Healing Community: Transforming Trauma in Relationship
Compassionate care in an integrative health center for people living with HIV/AIDS
by Judy Fleischman, BCC M.S. M.Phil., who served as Staff Chaplain at Housing Works, Inc. 2006-2009
Published July, 2008 in Plainviews, a publication of The Healthcare Chaplaincy (now Network), a leading multifaith, not-for-profit center for pastoral care, education, research, and consulting.
A clue to the journey on which I was embarking arrived in the form of a question from a chaplaincy mentor.
While interviewing me for a chaplaincy position, he cautioned, "Whoever serves in this role will be a lightning rod for this community. Some people thrive on this energy and some people are depleted. You need to ask yourself, which type of person are you?"
That was two- and a half years ago. Since that time, I have been privileged and challenged to deepen my understanding of this question while providing professional chaplaincy services. The setting has been an adult day treatment center for people living with HIV who face increased health risks. During this time, I have become increasingly aware that healing manifests in relationship. I consequently sought an integrative approach, which led to developing a model of inter-relational, interdisciplinary care entitled, Healing Community.
This model tailors treatment for individuals living with HIV and additional stressors including: homelessness, trauma, mental illness, drug addiction, alcoholism, domestic violence, and criminal activity. These factors contribute to their increased health risks, such as self-medication, self-isolation, and non-adherence to medical treatment.
Senior administrative staff and the substance use specialist estimate that 90% of clients
report history of trauma and 90% report history of drug addiction and/or alcoholism. Over 50% are diagnosed with a mental illness. The need for a compassionate container for caregiving is evident. This need led to an historic initiative, which in turn led to my hiring. The initiative was between Housing Works’ West 13th Street Adult Day Health Treatment Center, the largest of four sites in NYC, and HealthCare Chaplaincy (HCC). This effort marked a shift for the Center in defining spiritual care from pastoral counseling to professional chaplaincy.
The Center’s then executive director wanted to integrate spirituality in an inclusive,
broadly-defined manner. He saw this as a foundation for healing in an interdisciplinary context.
The resulting contract called for HCC to recruit a board-certified or certification-eligible,
professional chaplain who would provide twenty-one hours of care per week to clients and notably to staff, which was a new concept for this facility. Also, HCC provided two documents: a "Best Practices for People Living with HIV/AIDS," and a "Spiritual Assessment" template tool.
Noteworthy demographics include: 76% of all clients identify as male, 56% as African American/Black (predominately African and Caribbean American) 39% Hispanic, 5% Other. 4% identify as Transgender. Many clients identify as Gay (same sex partnering) or Bisexual. These demographics indicate the role that sensitivity to racial, multi-cultural, sexual orientation, and gender identity issues plays in serving these clients.
Clients’ religious demographics reveal inter-relational issues as well. The general intake census for religion, meaning what clients report during admission process is: 48% unknown, 7% none, 12% Protestant, 5% Roman Catholic, 4% Baptist, 3% Muslim, Buddhist 1%, and 19% Other. What they report in the chaplain’s presence is quite different. Based on over one hundred spiritual assessments as well as hundreds of individual sessions, 85% of clients identify as Christian, primarily Protestant and Roman Catholic. Significantly, many also report feeling alienated from their religious communities and/or their “Higher Power” (in monotheistic terms, God as they understand God to be).
Facing multiple hardships and unable to resolve discrepancies between espoused and operational theologies, many clients verbalize feelings of self-loathing and/or ambivalence in relationship with their Higher Power. Furthermore, many report feelings of guilt and shame as well as fear of abandonment in relationship with their religious communities and/or Higher Power. The strategy many clients then employ is self-isolation.
Another important factor is the theme of loss in relationship. Individuals experience statistically higher deaths in their circles of loved ones. These likewise occur at an earlier age than in the population at large. Coping with a sense of loss is often less than adaptive. Self-isolation and self-medication with drugs and/or alcohol are common.
Recognizing these interwoven issues, the organization adheres to a ‘harm reduction’ rather than abstinence based model of treatment. The healthcare program assembles an impressively diverse interdisciplinary team, including full medical and social work services and many other disciplines such as creative arts therapies, vocational rehabilitation, and forensic (incarceration history) counseling. The Center also operates a targeted outreach program to transgender persons. Advocacy (local to international) is a primary mission.
Finding the treatment modality that serves best has been a personal journey. During my first year, the greatest challenge was the steep learning curve in providing clinically meaningful documentation including chart notes for my billable services. Constant vigilance to detail is crucial for coordination of care and to demonstrate compliance with care and funding guidelines to overseeing external agencies in a climate of changing political conversation over “appropriate use” of these funds. I struggled to offer care and to document within the twenty-one hours allotted per week.
