We Don’t Leave Our
Wounded on the Battlefield
Recognizing the Potential for
Chaplaincy
in Post-Traumatic Treatment
Kevin Coughlin
CPE Resident
VA Palo Alto
Medical Center
June 28, 2004
To satisfy a requirement of
third-unit Residents in an accredited program of Level II Clinical Pastoral
Education (CPE, www.acpe.edu ) held at the
VA Hospital in Palo Alto / Menlo Park, Ca. as a satellite of the CPE program at
Stanford University.
T A B L E O F C O N T E N T S
B. Treatment modalities – Milieu
based, CBT
III.
Considering Spiritual Characteristics of PTSD…………………………..
A. A large component of the “S” in
PTSD is Spiritual Trauma......
B. The necessity and dilemma of Religion
in Recovery...
C. Inherent asset of Chaplain:...
IV.
Noteworthy concerns…………………………………………………...
V.
Conclusion……………………………………………………………….
A: A Grid for
Listening………………………………………………………………...
B.
Endnotes…………………………………………………………………………….
Ó Copyright 2004 Kevin J. Coughlin. All rights reserved. No part of this document may be copied, faxed, electronically transmitted, or in any other manner duplicated without express written permission from the author. kcoughlin911@earthlink.net
A C K N O W L E D G E M E N T S
This paper could not have been written without the coaching and
encouragement of the Rev. Susan G. Turley, ACPE Supervisor. I am particularly
grateful for the contributions (in reverse chronological order) of all the
staff of the National Center for PTSD for lessons learned, and especially Kent
Drescher, Ph. D., M. Div., and Chris Wenk, RCS, who, in addition to allowing me
to participate in their groups, reviewed this paper; Rev. Philip Salois, M.
S., Chief of Chaplain Services, VA
Boston, and Rev. Dr. Nelson Hayashida, VA Chaplain Resident; Rev. Jackson H.
Day, M. Div, MPH, Chaplain formerly in
Vietnam, now in Maryland; Dr. Jonathan Shay, Author “Achilles in Vietnam” and
his video-graphic artist sidekick Sandy
Berkowitz; Ed Brackenbury, counselor and friend; Steve Zeisler, Pastor
and friend; Kevin Ballard, S. J., counselor and “posse member”; Cpl. Roger
“Lee” Wilson (KIA 1/20/68); S/Sgt. Ezell, USMC Boot Camp; and last, but
certainly not least, my deceased parents, Dr. and Mrs. Paul J. Coughlin, who
did justice, loved mercy, and walked humbly with their God.
This paper is a first step in finally articulating a long-held, though previously not well defined, dream.
I
acknowledge that it is being written with a certain degree of pathos in excess
of that nominally found in a clinical paper, demonstrating my passionate
commitment. The intended audience for this paper is decision makers who design
and staff PTSD treatment programs. I
share your passion for your patients’ healing, and hope these observations will
in some way help their restoration and healing to be more comprehensive and holistic. It is my prayer that the reader will come to
comprehend as deeply as I have the need for such passionate commitment. It is
also my prayer that the reader will come away with some degree of the
comprehension that I have gained, that such passionate commitment must be
titrated with personal and professional boundaries in order to avoid several
potential clinical errors that will become evident throughout this paper.
From the beginning, I would like to be on record as stating that
the VA staff with whom I have worked in gathering my material is the most
passionate group of well-trained, compassionate, caring professionals with whom
I could ever hope to work. This
wonderful institution has gone to great lengths to overcome the reputation it
had, real or imaginary, in previous decades, and it shows. To steal a line from Ringo Starr and the
Oldsmobile commercial, “this is not your fathers’ VA.” There are those of us
who have had very bad memories of our encounters with the VA upon our return
home from Vietnam, where I served as a 19-year-old USMC Radio Operator &
Vietnamese Interpreter in a Combined Action Platoon just South of Hue in
1967-1968. (www.capmarine.com) before, during, and after Tet ’68.
