Holistic Trauma-Informed Care:
Integrating Spirituality &
Psychotherapy by Creating a
Healing Sanctuary
H. Jack Perkins, D. Min., LADC
Admission Director,
Rose Rock Recovery Center
ODAPCA’s 39th Spring Conference
April 4, 2014
Integration of Spirituality &
Psychotherapy: A Holistic Path for Making
Meaning Through Trauma. . .
. . . is an interactive session to assist participants gain an understanding of
trauma-informed counseling, explore meaningful ways of integrating
spirituality into evidenced-based interventions, and to demonstrate the use of
sacred literature and exercises to enhance the healing process.
LEARNING OBJECTIVES:
• Develop a greater sensitivity regarding the impact of trauma.
• Learn how to integrate spirituality in assessments and interventions in the
healing process.
• Learn how spiritual metaphors, practices and rituals enhance hope and
meaning.
• Review ethical issues when integrating spirituality in a thoughtful and ethical
manner.
Why include spirituality?
American Association of Medical Colleges (AAMC)
“…incorporate awareness of spirituality, and
culture beliefs and practices, into the care of
patients in a variety of clinical contexts… [and to]
recognize that their own spirituality, and cultural
beliefs and practices, might affect the ways they
relate to, and provide care to, patients.”
Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013
CBS Poll: Prayer Can Heal
February 11, 2009
Does prayer help healing?
Should doctors pray if asked?
Should prayer be standard?
Yes
80%
63%
34%
No
14%
25%
55%
Praying Often And Praying For Others:
Sixty percent of Americans say they pray at least once a
day. Two thirds say they pray for their own health, and 82
percent say they pray for the health of others. But praying
for people they don't know is less common. Protestants
are more likely to pray for people they don't know than
Catholics are.
A ROSE OF HOPE: TOWARD A NEW NEUROPSYCHO-SPIRITUAL APPROACH FOR PERSONAL
FORMATION OF ORPHAN PERSONS WITH
DISABILITIES
Suela Ndoja, MSc
Clinical Psychologist
Italian-Albanian Association
“Project Hope for Orphan‟s Persons with Disabilities”,
Address: L: 3 Heroj, Rr: Pal Engjëlli, Nr- 5 Shkoder,
Albania
American Psychiatric Association:
Practice Guidelines for the Psychiatric Evaluation
of Adults
“Important cultural and religious influences
on the patient’s life…evaluation ought to be
performed in a manner that is sensitive to
the patient’s individuality, identifying issues
of development, culture, ethnicity, gender,
sexual orientation, familial/genetic patterns,
religious/ spiritual beliefs….
Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013
In 1999 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the body
charged with evaluating and accrediting nearly 19,000 health care organizations and programs
in the United States, established Spiritual Assessment Standards as a response to the growing
need for a greater understanding of how spirituality impacts patient care and service.
www.jcaho.org
Examples of elements that could be but
are not required in a spiritual assessment
include the following questions directed
to the patient or his/her family:
• Who or what provides the patient with
strength and hope?
• Does the patient use prayer in their
life?
• How does the patient express their
spirituality?
• How would the patient describe their
philosophy of life?
• What type of spiritual/religious support
does the patient desire?
• What is the name of the patient's
clergy, ministers, chaplains, pastor,
rabbi?
• What does suffering mean to the
patient?
• What does dying mean to the patient?
• What are the patient's spiritual goals?
• Is there a role of church/synagogue in
the patient's life?
• How does your faith help the patient
cope with illness?
• How does the patient keep going day
after day?
• What helps the patient get through this
health care experience?
• How has illness affected the patient
and his/her family?
The American Nurses Association (ANA)
Code of Ethics
The measures nurses take for the patient
enable the patient to live with as much
physical, emotional, social, and spiritual
well-being as possible.
Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013
Social Workers
The NASW Standards for Social Work Practice
in Health Care Settings
The biopsychosocial-spiritual perspective
recognizes that health care services must take into
account the physical or medical aspects of
ourselves (bio); the emotional or psychological
aspects (psycho); the sociocultural, sociopolitical,
and socioeconomic issues in our lives (social); and
how people find meaning in their lives (spiritual).
Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013
Spirituality in Mental
Health Care
For over a century, the divide between
health care and religion has been deepest
and widest in the mental health specialties.
MH professionals have long considered
religious beliefs to be neurotic and often
inimical to good mental health . . . (p. 213)
Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013
Research on religion and mental health
•Religious/spiritual persons with acute emotional
problems tend to have better MH, not worse
•R/S cope better with illness, have less
depression & recover more quickly from
depression, often experience less anxiety, &
have lower rates of AOD use.
•Those with Severe & persistent MH disorders &
are involved in R/S activities cope better & have
fewer exacerbations requiring acute
hospitalizations.
Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013
Spirituality Research: Measuring the
Immeasurable
David O. Moberg
The growing body of evidence that there is
a strong positive relationship between
spiritual health and other forms of physical,
psychological, and social health would
seem to suggest that therapeutic
interventions with clients might be
enhanced by addressing spiritual
dimensions of the client’s life experiences.
~ Simpson, Newman, Fuqua, “Spirituality & Personality”
Defining the terms:
Religion and Spirituality
• Generally, spirituality is considered as a characteristic of individuals, while
religion is considered to be a social or organizational phenomenon. For present
purposes, we adopt the definitions of religion and spirituality offered in Koenig,
McCullough and Larson 52:
• Religion is an organized system of beliefs, practices, rituals and symbols designed
to: facilitate closeness to the sacred or transcendent (God, Higher Power, or
ultimate truth/reality) and foster an understanding of a person’s relationship and
responsibility to others in living together in a community.
• Spirituality is the personal quest for understanding answers to ultimate questions
about life, about meaning and about relationship to the sacred or transcendent,
which may (or may not) lead to, or arise from, the development of religious
rituals and the formation of community.
FIVE AREAS OF PERSONAL DEVELOPMENT
 Your spiritual side is what you believe about the purpose of life--why
you and others are here and what happens to you once you die.
 Your emotional side . . . consists of your feelings--how you recognize,
accept, and express them.
 Within your intellectual side, we include your beliefs, ideas, theories,
opinions, and logic, as well as the ways in which you learn, make
decisions, and think.
 Your social side is the part of you that interacts with other people,
God, and even animals. It includes your ways of talking, listening,
playing, celebrating, fighting, and otherwise being with others.
 Finally, your physical side includes your appearance, health, energy or
vitality, sexual drive, and the physical activities you pursue such as
walking, running, painting, swimming, dancing, and playing croquet.
G. Brain Jones and Linda Phillips-Jones, Men Have Feelings, Too! (Wheaton: Victor
Books, 1988), 22-23.
The impact of trauma
What’s the problem?
• An estimated 70% of adults in the US have experienced a traumatic event at
least once in their lives, & up to 20% of these people will go on to develop
PTSD.
• More than 13 million Americans have PTSD at any given time.
• Approximately one in 13 people in this country will develop PTSD during
their lifetime.
• An estimated one out of 10 women will get PTSD at some point in their lives.
• Women are twice as likely as men to develop PTSD.
• Almost 17% of men & 13% of women have experienced more than three
traumatic events.
http://www.chaada.org/default.asp
•
•
•
•
•
•
It has been shown that 3-7% of boys are sexually abused by the time they
reach eighteen and 2-5% of girls
About 3% of American men – a total of 2.78 million men – have experienced
a rape at some point in their lifetime (Tjaden & Thoennes, 2006).
In 2003, one in every ten rape victims was male. While there are no reliable
annual surveys of sexual assaults on children, the Justice Department has
estimated that one of six victims are under age 12 (National Crime
Victimization Study, 2003).
