Some may find it odd that I use "religion" and not "spirituality" in the sub-title of this paper. This is so since, with respect to health care outcomes, spirituality must be evidenced through concrete religious practice. Anthropologists tell us that in all cultures spiritual practices (religious rituals) are mediated in some way through a recognized agent, that is, priest, shaman, seer, prophet, medium, etc. This paper supports the premise that there exists an interface between spirituality and health in all cultures. Further, there is a need to increase the understanding among the participants in the interface between spirituality and health and show evidence through outcomes. There is need to articulate any spiritual experience that speaks of the meaning of human existence in clinical practice. The interface between spirituality and health is evidenced in holistic outcomes. A holistic outcome is greater than the sum of the contributions of its procedures. J C Smuts pioneered holistic thinking in the physical sciences with respect to evolution in a creative work entitled, Holism and Evolution. His approach shows evidence of holistic outcomes that transcend the physical and psychological disciplines. Spiritual practice (religious ritual) within specialized clinical settings shows similar evidence of holistic outcomes.
Within specialized the settings of hospitals, schools, and prisons the practice of a spiritual life-style (religious ritual) is conditioned by factors beyond the individual's personal choice. Ill health itself, the institutional environment, the prescribed treatment and often even the health care providers, as such, are not of the individual's choice. These are the "given" conditions, not of the individual's choice, which affect healing outcomes either positively or negatively. This is problematic for both the patient and the health care providers. Often, a religious mediator, (chaplain) knowledgeable in the ways and manners of the institution and perhaps unknown to the patient, assists with the spiritual life practices (religious rituals) when an individual is institutionalized. The belief system and ritual performances that the religious mediator represents and affirms are recognized as important to the well-being and health of the individual. Within a clinical context certain psychologists pioneered work in the area of spirituality and psychology. The psychologist Alfred Adler, (1870-1937), who initially studied medicine, recognized that a religious belief system is supportive of a healthy life-style that could result in healthy outcomes in the clinical context. Adler's Individual Psychology strives for holistic outcomes and develops a life-style that reinforces healthy relationships. These relationships preserve and promote health in the clinical context for both patient and care-giver. Striving for a holistic notion of health, Adler debated the relationship between religious views/ beliefs and mental health with a Lutheran Pastor, Ernst Jahn. From a pastoral perspective I have discussed Adler's psychology as a helpful professional tool. In his Individual Psychology Adler does not restrict his thinking about the helpfulness of beliefs and spiritual practices (rituals) to the Christian religion. Rather, he understands all belief systems and religions, that express a proper human spirituality, to embody a life-style that leads to healthy outcomes. These outcomes may be evidenced in the clinical context. Within the clinical context of holistic outcomes the participants forge the linkage between spirituality and health B formally and informally. Formally, the link is forged by the chaplain or religious mediator, and informally the link is forged by the others who share in the goals of a healthy life-style. Today, in clinical care, this linkage often formed in the context of a multifaith/mulicultural context. This is a growing phenomenon that brings about a new understanding and clarification of the role of the chaplain or religious mediator in the context of clinical health (holistic) outcomes. North America Christian culture, until recently, has accepted the professional institutional chaplain as the mediator in integrating the spirituality and health of an individual. This acceptance of the institutional religious mediator (chaplain) has its roots in the British penal system whose chaplains were to assist in the remedial intent of preparing prisoners to return to life in a Christian society.  In the development of psychiatric hospitals Chaplaincy served a similar purpose. General hospital chaplaincy, while adopting a similar professional structure, replaced the "remedial" aspect of prison and psychiatric hospital chaplaincy with the "pastoral" aspect of patient needs. No rehabilitation was needed. Thus, hospital chaplaincy developed a specific, explicit and continuing connection with the faith community of the individual. Chaplaincy (religious intervention) came to represent the linkage between spirituality and health in the health care institution. In striving for holistic outcomes from the interface of spirituality and health the role of chaplaincy or religious intervention needs further understanding in light of a multifaith context.