The
goal of this paper is twofold; the first purpose supporting the second:
1)
Describe several clinical observations / interventions that occurred during a
chaplain residency focused on the treatment of persons with Post Traumatic
Stress Disorder (PTSD)[i],
addressing the spiritual needs of veterans with PTSD, correlating them with
current publications and treatment literature, in order to:
2)
Illustrate the need for further participation of clinically trained
Professional Chaplains in the treatment of PTSD.
This paper will
include descriptions of certain clinical episodes which carry insights on the
relationship between spirituality and PTSD, and the need for the involvement of
spiritually competent therapeutic personnel. These descriptions will include;
·
Description
of the setting
·
Description
and assessment of the episodes, and what spiritual clinical interventions were
used
·
Context
from current literature on the topic
A summary of the observations and recommendations
drawn from these episodes will be presented in a Conclusion, followed by
Appendices, which will include instruments used during the residency at the
National Center for PTSD (NCPTSD) located at the Menlo Park Division of the VA
hospital in Palo Alto, California from September 2003 through May 2004.
Below is a description of the NCPTSD taken from its annual report on its website:
The National Center for Post-Traumatic Stress Disorder
(NCPTSD) was created within the Department of Veterans Affairs in 1989, in
response to a Congressional mandate to address the needs of veterans with
military-related PTSD. Its mission was, and remains:
To advance the clinical care and social welfare of America’s
veterans through research, education, and training in the science, diagnosis,
and treatment of PTSD and stress-related disorders.
The VA charged the
Center with responsibility for promoting research into the causes and diagnosis
of PTSD, for training health care and related personnel in diagnosis and treatment,
and for serving as an information resource for PTSD professionals across the
United States and, eventually, around the world. [ii]
The residential PTSD treatment program nominally
lasts 60 days but can vary depending upon the treatment needs of the patient
and the ongoing assessment – along with predefined standard checkpoints - of
the treatment team, in conjunction with the patient, of how the patient is
cooperating with and being served by the program.
At present there are several different groupings of
treatment modalities at use at the NCPTSD. The major ones would be:
psychotherapy, pharmacotherapy, and psycho-education. There is a thorough,
complex, well-defined and documented screening process for admission, which is
outside the scope of this paper. In addition to medical treatment provided by
MDs, RNPs, RNs and LVNs there is a
plentitude of structured and unstructured education/therapy that a patient
could receive that is “Group” and “treatment team” oriented, classified as Milieu based Cognitive Behavioral Therapy. After describing those two italicized
terms, this paper will focus on one of the Groups
Milieu (French: Setting or community) based
The importance of a community that provides a holding environment and ongoing mutual support is particularly evident with chronic PTSD, because everyone involved is exposed to an almost constant flood of intense, though usually not well articulated, emotions as well as to powerful undercurrents of isolation, avoidance, numbing, and hyper-vigilant distrust. PTSD programs and providers often utilize a therapeutic community model, as the basis for an inpatient milieu or a day treatment hybrid of outpatient care. Vet Centers have from their inception been therapeutic community-like milieus. [iii] These communities are composed predominantly of Vietnam vets, with the occasional WWII, Korea, or Gulf war vet included. Preparations are well under way to accommodate Iraqi and Active Duty Veterans. The community is self-governing, electing leaders for various service positions, subject to staff approval.
Cognitive-Behavioral
Therapy (CBT)
Among psychotherapies, CBT treatments
have received the most empirical study. CBT methods, together with psycho-education,
are the most recommended psychotherapy techniques. CBT includes methods such
as:
·
Cognitive therapy-
modification of unrealistic assumptions, beliefs, and automatic thoughts that
lead to disturbing emotions and impaired functioning.
·
Imaginal exposure- the
repeated verbal recounting of the traumatic memories until they no longer evoke
high levels of distress.
·
In vivo exposure-
confrontation with situations that are now safe, but which the person avoids
because they have become associated with the trauma and trigger strong fear.
Repeated exposures facilitate habituation to the feared situation.[iv]
3-way Mirror
3-way mirror is actually a tool
used in both the “Integration of PTSD” and, “Trauma Focus” groups. The patient
is led, under the guidance of the Facilitator and Co-facilitator through the
three basic “panels” of a “mirror”, thus reflecting his life back to him. In each panel the presence and significance
of drugs and or alcohol, if any, is addressed.