71% of male victims were first raped before their 18th birthday; 16.6% were
18-24 years old, and 12.3% were 25 or older (Tjaden & Thoennes, 2006).
Males are the least likely to report a sexual assault, though it is estimated
that they make up 10% of all victims (RAINN, 2006).
22% of male inmates have been raped at least once during their
incarceration; roughly 420,000 prisoners each year (Human Rights Watch,
2001).
The estimated risk for developing PTSD after any of
the following traumatic events:
• Rape (49 percent)
• Severe beating or physical assault (31.9 percent)
• Other sexual assault (23.7 percent)
• Serious accident or injury; for example, car or train accident (16.8 percent)
• Shooting or stabbing (15.4 percent)
• Sudden, unexpected death of family member or friend (14.3 percent)
• Child’s life-threatening illness (10.4 percent)
• Witness to killing or serious injury (7.3 percent) Natural disaster (3.8
percent)
http://www.chaada.org/default.asp
PTSD AMONG COMBAT PERSONNEL:
• Lifetime occurrence (prevalence) in combat veterans 10 – 30%.
• In the past year alone the number of diagnosed cases in the military jumped
50% – and that’s just diagnosed cases.
• Studies estimate that 1 in every 5 military personnel returning from Iraq and
Afghanistan has PTSD.
• 20% of the soldiers who’ve been deployed in the past 6 years have PTSD.
That’s over 300,000.
• 17% of combat troops are women; 71% of female military personnel develop
PTSD due to sexual assault within the ranks.
• Doing the breakdown by war:
• Afghanistan = 6 – 11% returning vets have PTSD
• Iraq = 12 – 20% returning vets have PTSD ~
http://healmyptsd.com/education/post-traumatic-stress-disorder-statistics
Teens and Children and PTSD:
• 15-43% of girls and 14-43% of boys will experience a traumatic event
• 3-15% girls and 1-6% of boys will develop PTSD
• As many as 30 – 60% of children who have survived specific disasters
have PTSD
• According to the National Center for PTSD: “Rates of PTSD are much
higher in children and adolescents recruited from at-risk samples. The
rates of PTSD in these at-risk children and adolescents vary from 3 to
100%.”
• 3 - 6% of high school students in the U.S. who survive specific disaster
develop PTSD
• More than 33% of youths exposed to community violence with
experience PTSD ~ http://healmyptsd.com/education/post-traumatic-stress-disorder-statistics
PTSD & GENDER
• Men have 30% greater risk of being involved in a traumatic event
than women, since they are more prone to witnessing a
death/injury and experiencing accidents, nonsexual assault,
combat, disaster, fire, serious illness, and injury.
• Sexual abuse is more common among women than men and is
more likely to lead to PTSD than other type of trauma.
Consequently, women have twice the reported risk of PTSD as men.
• The more severe women's PTSD, the more likely they are to
experience physical symptoms, such as shortness of breath,
headaches, joint pain, and abdominal pain.
• Men may under-report psychiatric symptoms and develop other
responses, such as alcohol/drug abuse, conduct disorders, and
violence.
Are We Living In A Traumatized Society?
The entire experience with trauma provoked disturbing insights that
have shaken us out of our complacency. The insight that humans have
a predisposition to repeat traumatic experience has led to the eruption
of a profound and disturbing fear: Our society appears to be in the grips
of a post-traumatic deterioration that could also end in self-destruction,
just as it does with patients who remain locked in the patterns of the
past. We have become convinced that trauma is not an
unusual or rare experience, but that it is in fact normative.
Just as a traumatic experience can become the central
organizing principle in the life of an individual victim, so too
is trauma a central organizing principle of human thought,
feeling, belief, and behavior that has been virtually ignored in
our understanding of human nature. Without this understanding
we cannot hope to make the sweeping changes we need to make if we
are to halt a universal post-traumatic deterioration.
Sandra Bloom, Creating Sanctuary: Toward The Evolution Of Sane Societies (1997).
AVOIDANCE OF PTSD TREATMENT
These percentages are likely to be somewhat understated, not
only because the prevalence of PTSD may increase during the two
years after exposure to trauma, but also because of soldiers' fears
of the repercussions of admitting they are having difficulty. Even
among soldiers with no mental health symptoms, general distrust
and perceived barriers to seeking mental health services were
obvious. Eighteen percent of these study participants reported they
would be too embarrassed to seek mental health services. Twenty
four percent felt admitting a problem could hurt their careers, and
31 percent felt they would be seen as weak.
Integration of
Spirituality in
assessments &
interventions
EVIDENCE OF RELIGIOSITY/SPIRITUALITY
• Over 90% of Americans believe in God or in a higher power;
• 60% belong to a local religious group;
• 60% think that religious matters are important or very
important in how they conduct their lives;
• 40% attend religious services almost weekly or more;
• 80% are interested in “growing spiritually”
Pargament (2007) and reported in the National Opinion
Research Center’s General Social Survey (Schott 2007),
(Bergin, 1983; Gartner et al., 1991;
Meichenbaum, 1994)
• A National survey conducted by Schuster et al. (2001)
found that after the terrorist attacks of September 11,
2001, 90% of Americans reported that they turned to
prayer, religions or some form of spiritual activity with
loved ones in an effort to cope;
• Following Hurricane Katrina, 92% of those who
survived and who were evacuated to shelters in
Houston said that their faith played an important role
in helping them get through
(www.kff.org/newsmedia/7401.cfm);
PATHWAY TO RECOVERY:
Integrating Spirituality & Psychotherapy
“Doing the will of God from your heart.” Ephesians 6:6
The Path to Recovery & Healing
Soul, ψυχη
Psuche
Psychology
Paradigms
Spiritual
Paradigms
Extreme Humanism
Extreme Religiosity
Integrated Paradigm
Jack Perkins, D. Min, LADC (2005)
Psychospiritual Model of Spiritual Formation
David Benner
This “psychospiritual” framework “refers to the fact
that the inner world has no separate spiritual and
psychological compartments” (1998, p. 110).
Suggesting that the terms soul and spirit are used
interchangeably in Scripture, Benner states that
psychospirituality represents the “immaterial inner
core of human personality” (1998, p. 540).
Consequently, he understands human beings as
integrated beings, and even more fundamentally that
“all persons are created spiritual beings” (1988, p.
104). Our spirituality represents the “human quest for
and experience of meaning, God, and the other” (1998,
p. 87). This spirituality is what it means to be human
(2002b, p. 15).
Spirituality: “The response to a deep &
mysterious human yearning for selftranscendence & surrender”
4 Expressions of our spiritual essence:
• Spirituality as a search for self-transcendence
• Spirituality is that we inherently seek to surrender to, or align
ourselves with, this self-transcendent being or thing
• Spirituality is a human desire to resolve issues of identity, to have a
personal sense of meaning and to know that our existence is not an
accident
• We seek an integration of our being
But me—who am I, and who are these my people, that we should
presume to be giving something to you? Everything comes from you;
all we’re doing is giving back what we’ve been given from your
generous hand. As far as you’re concerned, we’re homeless, shiftless
wanderers like our ancestors, our lives mere shadows, hardly
anything to us. God, our God, all these materials—these piles of stuff
for building a house of worship for you, honoring your Holy Name—it
all came from you! 1 Chronicles 29:14 (MSG)
Views According to Various Traditions:
• Nullification and absorption within God's Infinite Light (Chassidic schools of
Judaism)
• Complete detachment from the world (Kaivalya in some schools of
Hinduism, including Sankhya and Yoga; Jhana in Buddhism)
• Liberation from the cycles of Karma (Moksha in Sikhism, Jainism and
Hinduism, Nirvana In Buddhism)
• Deep intrinsic connection to the world (Satori in Mahayana Buddhism, Te in
Taoism)
• Union with God (Henosis in Neoplatonism and Theosis in Christianity,
Brahma-Prapti or Brahma-Nirvana in Hinduism)
• Innate Knowledge (Irfan and fitra in Islam)
• Experience of one's true blissful nature (Samadhi or Svarupa-Avirbhava in
Hinduism)
• Liberating the individual to return to a natural state (Dionysian Mysteries)
FAITH QUESTIONS
• What are you spending and being spent for? What
commands and receives your best time, your best energy?