Varieties of Pastoral Practice
On the occasion of National Pastoral Care Week 1990, Strunk writes in an editorial that this event draws attention to the notion of pastoral care as a generic term. What does it really mean? How wide are its parameters? Who are its participants?  In North America pastoral practice is historically understood as an enterprise that began with the early Christian community. In Acts and Mark we read of Jesus going about doing good and curing all who had fallen into the power of evil.  Further, the apostle James notes the influence on the ill person of the power of grace through the healing gifts of the community.  Christians believe that spiritual practices (religious rituals) and prayer strengthen the ill person, arouse confidence in divine mercy, and help bear trials in this life more easily. More than mere comfort and mental health is acknowledged in Christian belief about spirituality and health. However, comfort and mental health is a shared outcome of health with other religious belief systems in the contemporary multifaith clinical context. There is evidence to show that all human spiritual practices have a degree of demonstrable healthy outcomes for the individual and society. Within the holistic understanding of the Christian tradition, if bodily health is restored it is expedient for the health of the person, body and soul; the person being greater than the sum of the components. Further, from within the Catholic Christian tradition, Ashley and O'Rourke add >reconciliation' as an aspect of restored health. Pangrazzi notes that an increasing number of non-ordained lay individuals are engaging in spiritual health care practices, that is, acting as agents integrating spirituality and health. "In countries like Holland and Sweden, they are chaplains and receive a regular salary. In others, like France and Italy, they are part of chaplaincy teams, have more limited training, and offer volunteer service."  Do these differing approaches alter the linkage between spirituality and health? Are the health outcomes of the integration of spirituality and health affected by the blend of professional and volunteer agents? These questions need further clinical investigation.
The market place understanding of health care services, medical and spiritual, effects the outcomes of clinical intervention. Clifford observes that "unfortunately the non-theological image of the business enterprise has come to dominate much of the thinking and practice of many churchmen, especially on the North American continent."  In the context of human relationships, "pastoral counseling, as it has evolved over the past twenty-five years, has become a highly specialized part of the spiritual care ministry of the church and synagogue." notes North. From a Christian perspective one could ask: Is the shift to embrace the synagogue, as North suggests is happening, in keeping with the historical concept of pastoral care? Byrd and Jessen note that Christian and non-Christian religious bodies have presented themselves as engaging in specialized spiritual care B a ministry historically reserved to the Christian community.  These developments clearly impinge upon the understanding of the linkage between spirituality and health. How are non-Christian models of spiritual practices of the synagogue, the mosque, Hindu temple and Native Traditions to be integrated into the linkage between spirituality and health? This is a pressing question as the North American culture continues to adjust to an increasing presence of non-Christians in health care facilities. Johanson reviews Augsburger's book, Pastoral Counseling Across Cultures, and offers this critical analysis of a multicultural interface between spirituality and health.
Augsburger's book would do better to emphasize much more clearly the value of referral and finding ways to support indigenous healers. It is grandiose to suggest that a counselor should have facility at working in a nondirective way with an American couple, switch smoothly to a more authoritarian role when working with an Oriental couple, know how to make good contact with a Native American in the next hour, and move on to working with a woman who grew up with voodoo in Haiti. 
All religious traditions engage in an interface between spirituality and health. Saint Paul lists pastors as among Christ's gift to the Church and only the Christian tradition of "the cure of souls" has been gifted with pastors who provide spiritual care. Is there a distinction to be made in spiritual practice between the ordained holding office in the ecclesial community and the laity who minister in the name of the ecclesial community? Because Clifford,  tells us that "there is no universal agreement among its advocates as to the precise relation between the Church and the episcopally ordained ministry [pastors]," clergy and laity must continue their spiritual practices in light of "the meaning and significance of being a pastor in both historic and contemporary forms of the Christian Church." The issue here is ordained ministry in contrast to non-ordained ministry. Carroll Wise appeals to a pre-ecclesiastical understanding of spiritual practice based on the activity of Jesus as recorded in the New Testament. Jesus' activity fits no Levitical, nor ecclesiastical, model of priesthood or ordination. Wise says that the spiritual practice of Jesus was directed to the needs of the people and that the full meaning of this requires much reflection and elaboration.  The need for such reflection is heightened in our contemporary multifaith clinical context . With respect to healing and health care the non-Christian understanding of spirituality differs from that of Christian understanding. Western health care institutions have their genesis in a Christian understanding. The modern medical community has introduced a clinical component. The effect on health care outcomes from this differing approach between Christian and non-Christian spirituality needs further clinical investigation.