The first panel covers childhood up to
entry into the military. It addresses
the geography, socioeconomic structure and interpersonal relations of the
family, friends, and the major events in the child’s life as experienced by the
child, plus education and religious training if any. The last questions asked
before proceeding into the next mirror panel covering military service investigate
whether the patient had adopted the religious training, if any, as his own, and
what kind of God the patient had taken into the military with him. The patient is encouraged to be generally
descriptive of his God, with whatever combination of adjectives such as,
“nonexistent, present, aloof, loving, judging, punishing, etc. “ the patient
sees as being applicable.
In the second panel the military history of
the veteran is discussed. A major difference between this group and the Trauma
Focus group is that in this group the second panel specifically and
intentionally excludes any references to trauma. What is covered is length of service, major assignments &
significant events, commendations or medals outside the ordinary, and any legal
problems that might have existed.
The third and final panel examines the
patient’s life after service, covering his behavior with jobs, family, society,
and major incidents. At the end of each
panel the other patients in the community are encouraged to give feedback to
the veteran as to his strengths and challenges, and the items they find
synchronous with their own life.
At the end of the session, the facilitator
does a wrap-up, synopsizing some of the more significant formative factors, and
weaving a cohesive story of accomplishments and challenges, and declared or
perceived emotional responses. In this venue he reframes certain aspects where
the patient might have been giving too much weight to a certain real or
perceived negative aspect of himself. He usually also asks the chaplain for
observation and comment. At this point
I usually remind the veterans that chaplains are sometimes seen as
“cardiologists of a sort in that we listen for heart murmurs”. I then offer
some feedback, usually in the form of active reflective listening from a
spiritual perspective on one or more statements or themes that we have heard
from the patient in question. I might
also either reaffirm or spiritually reframe for the patient some particular
spiritual aspect of his story.
I
have found the use of this technique to be directly synchronous with that of
Chief of Chaplaincy in Boston, and former Army Combat Team leader in Vietnam
(long before he became a priest), Fr.
Philip Salois: “my work is to help the veteran to refound his or
her sacred story. I make deliberate use of that word re-founding
because for many their sacred story was lost on the battlefield. The process of
re-founding of one's sacred story is one of a journey away
from an adolescent view of God toward a more mature understanding of faith and
God's role in the course of humanity. It begins with helping the veteran to
discover where and when the connection was lost. This encounter is
pre-requisite to any authentic reconciliation with God as knowledge and
understanding must precede forgiveness and reconciliation.” [v]
Here
are three radically different examples:
1) One patient made a casual reference his
father giving him a quarter, when he had been seeking affection. When I later reaffirmed for him the feeling
of loss when his father had attempted to substitute cash for care, he had a
breakthrough and realized that that was precisely how he had treated his own children.
He then tearfully expressed compassion for his father and a strong desire to
effect spiritual reconciliation with his children. In the midst of his angst he
blurted out a painful sense of being trapped by a reference to an Old Testament
passage, “The sins of the father shall be passed on to the next generations”.
This is actually an immature and incomplete understanding of those
passages. It is also not an uncommon
understanding of those passages. As a
trained chaplain I first undertook the educational component, reframing the
passage for the veteran. Next it was
necessary to realize that the spiritual trauma occurred when this man, now in
his mid ‘50s, was but a youth, and his spiritual trauma was so complete that he
had not undertaken any spiritual growth since then. Thus he was faced with a
challenge to his old, amateur Theology, and an invitation to embrace a more
mature, liberating Theology. The transformation was shockingly visible. His eyes and mouth flew open in wonder, his
face brightened, and he said something to the effect of “I feel the weight the
world is now off my shoulders”.
Quite frequently more than a few veterans
will resonate with such a revelation. In this particular case a very large
majority did so.