• For what causes, dreams, goals or institutions are you
pouring out your life?
• As you live your life, what power or powers do you fear or
dread? What power or powers do you rely on and trust?
• To what or who are you committed in life? In death?
• With whom or what group do you share your most sacred
and private hopes for your life and for the lives of those you
love?
• What are those most sacred hopes, those most compelling
goals and purposes in your life?
James Fowler, The Psychology of Human Development and the Quest for Meaning, p. 3.
William James' Definition of
Religious Experience
Psychologist and Philosopher William James
described four characteristics of religious /
mystical experience in The Varieties of Religious
Experience. According to James, such an
experience is:
• Transient -- the experience is temporary; the
individual soon returns to a "normal" frame of
mind.
• Ineffable -- the experience cannot be
adequately put into words.
• Noetic -- the individual feels that he or she has
learned something valuable from the
experience.
Research by neurotheology indicates that during a
deep state of meditation:
Meditation &
The Brain
“Think on these
things…”
“For God so loved
the cosmos…”
• ATTENTION: Linked to concentration, the frontal
lobe lights up during meditation
• RELIGIOUS EMOTIONS: The middle temporal lobe is
linked to emotional aspects of religious
experience, such as joy and awe
• SACRED IMAGES: The lower temporal lobe is
involved in the process by which images, such as
candles or crosses, facilitate prayer and
meditation
• RESPONSE TO RELIGIOUS WORDS: At the juncture of
three lobes, this region governs response to
language
• COSMIC UNITY: When the parietal lobes quiet
down, a person can feel at one with the universe
SIGNS OF SENSORY INTEGRATION DISORDER
According to Sensory Integration International
• Extreme sensitivity (or underreaction) to touch, movement,
sights, or sounds
• Distractibility
• Social and/or emotional problems
• Activity level that is unusually high or unusually low
• Physical clumsiness or apparent carelessness
• Impulsivity, or lack of self-control
• Difficulty making transitions from one situation to another
• Inability to unwind or calm one's self
• Delays in speech, language, or motor skills
• Delays in academic achievement
SANCTUARY. . .
Ahhh . . . a sanctuary--a place of protection,
safety, peace and rest. A sanctuary of God is a
place inhabited by God--the Almighty Creator, our
Savior, Friend, and Comforter the Holy Spirit.
SPIRITUAL QUALITIES
 serenity,
 peace of mind,
 peace of conscience,
 goodness, honesty,
 genuineness,
 integrity,
 humility,
 kindness,
 generosity,
 courage,
 faith,
 tolerance,
 acceptance,
 optimism,
 wisdom,
 and discipline
Learn How to
Integrate Spirituality
in Assessments &
Interventions in the
Healing Process
RESPONSES TO TRAUMA
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Hyperarousal Continuum
Dissociative Continuum
~ flight or flight ~
~ defeat & surrender ~
Alarm
Vigilance
Fear
Terror
Adrenal Response—Excitement
Expressed externally (aggressive
behavior)
Heart rate, blood pressure, respiration
increases
Muscle tone intensifies
Cognitive processing decreases
Typically adult/male response
Homicide concern increases
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Freezing
Compliant
Dissociative
Fainting
Opioid Response–Serotonin decreases
Expressed internally (day dreaming)
 Heart rate decreases or stays the same
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Muscles become flaccid/numb
Cognitive processing decreases
Child/female response
Potential for suicide increases
Clinical Diagnoses Related to Trauma
• If the trauma did not involve an experience so intense as to
warrant a diagnosis such as Acute Stress Disorder (see below), and
if the symptoms do not represent ordinary bereavement , then an
Adjustment Disorder may be diagnosed.
• The predominant symptoms which characterize an Adjustment
Disorder can be depressed mood, anxiety, disturbance of conduct
(e.g., fighting, vandalism, reckless driving), or other maladaptive
reactions (e.g., physical complaints, work or academic inhibition,
social withdrawal). By its definition, an Adjustment Disorder
cannot last longer than 6 months, unless the precipitating
experience is ongoing or has ongoing consequences.
Clinical Diagnoses Related to Trauma, Cont.
• If, however, the precipitating experience involved actual or
threatened death or physical injury; the symptoms have elements
of dissociation, re-experiencing (i.e., flashbacks), avoidance of
reminders of the experience, and anxiety; and the symptoms
persist for several days and cause a serious impairment in normal
daily functioning, a diagnosis of Acute Stress Disorder (ASD) may
be made. If symptoms persist for longer than one month,
Posttraumatic Stress Disorder (PTSD) may be diagnosed.
• Children subject to repeated, ongoing abuse may also develop
Dissociative Identity Disorder, commonly known as “multiple
personality.”
We conclude that veterans’ pursuit of
mental health services appears to be driven
more by their guilt and the weakening of
their religious faith than by the severity of
the PTSD symptoms of the deficits in social
functioning . . . . This raises the broader issue
of whether spirituality should be more
central to the treatment of PTSD
Fontana & Rosenheck, 2004
• How can you assess your client’s spirituality and the
role it plays in his/her life?
• How can you, as a psychotherapist (helper),
incorporate your client’s spirituality into treatment?
• How can you nurture your client’s spiritual coping
efforts?
• What are the barriers/obstacles of integrating
spirituality into your psychotherapeutic efforts and
how can these be anticipated and addressed?
• What are the dangers of highlighting your client’s
spirituality and how can these be anticipated and
addressed?
Spirituality’s affect on clinical issues
• Isolation and Social Withdrawal. Defining spirituality as a connection to
the sacred, and encouraging trauma survivors to seek supportive, healthy
communities can directly address these symptoms.
• Guilt and Shame. Though not part of the diagnostic criteria for PTSD, guilt
and shame are recognized as important clinical issues. Spirituality may
lead to self-forgiveness and an emphasis on compassion toward self.
• Anger and Irritability. Beliefs and practices related to forgiveness can
address anger and chronic hostile attitudes that lead to social isolation
and poor relationships with others.
• Hypervigilence, Anxiety, and Physiological arousal. Inwardly-directed
spiritual practices such as mindfulness, meditation, and prayer may help
reduce hyperarousal.
• Foreshortened Future and Loss of Interest in Activities. Rediscovery of
meaning and purpose in one's life may potentially have enormous impact
on these symptoms.
Shame and the loss of hope ~ a future
Shame is a deep, debilitating emotion, with complex roots. Its cousins are guilt, humiliation,
demoralization, degradation and remorse. After experiencing a traumatic event, whether
recent or in the distant past, shame can haunt victims in a powerful and often unrecognized
manner. Shame impairs the healing and recovery process causing victims of trauma to stay
frozen, unable to forgive themselves for being in the wrong place at the wrong time. Shame
leaves victims with feelings of sadness and pain at the core of their being. They are unable to
feel the fullness of joy in their lives.