The Holistic and Unique Christian Perspective
Christian spirituality has taken on various historical perspectives as believers live out God's revelation in the person of Jesus of Nazareth. The fact that they are Christians, i.e. baptised, characterizes a spiritually distinct community. The relationship between pastor and parishioner in this community is expressed in persona Christi. This relationship needs to be re-examined in light of contemporary experience and the understanding of ordained and non-ordained ministry. Pastoral practice (ministry) focusses, of necessity, on the relationships of Christians among themselves. The interface between spirituality and health recounted in James's letter when sending for the presbyters at a time of illness records this unique relationship. In a crisis the prayer of faith will afford salvation to the sick person James says. This character is lacking in communities formed on natural (human) understanding or fellowship. It is the Christian holistic understanding of health care and healthcare outcomes that differs from a natural presence or fellowship. The latter, from a Christian perspective, is a matter of spiritual care appropriate to the human community.
Models of Religious Intervention (Chaplaincy) in Clinical Practice
Spiritual practice (religious intervention) needs a model. In 1988, Eades could write: "NIBIC chaplains live out the uniqueness of their ministry and represent a broader view of the clergy role than tradition defines for parish-bound pastors. The workplace of these chaplains is the same workplace inhabited by people who both go and don't go to church." In the mind of the National Institute of Business and Industrial Chaplains spiritual practice is not to be reserved to the Christian model. Nor is it likely that in the mind of the NIBIC the office of ordination would be understood as it is in the church. Traditionally, hierarchical churches required a model of ordination as pre-requisite for spiritual practice (religious intervention). This is not the case among congregational churches.
Does this shift in ministry focus affect health outcomes? North says that "we are pastors and lay persons with theological educations whose primary ministry is doing counseling and psychotherapy with individuals, couples, families and groups." Spiritual practices deal with issues of religious and spiritual care. Counselling and psychotherapy deal with issues of the health of the psyche and the spirit but not necessarily within a religious interface of spirituality and health. All issues of the psyche and the spirit do not necessarily involve religious practice. This lack of understanding of the distinction between the health of the human psyche and the human spirit, one on hand, and religious and spiritual health of the individual, on the other, comes about since theological education is no longer reserved to seminaries. This lack of distinction reflects a changing cultural context and raises the question of the relationship between the ordained and the laity with respect to the interface of spirituality and health. Any models developed to teach about spirituality and health will need to take into account these distinctions.
Clifford distinguishes three organizational aspects of the church which could influence the development of teaching models. First, there is a business outlook which tends to shun theological questions. Secondly, there is the "Catholic" outlook which looks upon spiritual practice as "the divinely ordained medium for the transmission of the gospel and sacramental life." And thirdly, the outlook based on "the Reformation doctrine of the Priesthood of all Believers" that commits the entire church to spiritual practice.  Clearly the first cannot be accepted as a tradition within the church. The second concerns the church's minister/pastor as one who derives office, purpose, and message from an authoritative source, the spiritual practice of Jesus of Nazareth, not the corporation in the market place. Clifford's "divinely ordained medium" and the "priesthood of all believers" are notions arising out of the historical community gathered in Jesus' name. It is the risen Christ whom Christian spiritual practitioners, both lay and ordained, represent. They have the message of the good news of what God has done in Jesus the Christ to share with all who are open to it. However, other, non-Christian models of teaching spirituality and assessing health care outcomes in a clinical setting must be considered since they have been shown to have a positive effect the health of patients in institutions. These non-Christian healing traditions need to be presented distinctly from the unique Christian interface between spirituality and health.
Muse warns of the danger that Christian spirituality can become "reduced to a mere symbol of the way to organize the psychic stuff of life on the road to psychological health according to prevailing secular norms" His warning is applicable to non-Christian religious practices as well. Within spiritual practices (religious intervention) one must not psychologize spirituality, nor spiritualize psychology. Such misunderstanding occurs within spiritual practice when goals of one are set through the insights and objectives of the other. These attempts have not always generated healthy outcomes in the interface between spirituality and health. Ashley and O'Rourke observe: "Some ministers are so secularized that they feel more comfortable in a psychotherapeutic role than in a spiritual one and thus fail their patients by refusal to speak in God's name."  The models developed to teach spiritual practices (religious ritual) in a multifaith context ought to distinguish clearly between the role of psychology and theology in providing clinical health care. Only then will the holistic outcomes for health be met and appropriately evidenced for all the participants on the health care team.
