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Resiliency After Violent Death: Lessons for Caregivers
"All I can say is, 'Oh my God, Oh my God." I feel like I'm going to split into pieces. Why did God let this happen? If there's a God, I hate him."
Margaret Grogan, whose son was murdered
" I rarely attended church before Adrianne was killed. However, the church I belonged to supported me more than I could possibly have imagined. Sometimes people said insensitive things, but I knew they were trying. I found my basic faith getting stronger. I don't think I could have survived without feeling God was with me."
Linda Jones, whose daughter was murdered
How to Provide Spiritually Sensitive Trauma Care
Janice Harris Lord, ACSW
Trauma care providers may not be addressing the whole person if they avoid inquiry about how the client's faith and religious perspectives are being affected by the trauma. For many people, spirituality forms the root of their identity. Consequently, neglecting the spiritual dimension is like ignoring a client's social environment or physical health state.1
Persons of faith who believed, before their traumas, that they were spiritually protected can react with despair when they or someone they love falls victim to trauma. The rules they believed in no longer seem to apply. Many people of faith base their lives on the belief that good things come to good people and bad things come to bad people. When something bad and undeserved happens, they may no longer be able to trust that belief system. They may have to reconstruct their theology to accommodate what has happened to them - and that process can be long and challenging.
Trauma also introduces integrity issues for many people. They may be told by faith leaders, family, or friends that they should forgive the person who brought about the traumatic circumstances because this is what God expects of them. While most trauma survivors recognize that this is a noble goal, they simply may be unable to do so at the time. They cannot accept that which seems unfair and undeserved as divine providence.
Faith leaders must learn enough about trauma that they will not underestimate or over-spiritualize symptoms. Faith-related scriptures or sayings can help, but they don't always. Rabbi George Stern2 points out that faith leaders must be aware of aspects of their teachings that lend themselves to interpretations that can be harmful for those who have experienced trauma. They must be willing to educate themselves and others where questions of interpretation may arise. Faith leaders must be competent and prepared to make referrals to the mental health community when it is warranted.
Likewise, trauma care providers must be sensitive to spiritual diversity and be prepared to make appropriate referrals to the faith community. They must learn enough about the faiths practiced in their communities to ensure that they do no harm by failing to recognize how spirituality can be affected by trauma - or how trauma can be affected by spirituality. Learning to recognize and affirm spiritual aspects of trauma is no different than learning about head injuries, post-traumatic stress disorder, or cultural diversity in an effort to better serve the suffering. Referrals for spiritual guidance should be made only to faith leaders who interpret their sacred texts and exercise religious practices in helpful rather than hurtful ways to those trying to resolve their traumas.
It is important to remember that not all those who proclaim a certain faith or alternative spirituality have the same experience. Ranging from true atheist to agnostic to true believer of a particular religion, persons may find themselves at different degrees of belief or non-belief at different times. Their faith may be dramatically affected by their traumatic experience, or it may be unchanged.
Let's begin with definitions. Many different definitions of faith, religion, and spirituality have been proposed through the ages, but for purposes of this article, these definitions are used:
Each person's spirituality journey must be respected as uniquely his or her own. Trauma care providers may find it challenging to set aside their own faith values and validate those that differ. It is challenging to attempt to genuinely understand and respect their perspective. Even non-verbal body language sometimes conveys an attitude that can make a client feel rejected. Facial expressions like subtle and unintentional frowns or turning the head away when a client brings up spiritual matters speak volumes. Folding ones arms across the chest generally communicates defensiveness or an unwillingness to listen, and that protective gesture can almost happen unconsciously. Getting comfortable with differences is not only a matter of education but one of commitment.
Native Americans, those of many Asian cultures, practitioners of Hinduism, Buddhism, and Islam, and other groups may avoid eye contact, control expression of feelings, and go to great lengths not to hurt feelings. This does not necessarily mean that they are being untruthful, avoiding the issue, or that they are not suffering. It may simply mean that they are being respectful and following mandates taught to them by their elders.