Trauma allows “shame thinking” to blossom from deep roots in culture, religion, family or our
childhood past. As children we tend to blame ourselves for things that happen around us,
because we are limited in our capacity to think about others being responsible. In a five-year
old’s mind if something bad happened, then she or he must have deserved it, therefore the
universe makes sense. It is not until around age 12 that we gain the cognitive capacity to see
how others’ actions and behaviors are more complex with varying degrees of culpability.
However, there are many confusing messages about responsibility in our culture, causing even
adult victims of trauma confusion over responsibility for the perpetrator’s actions. For
example, the way a woman was dressed being part of the questioning by a police officer
investigating a sexual assault.
Shame can dissolve positive self-esteem and leave victims of trauma feeling different and less
worthy and in some cases even bad or evil themselves. The trauma and the resulting shame
potentiate each other, causing greater intensity in the psychological wounds. The end result is
that a traumatized person no longer feels worthy of being loved, accepted, and having good
things happen to them in their life.
Dr. Angie Panos, “Healing from Shame Associated with Traumatic Events”
Spiritual Assessment
Spiritual assessment is defined as the process of
gathering and organizing spiritually based data into a
coherent format that provides the basis for interventions
(Hodge, 2001a; Rauch, 1993). The subsequent
interventions may or may not be spiritually based. As
implied above, a spiritual assessment may be conducted
for the purposes of using traditional, non-spiritual,
interventions in a manner that is more congruent with
clients’ beliefs and values.
Spiritual assessments should be multidisciplinary. Physicians, therapists, nurses,
and clinical pastoral staff should receive training on the value of spiritual
assessments and the tools that should be used to assess a patient’s spirituality.
Joint Commission: The Source [vol. 3, no. 2 (February 2005): 6-7]
Characteristics of Competent Assessors
■ A willingness and a desire to learn about how to conduct a
spiritual assessment
■ An understanding that there are many different spiritual and
religious perspectives
■ An ability to focus on spiritual issues with a patient without
forcing one’s own beliefs on him or her
■ A comfort level with discussing spiritual issues
■ A knowledge of appropriate responses to spiritual disclosures,
including prayer, meditation, walks in quiet nature areas, and so
forth.
Joint Commission: The Source, February 2005, Volume 3, Issue 2
ond PTSD: Soldiers Have Injured Souls
ne Silver
Post
Traumatic
Soul
Disorder
The spirituality history genre
Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009
spiritual history arguably forms its own genre. A “genre” is defined as “a category
of artistic, musical, or literary composition characterized by a particular style,
form, or content” (Webster, 1977). Harold Koenig provides the groundwork for this
genre study in Spirituality in Patient Care where he presents five criteria he
considers critical for a spiritual history (2007):
1. It must be brief.
2. It must be easy to remember.
3. It must obtain appropriate information.
4. It must be patient-centered.
5. It must be validated as credible by experts.
When all five of these criteria are used together, the critic is able to adjudicate the
strengths and weaknesses of various spiritual histories (LaRocca-Pitts, 2008b).
However, when discussing spiritual histories as a distinct genre only the first three
of these criteria are needed.
The spirituality history genre, continued
Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009
When we modify these three criteria in light of published spiritual
histories, we get the following requirements for this genre:
• 1. A spiritual history is brief: it contains a brief series of categories or
topics with pertinent questions.
• 2. A spiritual history is easy to remember: a memorable acronym is
used to recall the categories.
• 3. A spiritual history obtains appropriate information: its questions
address the patient’s spiritual resources, the patient’s use of them in
his/her past and current situation, and how these resources and
uses impact the patient’s medical care.
HOPE (Anandarajah & Hight, 2001)
• H – Sources of hope, meaning, comfort, strength, peace, love, and compassion: What is
there in your life that gives you internal support? What are the sources of hope,
strength, comfort, and peace? What do you hold on to during difficult times? What
sustains you and keeps you going?
• Organized religion: Do you consider yourself as part of an organized religion? How
important is that for you? What aspects of your religion are helpful and not so helpful to
you? Are you part of a religious or spiritual community? Does it help you? How?
• Personal spirituality/practices: Do you have personal spiritual beliefs that are
independent of organized religion? What are they? Do you believe in God? What kind of
relationship do you have with God? What aspects of your spirituality or spiritual
practices do you find most helpful to you personally?
• Effects on medical care and end-of-life issues: Has being sick (or your current situation)
affected your ability to do the things that usually help you spiritually? (Or affected your
relationship with God?) As a doctor, is there anything that I can do to help you access the
resources that usually help you? Are you worried about any conflicts
• H – Sources of hope, meaning, comfort, strength, peace, love, and compassion: What is
there in your life that gives you internal support? What are the sources of hope,
strength, comfort, and peace? What do you hold on to during difficult times? What
sustains you and keeps you going? between your beliefs and your medical situation/care
decisions? Are there any specific practices or restrictions I should know about in
providing your medical care?
Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009
CSI-MEMO (Koenig, 2002)
CSI-MEMO (Koenig, 2002)
CS – Do your religious/spiritual beliefs provide Comfort, or are they a
source of Stress?
I – Do you have spiritual beliefs that might Influence your medical
decisions?
MEM – Are you a MEMber of a religious or spiritual community, and is
it supportive to you? O – Do you have any
Other spiritual needs that you’d like someone to address?
FICA (Puchalski & Romer, 2000)
F – Faith, Belief, Meaning: “Do you consider yourself spiritual or
religious?” or “Do you have spiritual beliefs that help you cope with
stress?”
I – Importance or Influence of religious and spiritual beliefs and
practices: “What importance does your faith or belief have in your life?
Have your beliefs influenced how you take care of yourself in this
illness? What role do your beliefs play in regaining your health?”
C – Community connections: “Are you part of a spiritual or religious
community? Is this of support to you and how? Is there a group of
people you really love or who are important to you?”
A – Address/Action in the context of medical care: “How would you like
me, your healthcare provider, to address these issues in your
healthcare?”
FAITH (King, 2002)
F – Do you have a Faith or religion that is important to
you?
A – How do your beliefs Apply to your health?
I – Are you Involved in a church or faith community?
T – How do your spiritual views affect your views
about Treatment?
H – How can I Help you with any spiritual concerns?
SPIRIT (Abridged: Maugans, 1997; Ambuel
& Weissman, 1999)
S – Spiritual belief system: Do you have a formal religious affiliation? Can you describe this?
Do you have a spiritual life that is important to you?
P – Personal spirituality: Describe the beliefs and practices of your religion that you
personally accept. Describe those beliefs and practices that you do not accept or follow. In
what ways is your spirituality/religion meaningful for you?
I – Integration with a spiritual community: Do you belong to any religious or spiritual groups
or communities? How do you participate in this group/community? What importance does
this group have for you? What types of support and help does or could this group provide for
you in dealing with health issues?
R – Ritualized practices and Restrictions: What specific practices do you carry out as part of
your religious and spiritual life? What lifestyle activities or practices do your religion
encourage, discourage or forbid? To what extent have you followed these guidelines?
I – Implications for medical practice: Are there specific elements of medical care that your
religion discourages or forbids? To what extent have you followed these guidelines? What
aspects of your religion/spirituality would you like to keep in mind as I care for you?
T – Terminal events planning: Are there particular aspects of medical care that you wish to
forgo or have withheld because of your religion/spirituality? Are there religious or spiritual
practices or rituals that you would like to have available in the hospital or at home? Are there
religious or spiritual practices that you wish to plan for at the time of death, or following
death? As we plan for your medical care near the end of life, in what ways will your religion
and spirituality influence your decisions?
FACT (LaRocca-Pitts, 2008ab)
F – Faith (or Beliefs): What is your Faith or belief? Do you consider yourself a
person of Faith or a spiritual person? What things do you believe that give your
life meaning and purpose?
