest evidence for pastoral care comes from studies of patients with advanced illness. In the Coping with Cancer cohort, patients whose religious and spiritual needs were supported by their medical teams reported better quality of life, and religiousness was associated with a preference for more aggressive measures — a finding that made clear why clinicians need to understand, rather than assume, what a patient's faith implies for care (Balboni et al., 2007). Crucially, when spiritual care was provided, the pattern shifted: patients who received spiritual support from the medical team were more likely to enter hospice and less likely to receive aggressive interventions near death, with better quality of life in the final week (Balboni et al., 2010).

Where that spiritual support comes from turns out to matter. Patients whose spiritual needs were met largely by their own religious communities, without medical-team involvement, received more aggressive care and less hospice at the end of life — suggesting that spiritual support integrated into the clinical setting has effects that community support alone does not (Balboni et al., 2013). These outcomes matter because patients themselves rank being at peace and not being a burden among the factors most important at the end of life, alongside pain control (Steinhauser et al., 2000). The second demonstration models the relationship between spiritual support and end-of-life care that these cohorts describe.

The Chaplain and the Care Team

For all this evidence, spiritual care remains infrequent in practice, and the reasons are instructive. Surveys of patients, nurses, and physicians find that the largest barrier is not disagreement about its value but lack of training: clinicians report they do not know how to raise spiritual concerns and fear doing so clumsily, so the conversation does not happen (Balboni et al., 2013). The remedy is not to make every clinician a chaplain but to build a division of labour — clinicians trained to screen for spiritual distress and to refer, and board-certified chaplains equipped to provide specialist spiritual care.

This is why professional bodies have pressed for multidisciplinary education in spiritual care and for chaplains to be treated as full members of the palliative-care team rather than as visitors (Best et al., 2020). The model that emerges is generalist-plus-specialist: every member of the team attends to the spiritual dimension at a basic level, and the chaplain provides depth where distress is identified — the same structure medicine uses for pain, nutrition, and other cross-cutting needs (Steinhauser et al., 2017).

Interactive demonstrations

The three demonstrations below let the reader work with the core tools of pastoral care. The first assembles a structured spiritual history from the FICA domains; the second models how spiritual support relates to end-of-life care; the third balances positive against negative religious coping to show why the distinction matters.

Worked Example

Consider the end-of-life model in the second demonstration. It represents, in deliberately simplified form, the direction the cohort studies report: as the spiritual support a patient receives from the care team rises, hospice enrolment rises and aggressive intervention falls. Let spiritual support s run from 0 (none) to 10 (fully addressed). The model interpolates linearly between an unsupported and a fully supported rate.

Hospice enrolment is modelled as H(s) = H₀ + (H_max − H₀) × s/10, with an unsupported rate H₀ = 30% and a fully supported rate H_max = 70%. Aggressive end-of-life intervention (ICU admission or resuscitation) is modelled as A(s) = A₀ − (A₀ − A_min) × s/10, with A₀ = 25% and A_min = 5%.

Take a patient at the midpoint of support, s = 5. Then H(5) = 30 + (70 − 30) × 0.5 = 30 + 20 = 50%, and A(5) = 25 − (25 − 5) × 0.5 = 25 − 10 = 15%. Raising support to s = 8 gives H(8) = 30 + 40 × 0.8 = 62% and A(8) = 25 − 20 × 0.8 = 9%. The arithmetic makes the cohorts' claim concrete: moving a patient from moderate to high spiritual support raises modelled hospice enrolment by 12 percentage points and cuts modelled aggressive intervention by 6, without any change to the medical facts of the case — the difference lies entirely in whether the spiritual dimension of care was addressed. The demonstration recomputes both rates live as the support slider is moved. These figures are illustrative of the reported direction of effect, not estimates of any single study's magnitudes (Balboni et al., 2010).

Discussion

The standing of pastoral care as a health-care intervention has strengthened considerably, but it remains uneven. On one hand, the observational evidence is consistent: attention to spiritual needs is associated with better patient-reported quality of life and with end-of-life care that more closely matches what patients say they want (Balboni et al., 2007). On the other, most of that evidence is observational rather than experimental, and the field has struggled with the definitional and measurement problems inherent in studying something as heterogeneous as spirituality (Steinhauser et al., 2017).