Similarly, using the spiritual language of one's own faith can create distance from a client whose faith differs. It is important to develop inclusive spiritual language that does not seem foreign or offensive to a person of a different faith. For example, the word clergy is not used in Native American Spirituality, Hinduism, or Buddhism. These groups will likely be more comfortable with faith leader or spiritual teacher. The Bible is used only in Christianity. Jews use the Torah and the Talmud. Muslims use the Qur'an. Others use sacred texts. Christians worship in a church but followers of other faiths worship in a faith community, house of worship, temple, synagogue, mosque, or meditation center.
The guidance of Dr. Harold G. Koenig, Associate Professor of Psychiatry and of Medicine at Duke University Medical Center, who educates physicians about how to take a spiritual history, may well serve trauma care providers as well. He points out that (1) the questions should be brief, requiring only a few minutes to ask; (2) the questions should be easy to remember so they may be asked at the most appropriate time (usually within the context of a social history); and (3) the information sought should be all about the patient's (client's) beliefs and nothing about the physician's (trauma care provider's) beliefs.3
Conducting a brief spiritual assessment can help the trauma care providers ascertain whether or not a client wants to address spiritual issues. The following questions can be helpful in assessment. If responses indicate that the client has no interest in spiritual resources, the provider should move on to other areas of concern. If the client's responses are spiritually-oriented, then the provider should explore their answers as any other assessment issue might lead to exploration of strengths and areas of need.
"What is most important to you in your life right now?"
"What has been meaningful and helpful to you as you have coped with your trauma?"
"How are you feeling within yourself?"
"What has strengthened you as you deal with this?"
"Do you have a support system you rely on?
If you are comfortable addressing spirituality more directly, you may consider the three questions Dr. Dale Matthews, Associate Professor of Medicine at Georgetown University, asks his patients:4
"Is religion or spirituality important to you?"
"Do your religious or spiritual beliefs influence the way you look at your problems right now?"
"Would you like to include your religion or spirituality in the work we do together?"
Obviously, if the answer to the first question is "no," you would not explore it further.
The second question offers the opportunity to express how a client's religion or spiritual beliefs may shape their reaction to the trauma they are experiencing. The client's response to this question may inform about religious restrictions on medical treatment or anxiety about therapy. It may provide information about how the client understands forgiveness and justice, which may influence their level of cooperation with the justice system, if applicable
Validating a client's faith experience does not require expertise in the religions of the world, but it does require recognition of common ways to alienate someone spiritually. With an ironically invalidating title, The Complete Idiot's Guide to World Religions, the book suggests how to avoid errors when seeking information from someone of an unfamiliar faith:5
Referral, Consent, and Confidentiality
Offering spiritually sensitive trauma care requires identifying people in the community who represent the spiritual and cultural groups to be served, such as volunteers or spiritual leaders who are known and trusted in the community. These "gatekeepers" may not be official or recognized community leaders or traditional agency heads, but may have established relationships with trauma survivors and their families and are usually willing to help. These gatekeepers can usually be identified by asking community members who they would likely turn to for help in a time of trouble.
Trauma clients who are seeking spiritual "answers" that require expertise beyond listening and support should be referred to others for more specialized assistance. Trauma care providers can conduct a brief spiritual assessment, can learn about how the spirituality of the client is helping or hindering their healing from trauma, and can help a client sort out options for dealing with spiritual issues. However, they should not provide theological explanations or impart religious theology. Similar to helping clients acquire quality medical care or financial support services, trauma care providers should refer to appropriate, competent spiritual resources who do not re-victimize people theologically.
Chaplains who are certified by the Association of Professional Chaplains6 generally practice in hospitals and have been educated to meet the spiritual needs of a wide variety of people. Members of the American Association of Pastoral Counselors (AAPC)7, likewise, have received both theology and counseling education. Certification in either group requires that an individual complete four years of college, three years of theology school, and one to four years of Clinical Pastoral Education followed by written and oral board certification.
While these individuals may be the most appropriate referral sources, pastoral counselors of the victim's faith and culture also may be consulted. However, not every pastor who counsels is a pastoral counselor. Many who identify themselves as pastoral counselors have received no formal education in counseling at all, so it is important to ask.
It is not necessary to seek consent to include a spiritual assessment in the social assessment or other general inquiry aimed to support the whole person. However, anything beyond spiritual assessment and support requires the informed consent of the client. This includes written consent of the client before discussing his or her situation with a faith leader, teacher, parish nurse, chaplain, or spiritual/pastoral counselor.