A – Active (or Available, Accessible, Applicable): Are you currently Active in your
faith community? Are you part of a religious or spiritual community? Is support
for your faith Available to you? Do you have Access to what you need to Apply
your faith (or your beliefs)? Is there a person or a group whose presence and
support you value at a time like this?
C – Coping (or Comfort); Conflicts (or Concerns): How are you Coping with your
medical situation? Is your faith (your beliefs) helping you Cope? How is your
faith (your beliefs) providing Comfort in light of your diagnosis? Do any of your
beliefs or spiritual practices Conflict with medical treatment? Are there any
particular Concerns you have for us as your medical team?
T – Treatment plan, FACT moves beyond the content and purpose of the generic
spiritual history and asks for a judgment.
Spiritual Assessment
• What things do you enjoy doing? Are you doing them
now?
• Where does your sense of what to do come from?
• Do you have someone you talk to for [spiritual/
religious]
guidance [matters]?
• What gives your life meaning?
• What sustains you during difficult times?
• What do you hope for?
• Are you part of a religious or spiritual community? Is it a source of support? In
what ways?
• What aspects of your religion/spirituality would you like me to keep in mind as I
care for you?
• Does your religious or spiritual beliefs influence the way you look at your disease
and the way you think about your health?
• As we plan for your care, how does your faith impact on your decisions?
“SPIRITUAL ASSESSMENT: A REVIEW OF COMPLEMENTARY
ASSESSMENT MODELS” ~ David R. Hodge and Crystal Holtrop
Initial Narrative Framework
1. Describe the religious/spiritual tradition you grew up
in. How did your family express its spiritual beliefs?
How important was spirituality to your family?
Extended family?
2. What sort of personal experiences (practices) stand
out to you during your years at home? What made
these experiences special? How have they informed
your later life?
3. How have you transitioned or matured from those
experiences? How would you describe your current
spiritual/religious orientation? Is your spirituality a
personal strength? If so, how?
Interpretive Anthropological Framework
1. AFFECT: What aspects of your spiritual life give you
pleasure? What role does your spirituality play in
handling life’s sorrows? Enhancing its joys? Coping
with its pain? How does your spirituality give you
hope for the future? What do you wish to
accomplish in the future?
2. BEHAVIOR: Are there particular spiritual rituals or
practices that help you deal with life’s obstacles?
What is your level of involvement in faith-based
communities? How are they supportive? Are there
spiritually encouraging individuals that you maintain
contact with?
3.
COGNITIVE: What are your current religious/spiritual
beliefs? What are they based upon? What beliefs do
you find particularly meaningful? What does your
faith say about trials? How does this belief help you
overcome obstacles? How do your beliefs affect your
health practices?
4.
COMMUNION: Describe your relationship to the
Ultimate. What has been your experience of the
Ultimate? How does the Ultimate communicate with
you? How have these experiences encouraged you?
Have there been times of deep spiritual intimacy?
How does your relationship help you face life
challenges? How would the Ultimate describe you?
5.
CONSCIENCE: How do you determine right and
wrong? What are your key values? How does your
spirituality help you deal with guilt (sin)? What role
does forgiveness play in your life?
6.
INTUITION: To what extent do you experience
intuitive hunches (flashes of creative insight,
premonitions, spiritual insights)? Have these insights
been a strength in your life? If so, how?
Rays represent
transcendence-exceeding or
surpassing in degree
or excellence
Self-fulfillment,
realization of
one’s potential,
becoming fully
capable of one’s
potential
Social needs—
friendship,
affection,
acceptance, &
interaction
with others
Feelings of
achievement or selfesteem & need for
recognition or
respect from others
Security, stability,
& freedom from
fear or threat
Psychospiritual & Psychotherapy Goals
The essence of being human, our spirituality, is the response to a
deep and mysterious human yearning for self-transcendence and
surrender:
1. Primary expression is spirituality as a search for transcendence
2. Primary expression of human spirituality is that we inherently seek
to surrender to, or align ourselves with, this self-transcendent
being or thing
3. A human desire to resolve issues of identity, to have a personal
sense of meaning and to know that our existence is not accidental
4. We seek an integration of action and thought, interior life and
external behavior, affect and cognition, conscious and
unconscious, and so forth
David Benner, Psychotherapy and the Spiritual Quest, (1988) pp.104, 21
Incorporating Spiritually-Oriented Activities
Systematically assess for the client’s religious beliefs and activities
and determine how faith and spirituality have been used as a coping
activity.
Refer to scripture or use religious metaphors as teaching examples.
Pray with the client in the session.
Pray for the client.
Use religiously-based imagery, visualization and healing
remembrance activities.
Train clients in mindfulness and acceptance skills of learning how to
develop a detached, nonjudgmental observing style that focuses
attention on experiencing in the present moment. Train clients on
how to witness and accept, rather than avoid and interpret.
EXAMPLES OF SPIRITUAL COPING ACTIVITIES
•FAITH-BASED BELIEFS TO COPE
•ENGAGE IN PURIFICATION AND RELIGIOUS ACTIVITIES
•FEEL STRENGTHENED AS A RESULT OF HAVING ENDURED AND
SURVIVED
•CALL UPON FORGIVENESS
•PERFORM GOOD DEEDS
•CALL UPON RELIGIOUS SUPPORT
Questions For Psychotherapists :
1. How can you assess your client’s spirituality and the
role it plays in his/her life?
2. How can you, as a psychotherapist (helper), incorporate
your client’s spirituality into treatment?
3. How can you nurture your client’s spiritual coping
efforts?
4. What are the barriers/obstacles of integrating
spirituality into your psychotherapeutic efforts and how
can these be anticipated and addressed?
5. What are the dangers of highlighting your client’s
spirituality and how can these be anticipated and
addressed?
READINESS FOR ENHANCED
SPIRITUAL WELL-BEING
Have a desire for enhanced hope;
Never _____________________________ Always
1
2
3
4
5
6
7
8
9
10
Feel that there is meaning and purpose to their life;
Never _____________________________ Always
1
2
3
4
5
6
7
8
9
10
Have a sense of peace or serenity;
Never _____________________________ Always
1
2
3
4
5
6
7
8
9
10
H. Jack Perkins, D. Min., LADC, (2006) adapted the assessment tool by incorporating the use of continuums
and assisting clients in identifying weak areas with goals and objectives to address. The use of continuums is
predicated upon the belief that assessing these areas of spiritual well-being is not a “black or white”/“yes or no”
response. In reality, a person will move to the right or left on each of the continuums at different phases of life
and/or experiences. This nursing diagnosis is a standardized statement about the health of a client (individual,
family, or community) for the purpose of providing nursing care. One organization for defining standard
diagnoses is the North American Nursing Diagnosis Association now known as NANDA-International. Nursing
diagnoses are developed during the course of performing health assessments.
THE MIRACLE QUESTION
"Suppose tonight, while you slept, a miracle
occurred. When you awake tomorrow, what
would be some of the things you would notice
that would tell you life had suddenly gotten
better?“
Solution Focused Therapy (aka Brief Therapy) emerged in the 1980's as an
branch of the systems therapies. A married therapist couple from Milwaukee,
Steve de Shazer and Insoo Kim Berg are credited with the name and basic
practice of SFT.