During my second year, my focus shifted to larger issues of client safety and staff sustainability. A sense of urgency increased as we experienced a higher number of client deaths than in previous recent years, including several suspected suicides from drug overdose or neglect of medical treatment regimen.
Seeking to respond to the elevated stress, I began to frame challenges as inter-relational and to promote a spiritual foundation in terms of interdependence.
“Healing Community” integrates spirit-centered care, mindfulness meditation, and therapeutic play within an interdisciplinary context to promote healing in relationship.
Spirit-centered care is inter-disciplinary care in an integrative care setting, which is rooted in a person's experience of spirituality as the expression of what they value. Mindfulness meditation is a widely applied clinical method, which Jon Kabat-Zinn describes as "paying attention . . . nonjudgmentally."  Therapeutic play, from my perspective, is the experiencing of wholeness through creative expression, both verbal and non-verbal.
Inspiration for this inter-relational view of healing draws on two images from the spiritual traditions in which I practice. Buddhist cosmology offers Indra’s net, which extends infinitely and contains a jewel in each of its vertices. Each jewel perfectly reflects all the others. This illustrates what Zen teacher Thich Nhat Hahn coins as <I>"inter-being"</I> or interdependence. Transformation manifests in the moment of directly realizing this interdependence. 
The second image is drawn from Jewish mysticism and depicts revelation at Sinai, the moment when the people assemble and as Rabbi Arthur Waskow states, "become a community” [engaged in] a constantly unfolding process of revelation in which everyone
in every generation is able to be present. . . to join in partnership with God."  This revelation is a covenant or contract in relationship.
These images frame Healing Community as an inter-relational practice, which in Zen terms could be called "direct realization" and in Jewish terms, "ongoing revelation." Significantly, it can be presented in a secular manner, hence accessible to everyone. Contract in relationship is not new to this setting. I simply applied it in a new way.
The contract began in me. Identity and community became major issues for me in this setting. I wondered how could I offer care, even while utilizing professional chaplaincy skills, to a largely Christian demographic when this is not my path of spiritual practice? Also, as a Caucasian woman from a middle class background, how could I authentically engage with those for whom race, ethnicity, and poverty (to name a few issues) are daily challenges in relationship? Finally, how could I embody pastoral authority within a community, which tended to identify me as their pastor, a traditionally Christian, male authority figure?
This difficult process of introspection led me to embrace being different as an expression of being interdependent. Then, I could direct these differences to be of service.
Seeking to understand the purpose and scope of our contract in relationship, I began a research effort. My goal was to identify common values based on patterns emerging from individual sessions with clients and staff as well as spiritual assessments and groups. I utilized Non-Violent Communication (NVC), a model developed by psychologist Marshall Rosenberg, to formulate a needs assessment.
It is notable that clients and staff expressed differences in what they identified as paramount concerns. The primary needs stated by clients were: safety, trust, dignity, guidance, purpose, and belonging. Among staff, the primary needs stated were: sustainability, integrity, fulfillment, appreciation, and rest. To meet some of these needs, I advocated for a quiet, contemplative space, called the "Reflection Room," and for a bulletin board, which we named "Healing Community."
The room was decorated sparingly. Above the entrance, we posted a photograph taken in New York’s Central Park of children of different races holding hands and lying on the ground to encircle one word in the center: “Imagine.” Spiritual groups meet in the room as do other groups. The room also is available for general use consistent with guidelines posted on the door.
Inside the room, we placed a clear vase with vine cuttings growing roots. This was inspired by a verse from Psalm 80, "I took a vine cutting out of Egypt and planted it . . . and it struck root." These vines offered a poignant reflection for those reporting significant displacement and marginalization issues.
A large, framed print of abstract art that was hung on the wall became a powerful metaphor for making meaning of one’s experience. During groups, I refer to the art as "what’s happening" and the frame as "what it means to me." It focuses client’s attention on intention.
For instance, I asked a client reporting panic attacks, trauma history, and a gambling addiction to visualize the abstract art as himself standing at the slot machine. I pointed to the frame and asked, "what's your fear?" He replied, "losing." I then asked, "what's the bigger picture?" He smiled and replied, "trusting the unknown." I guided him in a succinct, breath-centered prayer using his words. "Breathing in, trusting" and "Breathing out, fear." He has repeated this prayer often and reports it as an effective intervention when feeling panic arising.
The "Healing Community" board resides close to the Center's entrance and promotes a sense of purpose and belonging. We decorate it seasonally. We attached a mirror and above it, posted the phrase (in English and Spanish): “Look Closely." Below, we posted a monthly "reflection" such as November's "How am I generous?" Clients contributed succinct writings or drawings to a compilation entitled, "Stories of Generosity," which was presented to the assembled community on Thanksgiving.