Issues surrounding confidentiality can get complicated for those who are both faith leaders and licensed therapists. These individuals must be careful to avoid dual relationships (separating pastoral and counseling functions) with their followers. A recent Texas case involved a faith leader who was both a Christian pastor and a Licensed Professional Counselor (LPC). In a counseling relationship, a woman in his congregation revealed information about her marriage to him and later alleged that he had revealed this information to the church board and congregation, directing them to avoid contact with the woman "until the time of repentance and restoration." By doing so, he ignored well-established ethical standards for both Licensed Professional Counselors in the State of Texas and pastoral counselors. The woman filed suit against the pastor and it is still moving through the courts with the 2nd Court of Appeals finding that, as a Licensed Professional Counselor, the pastor is accountable to professional standards for confidentiality established by the Texas Professional Counselors' Act.
Spirituality and religious practice are strengthening factors in the lives of many trauma survivors. Supporting them with spiritually-sensitive trauma care validates and supports them. On the other hand, some people find that their traditional religious beliefs and practices are more hurtful than helpful as they try to cope with traumatic experiences. Still others have no spiritual perspectives to their lives and should not have spiritual expectations placed on them. The focus of this article has been on how to conduct a brief spiritual assessment, how to respect and support a victim's faith perspective, and how to refer to appropriate spiritual leaders when the assistance needed is beyond the expertise of the trauma care provider. The author trusts that trauma care providers will take this information as only the first step. Developing a better understanding of what is happening spiritually with a client is achieved through ongoing gentle, respectful inquiry.
Copyright: Janice Harris Lord & Gift From Within
Janice Harris Lord is a Fellow in Thanatology: Death Dying, & Bereavement with Association of Death Education and Counseling (ADEC) and is a national consultant on crime victim issues. The 6th edition of her classic book for survivors, "No time for Goodbyes: Coping with Sorrow, Anger, and Injustice After a Tragic Death" has just been released, and the article above was excerpted from a forthcoming publication on Spiritually-Sensitive Multi-Faith Practices. She is a panel member on the DVD, Resiliency After Violent Death: Lessons for Caregivers, produced by Gift From Within.
Supplemental Information and Resources
Barton, David. 2004. Original Intent: The Courts, the Constitution, and Religion. Aledo, TX: Wallbuilder Press.
Canda, Edward and Leola Furman. 1999. Spiritual Diversity in Social Work Practice. New York: The Free Press.
Hopfe, Lewis. 1994. Religions of the World (6th Edition). New York: Macmillan.
Johnson, Jay and Marsha McGee. 1998. How Different Religions View Death and Afterlife. Philadelphia: The Charles Press.
Koenig, Harold. 2002. Spirituality in Patient Care. Philadelphia: Templeton Foundation Press.
Lampman, Lisa (Ed.). 1999. God and the Victim. Grand Rapids, MI: William B. Eerdmans.
Magida, Arthur and Stuart Matlins. 1996 and 1997. How to be a Perfect Stranger: A Guide to Etiquette in Other People's Religious Ceremonies (Volumes I and II). Woodstock, VT: Jewish Lights
Scales, T., Terry Wolfer, David Sherwood, Diana Garland, Beryl Hugen, and Sharon Pittman. 2002. Spirituality and Religion in Social Work Practice. Alexandria, VA: Council on Social Work Education.
Toropov, Brandon and Father Buckles Luke. 2001. The Complete Idiot's Guide to World Religions (2nd Edition). New York: Alpha Books.
Van Hook, Mary, Beryl Hugen, and Marian Aguilar. Spirituality Within Religious Traditions in Social Work Practice. Pacific Grove, CA: Brooks/Cole.
1Koenig, H.G., M. McCullough, and D.B. Larson, Handbook of Religion and Health, New York: Oxford University Press, 2001.
3Koenig, H.G., Spirituality in Patient Care, Philadelphia: Templeton Foundation Press, 2002: 21.
4Matthews, D.A. and C. Clark, The Faith Factor, New York: Penguin, 1999.
5 Toropov, Brandon and Father Luke Buckles, The Complete Idiot's Guide to World Religions, New York: Alpha Books, 1997, 21-25.
6For more information go to www.professionalchaplains.org.
7 For more information go to www.aapc.org.
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