Robert Schuller, encourages us to dream big dreams and take them to
God, for there is “No dream too big for God.” Prayer: My Soul's
Adventure with God: A Spiritual Autobiography (1995)
Spiritual metaphors,
practices & rituals
that enhance hope &
meaning
Functions of Spiritual Rituals
Several major meta-analytic reviews have been
conducted that demonstrate that individuals who
use religious and spiritual coping efforts
demonstrate greater physical and emotional wellbeing (Ano &Vasconcelles, 2005; Gall et al., 2005;
Miller & Kelley, 2005; Pargament. 2007). Religious
coping has been found to have a significant
association with a variety of adjustment indicators
including lower levels of depression and alcohol
consumption, fewer somatic complaints, fewer
interpersonal problems, lower mortality, and greater
levels of life satisfaction, more use of social
supports and overall improved coping ability.
Functions of Spiritual Rituals
Individuals who have been victimized often describe themselves in negative
self disdaining terms that can become self-fulfilling prophecies. As a result of
experiencing this traumatic event, victims may convey that they feel:
“dirty, contaminated, desecrated, polluted, worthless, stupid,
emptied, as if I fell into a bottomless pit”
“I’m dead inside. I am an emotional orphan. Feel stagnated. I am
carrying too many battle scars.”
“I feel this is God’s punishment for my sins. God has abandoned me.
I am all alone, a burden to others.”
Such expressions of feeling permanently scared and damaged and
mentally defeated contribute to the absence of the ability to engage in
mental planning and adaptive coping. Ehlers and Clark (2000) highlight
that traumatized individuals who evidence persistent PTSD have an
inability to develop a coherent recounting (narrative) of trauma
experiences.
Spiritual & Religious Activities Can Act To:
1. Normalize reactions and internal spiritual struggles.
2. Encourage emotional expression, emotional control and emotional comfort
by fostering self-disclosure and sharing. (Pennebaker, 1997 has
highlighted the benefits of “opening up” and sharing accounts of
trauma, instead of keeping them “secret.”)
3. Convey a sense of “control” and “mastery” that helps people feel that they
are not mere victims of arbitrary events in which “bad thing happen to good
people” or that “good things happen to bad people.” A belief in a “higher
power” who is perceived as being in control implies less arbitrariness in
what happens.
4. Foster social connectedness with fellow congregants, clergy and with a
higher power or deity. Participation in a faith community can help a victim
find ways to create blessings from his/her tragedy. This is not to minimize
the tragedy or make it seem salutary or beneficial. Rather, through such
activities as sharing one’s story with others and/or ministering to others who
face a similar situation, one has the opportunity to see that blessings can
come from hardship and adversities.
Spiritual & Religious Activities Can Act To:
5. Promote group cohesiveness, connection and a sense of communion,
both with the past and the present.
As Cacioppo et al., 2005 also observe, “socially connected individuals
are more likely to behave in a selfless fashion reinforcing their
connections to others and enhancing their self-esteem. Socially
isolated individuals are more likely to act in a socially protective and
self-deflating manner. Social isolation and accompanying loneliness
can have negative physiological consequences (increasing
sympathetic activation and contribute to sleep disturbances that can
exacerbate stressful reactions).”
Spiritual & Religious Activities Can Act To:
7. Provide opportunities for public expressions of shared grief and mutual
support and reassurances that victims’ sacrifices and lives will be
remembered, honored and commemorated. As Elie Weisel (1960)
observed:
“I belong to a people whose suffering is the most ancient in
the world. I belong to a people whose memory keeps the
suffering alive. Just as all days were created for one day
alone, the Sabbath, all other words were created and given
for one word alone. Remember!”
8. Offer a degree of closure on a painful period and encourage transition behaviors to
engage in new adaptive activities and nurture hope. As Snyder (2002) observes:
“there is a need to nurture hope and optimism that leads to engaging in goal
directed behaviors and embracing positive strivings and visions.
Encourage access to inner strengths, empowerment, control and
acceptance.”
Spiritual & Religious Activities Can Act To:
9. Nurture meaning-making in the face of misfortune. As Gall et al. (2005,
pp 95-96) observe:
“If a higher power is perceived to be at work in a stressful
event, then the event may be viewed as an opportunity to
learn something that this higher power is trying to teach. The
event may also serve as a ‘wake-up call’ to take stock of life
and rearrange priorities”
10.Provide guidance in the form of coping models. The Bible, the Torah, the
Koran and other holy scriptures can be viewed as “inspirational self-help
books,” providing a framework to cope with stress.
SPIRITUALITY-ORIENTED PSYCHOTHERAPEUTIC
INTERVENTIONS
How can therapists use metaphors, analogies
and story-telling as a way to help victimized
individuals become “unstuck” and reframe
events?
Psychotherapists are good “story tellers” and they incorporate
metaphors ands analogies in their stories in a timely and judicious
fashion and in a manner that is personally relevant to the individual
being helped. The psychotherapist can use the client’s experience to
select the relevant metaphorical example and spiritual activities that
nurture hope and help individuals get "unstuck” from the negative
impact of having been victimized.
Create A Welcoming Environment
Goals of Using Christian Metaphors, Stories, &
Rituals/Practices:
Metaphoric Imagery Work: Metaphoric imagery work can
focus briefly on a specified image until a
particular goal is accomplished. We believe this is most
effective when experienced not only visually, but also
kinesthetically and auditorally.
Metaphoric Narratives: The stories or narratives told at this
level are more circumscribed in their content and purpose
than the strategic metaphors, they are often shorter.
Metaphoric Actions: Thus far we have presented metaphors
as stories and in guided imagery work.
“The Use of Metaphors in Psychotherapy”, ELIEZER WITZTUM, M.D.
ONNO VAN DER HART, PH.D. BARBARA FRIEDMAN, M.A., M.F.C.C.
Function of Metaphors, Stories, &
Christian Rituals/Practices
• Normalize reactions and internal spiritual struggles.
• Convey a sense of “control” and “mastery” that helps
people feel that they are not mere victims of arbitrary
events.
• Foster social connectedness with fellow congregants, clergy
and with a higher power or deity.
• Promote group cohesiveness, connection and a sense of
communion, both with the past and the present.
Function Cont.
• Provide opportunities for public expressions of shared grief
and mutual support and reassurances that victims’
sacrifices and lives will be remembered, honored and
commemorated. As Elie Weisel (1960) observed:
“I belong to a people whose suffering is the most
ancient in the world. I belong to a people whose memory
keeps the suffering alive. Just as all days were created for
one day alone, the Sabbath, all other words were created
and given for one word alone. Remember!”
Function Cont.
Traumatic memories are not obstacles to be
obliterated, removed, escaped from (for these
efforts will fail), but these memories are a bridge
from the past to the present and the future.
Memories are not to be forgotten, but to be
contained and sanctified. Jeffrey Jay (1994), in a
thoughtful article, “Walls for wailing,” highlights
the need for traumatized individuals to “move
toward memory,” rather than “move beyond
memory.” Thou shalt remember, thou shalt seek
an accounting! Jay also advises:
“One must have the courage of memory because
through it, one can seek God.”
Function Cont.
• Offer a degree of closure on a painful period and
encourage transition behaviors to engage in new
adaptive activities and nurture hope.
• Nurture meaning-making in the face of misfortune.
• Provide guidance in the form of coping models. The
Bible, the Torah, the Koran and other holy scriptures
can be viewed as “inspirational self-help books,”
providing a framework to cope with stress.
Jesus Offers Spiritual Cleansing
Jesus said, "Everyone who
drinks this water will get
thirsty again and again.
Anyone who drinks the water I
give will never thirst—not
ever. The water I give will be
an artesian spring within,
gushing fountains of endless
life." ~ John 4:1-26
Bread of Life
Explore the value of using metaphors in Christian
counseling
Jesus said to them, “I am the bread of life; whoever
comes to me will never hunger, and whoever believes in
me will never thirst.