Two cautions follow. The first is causal: patients who receive and accept spiritual care may differ systematically from those who do not, so associations with better outcomes cannot be read straight off as effects of the care itself. The second is definitional: “spirituality” spans organized religion, private belief, and secular sources of meaning, and a measure that blurs these may obscure as much as it reveals. The most defensible reading is that the spiritual dimension of illness is real and consequential for how patients cope and decide, that assessing it is low-risk and often welcomed, and that specialist spiritual care is a reasonable response to identified distress — while the magnitude of its independent effect on hard outcomes remains to be established by stronger designs (Balboni et al., 2022).

Current Directions

Three lines of work are shaping the field. The first is the maturation of chaplaincy research itself: once almost anecdotal, it now includes validated outcome measures, case-study methods, and a growing number of intervention trials, giving the profession an empirical base comparable to other allied-health disciplines (Fitchett, 2017). The second is the drive toward consensus and standards: large evidence syntheses have taken stock of what is and is not known, mapped the definitional terrain, and set research priorities for spirituality in serious illness (Balboni et al., 2022); (Steinhauser et al., 2017).

The third is education and integration. Recognizing that lack of clinician training is the binding constraint on delivery, professional bodies have developed multidisciplinary curricula in spiritual care and pressed for chaplains to be embedded in palliative and primary-care teams rather than called only in extremis (Best et al., 2020). Open questions remain sharp: how to demonstrate causal effects on hard outcomes with designs stronger than observational cohorts; how to measure spiritual distress reliably across faith traditions and the non-religious; and how to scale specialist spiritual care given a limited chaplaincy workforce.

Common Misconceptions

“Pastoral care means imposing religion on patients.”

Contemporary pastoral care is patient-led and non-directive: it works with a patient's own beliefs and values, serves the non-religious as readily as the religious, and aims to help people mobilize their own resources of meaning, not to convert them (Puchalski & Romer, 2000).

“Religion is simply good for health.”

The evidence is more precise: the quality of religious coping matters, not its mere presence. Negative religious coping — feeling punished or abandoned — predicts poorer adjustment, so spiritual struggle is a risk factor, not a benefit (Pargament et al., 2000).

“Spiritual care is only for the dying.”

Although the strongest evidence comes from end-of-life care, spiritual needs arise across illness and crisis, and assessment is recommended as a routine part of whole-person care rather than a terminal add-on (Steinhauser et al., 2017).

“Any clergy visit is the same as professional chaplaincy.”

Board-certified chaplains complete graduate training and supervised clinical pastoral education, and spiritual support integrated into the care team has effects that community religious support alone does not (Balboni et al., 2013).

Glossary

Biopsychosocial-spiritual model.

An extension of the biopsychosocial model that adds the spiritual domain, holding that physical, psychological, social, and spiritual factors jointly shape a person's experience of illness.

Chaplain.

A professional spiritual-care provider, typically board-certified through graduate theological education and supervised clinical pastoral education, who serves patients across faith traditions and the non-religious.

Clinical pastoral education (CPE).

The supervised, experiential training model, founded in the 1920s, that professionalized pastoral care through bedside practice, case presentation, and reflection.

FICA.

A spiritual-history tool organizing inquiry into four domains: Faith and belief, Importance, Community, and how to Address spiritual concerns in care.

Hospice.

A model of care for people near the end of life that prioritizes comfort, dignity, and quality of life over life-prolonging intervention; enrolment is one outcome associated with team-provided spiritual support.

Negative religious coping.

Spiritual struggle — feeling punished or abandoned by a higher power, or wrestling with religious doubt — which predicts poorer psychological and health adjustment.

Palliative care.

Interdisciplinary care aimed at relieving suffering and improving quality of life for people with serious illness, within which spiritual care is treated as a core domain and the chaplain as a full team member.

Pastoral care.

A form of counseling providing emotional and spiritual support to people facing illness, loss, and crisis, attentive to meaning rather than cure.

Positive religious coping.

Drawing on belief as a resource — benevolent reappraisal, seeking spiritual connection, collaborative coping — which is associated with better adjustment.