2) In
what I call a “redemptive moment” some patients have expressed their anger and
disappointment in God, and “God’s representative”, the Chaplain. In this group
they had finally come to grips with that. There were times and places in
Vietnam where the chaplain was not held in high esteem. The term “God Squad”, or “Sky Pilot” could
be said with an attitude of either respect or derision. However, the question of attitude was never
in doubt when one heard phrases such as, “those guys who argue about which one
has the best imaginary friend”, “Titless Nun”, and worse.
I have had the blessed experience of having patients at the NCPTSD tell me that they had experienced “180 degree turnarounds”, “incredible awakenings”, “epiphanies”, and “new understandings” about God and about Chaplains, and how they attribute that to my interaction with them in group. One patient in particular confessed that his anger and resentment towards chaplains had grown into something bigger; a general resentment toward God and religion and church. He had thus rejected, and then continuously deprived himself of the faith community in which he had grown up. By helping him reassess his initial response, now with sober, mature eyes, we were able to refound his spiritual basis. He asked if I could accept his request for forgiveness on behalf of the chaplain in Vietnam by whom he had felt betrayed. This man is now well down the path of reconciliation and healing.
3)
In another incident the chaplain (not me, but I was present), was requested to
consult with the patient by the psychiatrist and help the psychiatrist
understand the patient better via reframing. The psychiatrist had assessed the
patient as, “delusional, hearing voices”, and was considering prescribing
antipsychotic medication. The patient, a “Charismatic Pentecostal Christian”,
had been using the language of his faith heritage, “I can hear Satan telling me
to drink” to describe what the psychiatrist would have nominally called “urges
to drink”. The clinically trained chaplain, upon hearing the “disconnect”
between the two languages, used probing questions to effectively serve as a
translator to each. After this episode, the patient expressed gratitude and
stated that he now felt a deep sense of trust. A large factor amongst PTSD
patients is lack of trust, especially of superiors. This “restored trust”, in
which the Chaplain had served as a primary and compassionate catalyst, was what
the patient described as a “cornerstone” of his recovery. The patient was most
eloquent in expressing his appreciation of the Psychiatrist and other staff
including the Chaplain.
The “Integration of PTSD” group meets
weekly, consisting of all patients not participating in conterminous groups
(Such as Trauma Focus), and a single patient is chosen on a volunteer basis
after screening for several criteria. One of these is that the patient will not
be participating in the Trauma Focus Group during this admission at
NCPTSD. The reasoning behind this is
that this very tool will be used to a deeper level in the trauma work in the
Trauma Focus Group.
The Trauma Focus Group (of which there are
usually several running concurrently) meets 3 times per week, and is an
integrated cohort, usually four or five patients and approximately two
facilitators.
There are quite a few other groups that a veteran may attend. They are more completely described in the follow-on paper to this one. Each are places where a Chaplain could viably and profitably (as viewed by the Treatment Team and Patient) serve.
A
substantial and growing body of literature is concerned with the Spiritual
aspects of recovery from Trauma. This
is because the spirit has been traumatized.
Whether it is a jagged, raw wound - or a cauterized numb one - the
outcome is the same; a person in crisis is neither spiritually whole nor
connected to their community. This
appears to be accentuated in veterans who have either had conflicts between the
religious teachings of their family of origin and conditions in the military,
up to and including combat, or in veterans with no religious teachings at all.
In the combat veteran, conditions surrounding the trauma are typically
accentuated by such other surrounding factors as foreign culture, language,
customs, etc. This has the potential for being traumatizing in and of itself,
but at a minimum it removes the comforting
“grounding” bearings of familiarity that our spirits seek in time of
trauma, which might have been used to
offset or ameliorate the effects of the trauma.
While it is true that there are mandatory
legal and spiritual concerns about bringing spirituality into treatment (such
as “respect for individual diversity”, and “abuse of spiritual power”,
described briefly in sections II and IV of this paper, and discussed more fully
in a follow-on paper), it is also true that there is a growing body of evidence
to support the absolute need for certain patients to have immediate clinical
access to, and recognition of, their unique spiritual needs. In 1992 a 10-page article in the Journal of
Consulting and Clinical Psychology pointed out the hazards of pure CBT with
patients who had strong religious beliefs.
