Spiritual caregiving silence: an exploration of the phenomenon and its value in end-of-life care Lynn Bassett Master of Arts in Pastoral Theology A thesis submitted to Lancaster University in partial fulfilment of the requirements for the degree of Doctor of Philosophy. The candidate has already achieved 180 credits for the assessment of taught modules within the blended learning PhD programme. December 2016 Faculty of Health and Medicine Lancaster University I declare that this thesis is my own work and has not been submitted for the award of a higher degree elsewhere Acknowledgments My thanks go to my academic supervisors Dr Sarah Brearley and Dr Amanda Bingley for their patience, support and sustained belief in my work; to Professor Katherine Froggatt for early tutoring and continued support and encouragement; to Jenny Brine, specialist librarian, whose clear-headed humanity helped me to navigate the mysteries of database searching; to my peers who have journeyed with me on the 2010 PhD Palliative Care programme and who have become firm friends; to the chaplains who participated in this research for giving their time and sharing such rich experience; to Lydia McLean for proof-reading and to my long- suffering husband, Phil, who has listened, waited and shared the birth-pangs as this thesis has unfolded. Finally, I give thanks to God for his inspiration and constancy, especially when I could not, myself, see the way. In the PhD journey, as in all things, the prayer of Thomas Merton has been a reassuring guide. My Lord God, I have no idea where I am going. I do not see the road ahead of me. I cannot know for certain where it will end. Nor do I really know myself, and the fact that I think that I am following your will does not mean that I am actually doing so. But I believe that the desire to please you does in fact please you. And I hope I have that desire in all that I am doing. I hope that I will never do anything apart from that desire. And I know that if I do this you will lead me by the right road though I may know nothing about it. Therefore will I trust you always though I may seem to be lost and in the shadow of death. I will not fear, for you are ever with me, and you will never leave me to face my perils alone. Thomas Merton, Thoughts in Solitude (1997:81) 2 Lynn Bassett, MA Pastoral Theology. Spiritual Caregiving silence: an exploration of the phenomenon and its value in end of life care, PhD Palliative Care, December 2016 Abstract Towards the end of life, silence seems to take increasing prominence in caregiving relationships. A complex phenomenon, silence has been less explored than verbal interventions, yet to be an effective element of care, silence requires skill and practice from professional caregivers. This research, undertaken in the United Kingdom between 2013 and 2016, sought a deeper understanding of a type of silence that contributes to palliative spiritual care. A two phase phenomenological methodology was adopted, using heuristic inquiry and hermeneutic phenomenology. Data were gathered through self-inquiry and unstructured interviews with 15 palliative care chaplains. A descriptive and hermeneutic analysis facilitated explication of the lived experience to produce an interpretation of the nature, meaning and value of spiritual caregiving silence in end-of-life care. Spiritual caregiving silence emerges as a way of being with another person, complementary to speech and non-verbal communication, in which the caregiver takes both an active and participative role. It evokes a sense of companionship and connection and creates accompanied space, allowing the other person to be with themselves in a way they may not be able to be alone; this demands a depth of engagement from the caregiver. Silence provides a means of, and medium for, communication beyond the capacity of words and has the potential to enable change, leading to expression and acknowledgment of truth. It offers patients, and their families, opportunities to find acceptance, restoration and peace. The thesis concludes that spiritual caregiving silence is a person-centred phenomenon that supports the wellbeing of patients at the end of life, and their family members, by drawing on cross-disciplinary knowledge and experience. The interpretive process, illuminated by examples of specialist lived experience, has produced a deeper understanding of the phenomenon that may find resonance with the experience of other caregivers, to stimulate further discussion and inform clinical practice. 3 Table of contents Acknowledgments ...................................................................................................................... 2 Abstract ...................................................................................................................................... 3 Table of contents ....................................................................................................................... 4 Tables ..................................................................................................................................... 8 Figures .................................................................................................................................... 8 Abbreviations ......................................................................................................................... 9 CHAPTER ONE Introduction: The research in context .................................................................................... 10 1.1 Research design ............................................................................................................. 14 1.2 Research question, aim and objectives ......................................................................... 15 1.3 Background of the researcher........................................................................................ 16 1.4 Contribution to knowledge ............................................................................................ 16 1.5 Thesis structure .............................................................................................................. 17 CHAPTER TWO Background: Palliative spiritual caregiving and the phenomenon of silence ....................... 20 2.1 Palliative care ................................................................................................................. 20 2.2 Spiritual care .................................................................................................................. 22 2.2.1 The role of the chaplain .......................................................................................... 25 2.3 Concepts of care, conversation and contemplation ...................................................... 27 2.4 Silence ............................................................................................................................ 32 2.4.1 Silence in human interaction .................................................................................. 33 2.4.2 Silence in therapeutic relationships ........................................................................ 35 2.4.3 Silence in religion and spirituality ........................................................................... 37 2.5 Conclusion ...................................................................................................................... 39 CHAPTER THREE Literature Review: Existing understanding of silence in caregiving contexts ....................... 41 3.1 Method........................................................................................................................... 41 3.1.1 Search strategy ........................................................................................................ 42 3.2 Results ............................................................................................................................ 45 3.2.1 Location, methodology and philosophy .................................................................. 50 3.3 Data synthesis and interpretation ................................................................................. 51 3.3.1 Focus One: The relationship of silence and speech ................................................ 52 4 3.3.2 Focus Two: The use of silence ................................................................................. 54 3.3.3 Focus Three: The practice of silence ....................................................................... 57 3.3.4 Interpreted line-of-argument ................................................................................. 59 3.4 Conclusion ...................................................................................................................... 61 CHAPTER FOUR Methodology: A phenomenological approach ....................................................................... 62 4.1 Philosophical paradigm .................................................................................................. 62 4.1.1 Ontology and epistemology .................................................................................... 65 4.2 Methodology .................................................................................................................. 68 4.3 Methods ......................................................................................................................... 73 4.3.1 Phase One: Heuristic inquiry ................................................................................... 74 4.3.1.1