Relationality Word Pictures from John’s Gospel
Poetic Description
Relationality
Component Implication
Word (1:1, 14; 8:12)
Wisdom/deity within humanity
Support social self/mind
Light (1:4-5; 8:12; 9:5)
Wisdom/righteousness displayed Inspire hope for holy living
Lamb of God (1:35)
Sacrificial burden bearer
Prevent or bear others’ pain
Messiah (4:25-36)
Redeemer and healer
Intercede and cure
Living water (4:13; 7:37) Refreshment resource
Encourage and refresh
Bread of life (6:35, 48)
Nurturance source
Nurture and support
Gate (10:7)
Watchman/security system
Provide safety
Good Shepherd (10:11) Attendant, protector, provider
Selflessly serve
Resurrection (11:25-26) Guide through death
Affirm life and hope
Eternity’s pioneer (14:3) Caretaker for an eternal home
Foster role and place
Way (14:6)
Pathway and guide to eternal life Inspire wisdom
Truth (14:6)
Ultimate authority for reality
Speak truth in love
True Vine (15:1, 5)
Supply connection and lifeline
Establish life in community
Advocate (16:23)
Intercessor and ally
Communicate alliance
STEPHEN P. GREGGO, “BIBLICAL METAPHORS FOR CORRECTIVE EMOTIONAL RELATIONSHIPS IN GROUP WORK”
Ethical issues
Spirituality seen as diversity
The Preamble to the NASW Code of Ethics states that “social
workers should be sensitive to cultural and ethnic diversity and
strive to end discrimination, oppression, poverty, and other forms
of social justice”(NASW, 1996). The Code of Ethics promotes the
principle that social workers are to respect the inherent dignity and
worth of the person, especially in the areas of diversity” (NASW,
1996).
The NASW Board of Directors, at its June 2001 meeting accepted
the following definition of culture: “The word ‘culture’ is used
because it implies the integrated pattern of human behavior that
includes thoughts, communications, actions, customs, beliefs,
values, and institutions of a racial, ethnic, religious, or social group”
(NASW, 1996).
Standard 2. “Social workers shall seek to develop an
understanding of their own personal, cultural values and
beliefs as one way of appreciating the importance of
multicultural identities in the lives of people.”
The importance of self-awareness and self-understanding is crucial in all
areas of diversity and the area of spirituality is no exception.
• Social workers often have unresolved issues in the area of spirituality and
may be on their own personal journey of self-discovery.
• This may be reflected in avoidance of the subject of spirituality with clients
or a diminishing of the importance of personal faith or belief system to the
client in matters such as problem solving or life goals.
• On the other hand, the social worker may give more importance to or have
more interest in exploring issues of spirituality than the client.
• It is often helpful for a social worker to complete their own spiritual
chronology or timeline which may assist them in examining the formation
of their own belief system and values. Careful spiritual self-assessment will
assist the social worker in determining the meaning and impact of
spirituality in their life which in turn will enable them to better assess the
impact of spirituality on the life of their clients.
DSM-IV Religious & Spiritual Problems
The inclusion in the DSM-IV of a new diagnostic category
called "Religious or Spiritual Problem" marks a significant
breakthrough. For the first time, there is acknowledgment
of distressing religious and spiritual experiences as
nonpathological problems. Spiritual emergencies are crises
during which the process of growth and change becomes
chaotic and overwhelming. The proposal for this new
diagnostic category came from transpersonal clinicians
concerned with the misdiagnosis and mistreatment of
persons in the midst of spiritual crises.
David Lukoff, Ph.D., is a Professor of Psychology at Saybrook Graduate School
Mental Health and Spirituality
The mental health field has a heritage of 100 years of ignoring and
pathologizing spiritual experiences and religion. Freud promoted this
view in several of his works, such as in Future of an Illusion wherein he
pathologized religion as:
A system of wishful illusions together with a disavowal of reality, such
as we find nowhere else...but in a state of blissful hallucinatory
confusion.
Freud also promoted this view in Civilization and Its Discontents, where
he reduced the "oceanic experience" of mystics to "infantile
helplessness" and a "regression to primary narcissism." The 1976 report
Mysticism: Spiritual Quest or Psychic Disturbance [1] by the Group for
the Advancement of Psychiatry (GAP) followed Freud's lead in defining
religion as a regression, an escape, a projection upon the world of a
primitive infantile state.
David Lukoff, Ph.D., is a Professor of Psychology at Saybrook Graduate School
Examples of spiritual & religious issues . . .
• Mystical experience
• New Religious Movements and cults
• Psychic opening “I felt like I was drawing knowledge”
• Visionary experience
• Kundalini awakening
• Near-death experience
• Possession experience
• Shamanic crisis
• Loss of faith
• Alien encounters
• Terminal & life-threatening illness
• Changes in membership, practices & beliefs
David Lukoff, Ph.D., is a Professor of Psychology at Saybrook Graduate School
Four ethical pitfalls when attempting to integrate
psychology and religion
• Integrity Issues: Blurred Boundaries and Dual Relationships
• Respect Issues: Spiritual and Religious Bias
• Competence Issues: A Member of a Faith Tradition Does Not Make
One an Expert
• Concern Issues: Destructive Religious Beliefs and Behaviors
Thomas Plante: “Professional
and scientific psychology
appears to have rediscovered spirituality and religion
during recent years, with a large number of conferences,
seminars, workshops, books, and special issues in major
professional journals on spirituality and psychology
integration.”
“Integrating Spirituality and Psychotherapy: Ethical Issues and Principles to Consider”
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 63(9), 891–902 (2007)
ETHICAL ISSUES FOR CONSIDERATION WHEN
INCORPORATING SPIRITUALITY
IN TREATMENT
• Social workers must clarify their own spiritual values before trying to help clients
incorporate their spirituality into healing
• The social worker also must utilize tools that will assist in determining if the client
would be served in a more productive way with the inclusion of spiritual issues in
counseling.
• Spiritual assessment or screening should be incorporated into every assessment to
give added information on the importance of spiritual matters to the client.
• The social worker must understand that spirituality is an aspect of diversity just as
ethnicity and race.
• When utilizing spirituality as a strength and an aspect of diversity, the social
worker must self monitor to avoid any violations of ethical principles.
ETHICAL ISSUES IN SPIRITUAL ASSESSMENT, Linda Openshaw & Cynthia Harr (2005)
Steps for ethical problem solving when perception is that
incorporating spirituality may be an ethical violation
• determine if there is an ethical dilemma
• identify key values, principles and knowledge central to the dilemma
• prioritize relevant values and ethical principles
• face any personal biases that could cloud your perspective
• consult with colleagues about the dilemma as needed
• develop an action plan consistent with the ethical values identified
• implement the plan using the most appropriate practice skills and
areas of competence
• Reflect on the outcome of the ethical decision making process Reamer
& Conrad, “Professional Choices” (NASW video, 1995).
Issues of diversity
Preamble of NASW Code of Ethics:
“Social workers should be sensitive to cultural and ethnic diversity
and strive to end discrimination, oppression, poverty, and other
forms of social justice”(NASW, 1996). The Code of Ethics promotes
the principle that social workers are to respect the inherent dignity
and worth of the person, especially in the areas of diversity”
NASW, 1996).
Culture: “Implies the integrated pattern of human behavior that
includes thoughts, communications, actions, customs, beliefs,
values, and institutions of a racial, ethnic, religious, or social
group” (NASW, 1996).
“The term culture includes ways in which people with disabilities
or people from various religious people who are gay, lesbian, or
transgender experience the world around them (NASW Standards
for Cultural Competence, 2001).