“Cognitive-behavioral therapy (CBT) has been found to be an
effective treatment for clinical depression (see Dobson, 1989). However, CBT may not be equally effective
for religious patients. One reason is
that CBT, with its emphasis on such values as personal autonomy and
self-efficacy as necessary for mental health (see Beck, Rush, Shaw &
Emery,1979), may clash with the cultural values of some religious individuals
who may regard such values as alien to their assumptive world of dependency on
a divine being. Indeed, there is
evidence that this value discrepancy may result in underutilization of mental
health services by highly religious individuals.”[vi]
Additionally, and more strongly, “Keeping spirituality out of the clinic is
irresponsible.” (Emphasis
mine)
appears in the article “’God and Health’”[vii],
where Newsweek addresses the question; “Can religion improve health? While the debate rages in journals and med
schools, more Americans ask for doctors’ prayers”. In this article is the
previous statement, attributed to Duke University’s pioneering
faith-and-medicine researcher Dr. Harold Koenig, who, along with others
believes that a growing body of evidence points to religion’s positive effects
on health.
In the relatively few NCPTSD Website
documents on “spirituality”, several of the various ramifications of
spirituality are discussed in varying levels of detail and scope: “spirituality
vs. religion”; “reminders of the proscription against proselytizing”; “the
uniquely personal nature of spirituality”;
and various syncretistic combinations of certain Eastern religious practices
reframed and relabeled as “spirituality”.
Several of them, written by people not of the chaplaincy protocol,
acknowledge the difficulties inherent in Avoiding Proselytizing, and trying to
Separate Spirituality from Religion.
2)
Separating Spirituality
from Religion. Or the stated or inferred general difficulty of touching onto
ground usually thought of as belonging to the ministry. Few psychotherapists
have received formal training in spiritual matters. If a therapist is to
attempt to help others with their spiritual search it is important that the
therapist have a spiritual discipline. But spiritual practices are extremely
demanding of one's time, challenging to one's ordinary concepts, and make one
more prone to commit the (albeit subtle) error of proselytizing. Spirituality
is far more than a set of practices and ideas.
It is one’s worldview and way of living. This is not to indicate or
imply that many therapists to not have a spiritual worldview, but to indicate
their own stated reserve in touching upon that ground that is seen as belonging
in the realm of ministry, and to also indicate, as we show in the endnote
referred to above, there is a large segment of clinical people who are not
religiously involved.
These cautions are wrapped in another
more comprehensive one. These patients
are here seeking to unravel their own Gordian knots, which cannot be fully
addressed by either taking generic classes on spirituality or by deferring
treatment of the patient’s spiritual needs until the next time a Chaplain may
be available offline to - and thus disconnected from - the treatment process on
an ad-hoc basis. The professionally trained chaplain is uniquely qualified to
offer a “Sword of Alexander” to the Gordian knot in the form of a question,
challenge, teaching, or empathic observation relative to that patient’s faith
background. Chaplains are trained to “walk alongside” a patient as they find or
rediscover their spiritual path. Chaplains are trained to perform spiritual
assessments, diagnose the spiritual injury, and provide the patient with
spiritual intervention strategies, which could lead to spiritual breakthroughs
or, in some traditions known as transcendences or redemptive moments. These are
“pivot points” in the healing process.
Several
of the more cogent articles from the disciplines of psychology and social work
either allude to, or make pointed reference to, the fact that their discipline
is not trained in this “spiritual assessment, diagnosis, and intervention
technique” protocol.