RCOPE.

A validated inventory of religious coping strategies that operationalized the positive/negative distinction and made religious coping measurable in health research.

Religious coping.

The ways people draw on religious or spiritual belief to interpret and manage stress, divided into positive forms associated with better adjustment and negative forms that predict worse adjustment.

Spiritual distress.

A state of crisis in a person's sources of meaning, hope, or connection, provoked by illness or loss, which can be assessed and is a principal indication for specialist spiritual care.

Spiritual history.

A structured inquiry into a patient's beliefs, practices, and communities of support, taken so that care can be aligned with the patient's own framework of meaning.

Whole-person care.

The biopsychosocial-spiritual model in which physical, psychological, social, and spiritual needs are addressed together by a coordinated care team.

Key Researchers

Tracy A. Balboni. American radiation oncologist and palliative-care researcher whose cohort studies established the associations between spiritual support and end-of-life care, and who led the 2022 review of the evidence on spirituality in serious illness. ORCID · Google Scholar

Anton T. Boisen (1876–1965). American chaplain who founded the clinical pastoral education movement in the 1920s, placing theology students at the bedside to learn from patients as “living human documents.” Wikipedia · Wikidata

Richard C. Cabot (1868–1939). American physician who pioneered medical social work and, with Boisen, helped launch clinical pastoral education through his call for a supervised clinical year in theological training. Wikipedia · Wikidata

George Fitchett. American chaplain-researcher who has led the development of the empirical evidence base for healthcare chaplaincy, including spiritual-assessment models and case-study methods. ORCID · Google Scholar · Faculty page

Harold G. Koenig. American psychiatrist who founded the Duke Center for Spirituality, Theology and Health and is among the most prolific researchers on religion, spirituality, and health outcomes. ORCID · Wikipedia

Kenneth I. Pargament. American clinical psychologist who founded the empirical psychology of religious coping and developed the RCOPE measure and the distinction between positive and negative religious coping. ORCID · Wikipedia · Google Scholar

Christina M. Puchalski. American physician who founded the George Washington Institute for Spirituality and Health and created the FICA spiritual-history tool used to structure clinicians' spiritual assessment. Google Scholar

Frequently Asked Questions

What is pastoral care in simple terms?
It is emotional and spiritual support for people going through illness, loss, or crisis, provided by chaplains and other trained spiritual-care providers. It attends to questions of meaning, hope, and coping rather than to medical treatment, and works with a person's own beliefs, religious or not (Puchalski & Romer, 2000).

Is pastoral care only for religious people?
No. Modern pastoral care is patient-led and serves the non-religious as readily as the religious; the provider works with whatever framework of meaning the person has, rather than imposing one (Balboni et al., 2022).

How is a hospital chaplain trained?
Board-certified chaplains typically complete graduate theological education and several units of supervised clinical pastoral education, the experiential training model founded in the 1920s. This is what makes chaplaincy a clinical profession rather than informal religious visitation (Fitchett, 2017).

What is a spiritual history?
A structured inquiry into a patient's beliefs, the importance of those beliefs, their community, and how they want spiritual concerns handled in care — captured by tools such as FICA. It helps clinicians understand patients and identify spiritual distress (Puchalski & Romer, 2000).

Does attending to spiritual needs actually affect care?
Cohort studies find that patients whose spiritual needs are supported by their medical team receive less aggressive end-of-life care, are more likely to enter hospice, and report better quality of life near death (Balboni et al., 2010).

Is religion always good for coping with illness?
Not uniformly. Positive religious coping helps, but negative religious coping — feeling punished or abandoned by God — predicts poorer adjustment. Identifying such spiritual struggle is a main reason to involve pastoral care (Pargament et al., 2000).

Why is spiritual care so infrequent if it helps?
The largest barrier is lack of clinician training: doctors and nurses often report they do not know how to raise spiritual concerns and worry about doing so badly, so the conversation is skipped (Balboni et al., 2013).

How does pastoral care fit with the rest of the medical team?
The emerging model is generalist-plus-specialist: every team member attends to the spiritual dimension at a basic level and screens for distress, while board-certified chaplains provide specialist care where distress is found (Best et al., 2020).

References