NASW Standards for Cultural Competence,
• Standard 1. “Social workers shall function in accordance with the values, ethics, and
standards of the profession, recognizing how personal and professional values may
conflict with or accommodate the needs of diverse clients.”
• “Social workers shall seek to develop an understanding of their own personal, cultural
values and beliefs as one way of appreciating the importance of multicultural identities in
the lives of people.”
• “Social workers shall have and continue to develop specialized knowledge and
understanding about the history, traditions, values family systems and artistic expressions
of major client groups that they serve”
• Standard 4. “Social workers shall use appropriate methodological approaches, skills, and
techniques that reflect the worker understands of the role of culture in the helping
process”
• Standard 5. “Social workers shall be knowledgeable about and skillful in the use of
• services available in the community and broader society and be able to make appropriate
referrals for their diverse clients
• Standard 6. “Social workers shall be aware of the effect of social policies and programs on
diverse client populations, advocating for and with clients whenever appropriate”
• Standard 7. “Social workers shall support and advocate for recruitment, admissions and
hiring, and retention efforts in social work programs and agencies that ensure diversity
within the profession”
• “Social workers shall advocate for and participate in educational and
• training programs that help advance cultural competence within the profession”
Strength-based therapy
William Hambleton Bishop . . .
As a therapist when I claim to be ‘strength based’ I
am saying that I am committed to creating hope and
change by helping my clients to focus on the
positive, the effective, and the reasonable solutions
that are available. I have clients isolate their
strengths, the strength of significant others, the
solutions that are working or worked in the past,
what they are hopeful about, and what aspects of
their character can be specifically used in creating
and implementing a solution.
Mandate of strength-based therapy
• It is an empowering alternative to traditional therapies which typically describe
family functioning in terms of psychiatric diagnoses or deficits.
• It avoids the use of stigmatizing language or terminology which families use on
themselves and eventually identify with, accept, and feel helpless to change.
• It is at odds with the "victim identity" -- epitomized in popular culture by the
appearance of individuals on television or talk radio sharing intimate details of their
problems—which is inherently self-defeating.
• It fosters hope by focusing on what is or has been historically successful for the
person, thereby exposing precedent successes as the groundwork for realistic
expectations.
• It inventories (often for the first time in the person's experience) the positive
building blocks that already exist in his/her environment that can serve as the
foundation for growth and change.
• It reduces the power and authority barrier between the person and therapist by
promoting the person to the level of expert in regards to what has worked, what
does not work, and what might work in their situation.
• It reduces the power and authority barrier between person and therapist by placing
the therapist in the role of partner or guide.
• Families are more invested in any process where they feel they are an integral part.
• And lastly - it works
Ethically sound practice entails obtaining the
knowledge to exhibit spiritual sensitivity clients.
Social workers are increasingly recognizing the importance of strengths
(Cowger, 1994; Hwang & Cowger, 1998; Saleebey, 1997).
Reviews have consistently found a generally positive association between
spirituality and a wide number of beneficial characteristics (Ellison & Levin,
1998; Gartner, Larson & Allen, 1991; Koenig, McCullough & Larson, 2001;
Pargament, 1997)
To tap clients’ spiritual assets for the purposes of ameliorating problems,
practitioners must use methods designed to identify clients’ strengths
(Ronnau & Poertner, 1993).
David R. Hodge and Crystal Holtrop, “SPIRITUAL ASSESSMENT: A REVIEW OF
COMPLEMENTARY ASSESSMENT MODELS”
Client autonomy . . .
there is the issue of client autonomy. Many clients
desire to integrate their spiritual beliefs and values
into the helping relationship (Privette, Quackenbos &
Bundrick, 1994). According to Gallup data reported
by Bart (1998), 66% of the general public would
prefer to see a professional counselor with spiritual
values and beliefs and 81% wanted to have their own
values and beliefs integrated into the counseling
process. Further, research suggests that spirituality
tends to become more salient during difficult
situations (Ferraro & Kelley-Moore, 2000;
Pargament, 1997), when individuals may be more
likely to encounter social workers.
Major Religions of
the World
Vicarious trauma &
healing for the healer
Who Heals The Healer?
by Mary Severson - age 10
My love healed the healer,
when her soul was cold.
My love healed the healer,
when her spirit folds.
My love healed the healer,
when her strength was gone.
My love healed the healer,
when she was frightened like a fawn.
My love healed the healer,
when she feels unsure.
My love healed the healer,
when she is insecure.
I followed the Light that brought me to her,
I gave the love that helped me heal her.
Who Heals the Healer?
Vicarious Trauma, Compassion Fatigue, Secondary Trauma:
• A pervasive effect on the identity, worldview, psychological
needs, beliefs, and memory systems of therapist who treat
trauma survivors. ~ Karen Saakvitne & Laurie Peariman,
1990
• VT is “an aggregation in the nervous system of the negative
impact that is vicariously experienced. . . In hearing the
details of a patient’s suffering, the therapist’s body reacts
(often subtly and unconsciously) to the description of the
trauma event as if she were experiencing it.” ~ Babette
Rothschild, Help For The Helper
Judith Herman’s Description of
Vicarious Trauma Symptoms:
• The most common constrictive responses are doubting or
denial of a patient’s reality,
• disassociation or numbing,
• minimization or avoidance of traumatic material,
• professional distancing,
• or abandoning the patient.
• The most common intrusive responses are assuming the
role of the rescuer and stepping over boundaries that
ultimately disempower the patient.
Herman, J.L. (1992). Trauma and recovery. New York: Basic Books.
VT Cont.
• Interestingly, a number of studies have found that the effects
of vicarious traumatization are lower in therapists with more
experience in working with trauma than in people new to this
work (Cunningham; Jackson; Way, Van-Deusen, Martin,
Applegate & Jandle, 2004).
• A higher level of education on the part of clinicians also is
associated with fewer symptoms of vicarious trauma (Baird &
Jenkins, 2003).
How does your spirituality help you
when hearing story after story?
Can you still do this?
Mark Twain once said, "The physician who knows only
medicine, knows not even medicine.“
Paul reminds us that in our
weakness and suffering that we
grow in humility and cannot pride
ourselves in our
accomplishments.
VT should serve “to make us
rely, not on ourselves but on
God who raises the dead.”
(2 Corinthians 1:9)
Strategies For Reducing VT/SPTSD
• Clearing A Space before entering a therapy session. This is
useful for keeping your own issues separate from the client’s
as well as ensuring that you can be fully present with the
client.
• Positioning yourself so that you are sitting next to or kittycorner from the client during sessions, rather than directly
across from the client. This allows you to avoid taking in
negative emotional energy coming from the client, such as
rage or terror regarding their traumatic experiences.
• Maintaining respect for your client’s ability to heal and to
deal with their own issues. This includes not leaping in and
rescuing a client when crises arise.
Strategies For Reducing VC/SPTSD, cont.
• Clearing A Space again at the end of a therapy session,
putting down the client’s issues rather than carrying them
with you.
• Honoring your own feelings, and allowing a safe time and
place to deal with those. This includes maintaining a
Focusing attitude of curiosity, openness and acceptance
towards your feelings.
• Attending to your own triggers. Focusing is very useful in
doing this, as described above.
• Self-care, self-nurturing, balance in life activities and within
self, and connection to self, to others, and to something
larger (eg. a purpose). {To Christ}
DEALING WITH VICARIOUS TRAUMATIZATION IN THE CONTEXT OF GLOBAL FEAR ~ Catherine Hudek
THE
END
or
THE BEGINNING
H. Jack Perkins, D. Min., LADC
Admission Director,
Rose Rock Recovery Center
918.256.9153
jperkins@odmhsas.org