Staff contribute as well. December's "what does peace mean to me?" resulted in a peace banner. The endeavor offered a bright antidote to despair and hopelessness. People were grieving deaths (some quite recent) of loved ones, some of whom were clients. Participants shared tears and laughter as they reported experiencing themselves as members of an extended family.
Recognizing the need for co-creative ritual, I reached out to clients and staff in preparing for then frequent memorial services. Clients participated in all aspects. This helped to contain and contextualize grief as a shared journey.
Entering my third year in the Center, I suggested and collaborated with several clients and the director of creative arts therapies to initiate a "Reflection Board." Its purpose is to hold participants' reflections on what had become our monthly "Healing Community" theme. The board has the appearance of a big mirror. The reflections have evolved. For instance, for this June's, "How do I feel about working together?," one client drew a big circle with a dot at a distance from it. Beside the circle, he wrote, "them" and beside the dot, "me." His contribution empowered peers to express inter-relational stressors as well as benefits.
I also initiated a Healing Community monthly outing, which connects with the monthly theme. Each trip is co-facilitated whenever possible with a colleague to link our disciplines. During our first outing, a psychiatric social worker joined to offer a trip to a museum whose artwork illustrates the interplay of spirituality and psychology with the theme of "Transformation." This June’s trip was to a community garden with the theme of "Working Together."
Current spiritual groups reflect pressing issues, namely: "Living with Dying," "Moving On,"Spirituality and Recovery," "Spirituality and Health," and a monthly "TranSpirit" (for
transgender persons and friends). Additionally, a minister from a nearby church offers a
non-denominational, Christian Sunday service and Bible study.
I integrate mindfulness meditation, voice dialogue (a psychological method of integrating aspects of oneself, developed by Drs. Sal and Sidra Stone), breath-centered spontaneous prayer, and therapeutic play (especially music, movement, and touch).
During groups, rather than stating “group rules,” I facilitate a process for clients to enter
into a contract concerning guidelines for communicating. As we close, participants enter into a contract to take up a mindfulness practice, which we articulate together, during the week. This usually incorporates a form of breath-centered prayer. Simple repetitive phrases reflect meaning, such as "breathing in calm, breathing out fear." Many clients report this as a skillful intervention, which helps them to reduce self-harmful behaviors, promotes insight, and fosters healing friendships.
We celebrate interdependence as a community with an event in July called, "A Day of Unity: Celebrating Diversity, Expressing Who We Are." It incorporates a participatory music and art program. This month will mark our three-year anniversary.
These efforts have born fruit. While the issues appear to be complex, and there have been a number of coordinated organizational initiatives including Healing Community outreach, this endeavor has contributed to several tangible outcomes.
I see clients more engaged in treatment. Staff are more aware of self-care and client care as a collaborative and shared responsibility. Most of all, I see a more appreciative and pro-active community reshaping itself to simultaneously value differences and express these with a sense of common purpose. Our next step might be to produce measurable data to quantify impact on specific clinical issues and outcomes.
A poignant portrait of the impact of these efforts arrived just before Father’s Day this year.
During "Moving On" group, an African American woman whose son had unexpectedly died in his early 20’s, shared her rage: "I am angry with my Father [referring to her Higher Power] and don't understand." A Hispanic woman in her mid-20's said, "It makes me sad because I think of my kids [in foster care] who I haven’t seen in years. My kids and my father. He's the reason I've got them. I don't want to think about that." As we went deeper, clients cried and reached out to one another. As our time together drew to a close, I said, "let's stand" and led the group in a breath-centered spontaneous prayer with everyone holding hands. This transformed into a group hug. While reflecting alone immediately afterwards in silence, a client returned to the room. He had forgotten his paper. Seeing me, he said, "this room finally served its purpose." I nodded silently.
I look forward to extending this vision widely, beginning with a website,www.sensingwonder.com. As our world grows larger and smaller, Healing Community is our shared purpose and awesome responsibility. Like a lightning rod, we can be energized when inconceivable power moves through us. Nothing to fear. Nothing to hold us back. How marvelous!
 Jon Kabat-Zinn, Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, Hyperion, 1994, 4.
 Thich Nhat Hahn, Being Peace, Parallax Press, 1987, 87.
 Rabbi Arthur Waskow, Seasons of Our Joy, Beacon Press, 1982, 191-192.
Judy Fleischman served as Staff Chaplain at Housing Works' West 13th Street Adult Day Treatment Center in New York City from 2006-2009. She is a Zen Buddhist priest with Village Zendo and served for eight years as coordinator of the New York City Chapter of Buddhist Peace Fellowship. She also served as a member of The Buddhist Council of New York and became an adult Bat Mitzvah at Congregation Rodeph Sholom in New York City.