In this presentation has tried to show that spiritual practices have traditionally had their proper mediator in the linkage between spirituality and health. The nature of Christian health care spirituality differs from other religious traditions in terms of the intervening agent and the expected spiritual outcomes. Any model of teaching about spiritual health care that is to be developed for clinical intervention will need to take into account this difference in a multifaith context. The integrated role of the religious mediator continues provides on-going opportunity for documentation on health care outcomes in a multifaith context. The integration and intervention of holistic Christian health care practices strive for unique outcomes within a multifaith context.
 J. C. Smuts, Holism and Evolution (New York: Macmillan, 1926).
 Hendrika Vande Kemp, "Wholeness, Holiness, and the Care of Souls: The Adler-Jahn Debate in Historical Perspective," Journal of Individual Psychology, 2000, Vol. 56.
 Allan Savage, Alfred Adler's Social Interest: A Holistic Pastoral Psychology," Explorations: Journal for Adventurous Thought, 1998, Vol. 16, No. 3; and Pastoral Theology/Practice and Alfred Adler's Individual Psychology, Quodlibet: Online Journal of Christian Theology and Philosophy, 2001, Vol. 3, No. 3 (www.Quodlibet.net).
 J. T. L. James, A Living Tradition: Penitentiary Chaplaincy (Ottawa, ON: Correctional Service of Canada, 1990), p. 5.
 Orlo Strunk, Editorial: Celebrating the Reality of Pastoral Care," The Journal of Pastoral Care, 1990, Vol. 44, No. 3.
Acts 10:38; Mark 16:18
 James 5:14- 16
 Benedict Ashley & Kevin O'Rourke, Health Care Ethics: A Theological Analysis (St Louis, MO: Catholic Health Association of the United States, 1987).
 Arnaldo Pangrazzi, "Chaplaincy in Europe," Journal of Pastoral Care, 1995, Vol. 49, No.1, p. 74.
 Paul Clifford, The Pastoral Calling (Great Neck, NY: Channel Press, 1961), p. 6.
 William North, The American Association of Pastoral Counselors," The Journal of Pastoral Care, 1988, Vol. 42, No.3, p. 197.
 Julian Byrd & Arne Jessen, "The Challenge of Chaplains of the American Protesrant Health Association," The Journal of Pastoral Care, 1988, Vol. 42, No. 3, p. 231.
 Gregory Johanson, A Critical Analysis of Pastoral Counseling Across Cultures," Journal of Pastoral Care, 1992, Vol. 46, No. 2, p. 172.
 Ephesians 4:11
Paul Clifford, The Pastoral Calling (Great Neck, NY: Channel Press, 1961). P.11.
 Homer Jernigan, Prolegomena to a Pastoral Theology," Journal of Pastoral Care, 1991, Vol. 24, No. 3, p. 222.
 Carroll Wise, The Meaning of Pastoral Care, (New York, NY: Harper & Row, 1966), p. 4.
 James 5:14 - 16
 Robert Eades, The National Institute of Business and Industrial Chaplains," Journal of Pastoral Care, 1988, Vol. 42, No. 3, p. 247.
 William North, The American Association of Pastoral Counselors," Journal of Pastoral Care, 1988, Vol. 42, No. 3, p. 197.
 T. H. Sanks, Education for Ministry Since Vatican II, Theological Studies, 1984, Vol. 45, p. 498.
 Paul Clifford, The Pastoral Calling, (Great Neck, NY: Channel Press, 1961), p. 6.
 Stephen Muse, Keeping the Wellsprings of Ministry Clear," Journal of Pastoral Care, 2000, Vol. 54, No. 3, p. 260.
 Benedict Ashley & Kevin O'Rourke, Health Care Ethics: A Theological Analysis (St Louis, MO: Catholic Health Association of the United States, 1987), p. 399.
Allan Savage is Catholic Chaplain to the Thunder Bay Regional Hospital and represents the Ontario Conference of Catholic Bishops to the Ontario Multifaith Council. He has published articles on such topics as Supervised Pastoral Education, pastoral care and the relationship between psychology and theology. His first book discusses a phenomenological understanding of liturgy texts and his second, with co-author Sheldon Nicholl, MA (psychology), discusses the influence of Adlerian psychology on theological topics. Allan is a member of the Society for the Study of Theology (UK) and the Catholic Theological Association of Great Britain.