The two articles on the NCPTSD Website by
chaplains on spirituality and trauma are quite brief, but manage to pointedly
address two of the biggest challenges to addressing the angst experienced by
some warriors when they face Theodicy, a term used to describe the conflict
between their childhood beliefs of “God is good and God is powerful” and “If
that is true, why is this horror happening now”?!
a)
“The majority of Vietnam veterans were raised in Judeo-Christian
families with a view of God as a father-image, that is, the strong, stern
disciplinarian capable of inflicting severe punishment. In these families, the
difference between right and wrong was clearly defined for children and it was
defined within religious parameters. Adolescents going to war brought with them
their adolescent concept of God. For many young soldiers, their concept of God
was tested, challenged and potentially destroyed by the magnitude of evil all
around them. In Vietnam, soldiers discovered that their concept of God did not
provide answers or explanations for what they were going through. For many, the
experience of the war shattered their religious concept of right and wrong. For
many, the exposure to evil resulted in deep feelings of guilt and shame.” [viii] It also gave formerly devout believers
reason to doubt a God that they had formerly (rightly or not) thought of as
being powerful enough to protect them from harm, suffering, and evil.
b) “A cognitive or "theological"
grasp of the problem is a necessary adjunct to PTSD therapy for veterans.
Religious questions must not be cloaked under another guise, but should be
confronted directly. Most PTSD clients with religious questions already have
some understanding of the disjuncture between their actions and their belief
system. They should be encouraged to probe even more deeply.” [ix]
These
cogent and succinct declarations give rise to a host of questions. Please
consult Appendix A for a set of questions I developed to use as a screening
mechanism for these.
There is an inherent asset of the Chaplain
having been the de facto designated point of contact for issues Religious,
Spiritual, Emotional, Societal and Relational during the formative periods of
these men’s military experiences. Whether the patient sees the chaplain in a
positive light or negative one, there is a long-standing relationship. Thus,
even if, as above, there is need for healing in the veteran / chaplain
relationship, there is an embedded “continuity of care” inherent in the
relationship. Both parties understand that the chaplain does have a spiritual duty
towards the veteran. Even as this paper is being written there are chaplains
mingling with and ministering to our Armed Services in Iraq. [x]
Prejudice
(with foundation) of Staff towards Religious Staff
Clinical Staff have seen instances where even
the best-intentioned prayer and family visits turn sour in the presence of
ministerial personnel. One or more of the following factors may be at play.
1) Lack of training of ministerial personnel in the
clinical environment.
2) Transference of perceived power by the family or
patient towards the ministerial staff, potentially affecting a “Staff
Split”.
3) Unrealistic expectations put on both ministerial and
clinical staff by patients & family, and they are all frustrated when the
mortality rate remains at 100%.
4) The fact is that good, bad, or indifferent, people’s
behavior changes in the presence of the clergy; Along with the hoped for
consolation and encouragement, (not to mention Spiritual Assessment and
reconciliation/restoration/healing) one might encounter anything from “Don’t
cuss in front of the preacher” to downright hostility to “I am depending upon a
miracle cure”.
5)
Image of the pastor
by staff: “Surprisingly Few Adults Outside of Christianity Have
Positive Views of Christians.” [xi]
In a poll
by the highly respected church researcher George Barna, the image of believers
by non-believers in today’s world is low.
The outsider sees the divorce rate, as well as other behavioral (moral)
indicators, that are the same as the non-believer’s and thus understandably
question the value of belief, much less the value of ministers. Ministers in
the press in a negative way have cast a very dark shadow on the ones who are
doing worthwhile and useful work. Too many people have suffered at the hands of
corrupt ministers for there to be a global assumption of trust inherent in the
position or title.
Peership
Given all the above, it is not surprising that the
Professional Chaplain has some work to do to convince his / her peers in the
interdisciplinary team that there is practical clinical value-add in their
ministry. Fortunately for this truth, chaplains hold themselves as accountable
for their ministry to, and holding a spiritual duty towards, staff as well as
patients.
Each
clinician has the responsibility to have an accountability and support
structure in place to ameliorate the negative effects and enhance the positive
effects of the factors below. These factors are discussed in great detail in
other professional clinical publications, and are thus outside the scope of
this paper. They are mentioned here to
indicate to the reader that the author is familiar with and has considered
them.
Over-Identification
Any
situation that might arise when a person in clinical setting begins to
overly-relate to the patient; Be it
that of a therapist who has been raped counseling a rape victim, or a Vietnam
Vet Chaplain ministering to another Vietnam vet.
Transference
The process by which emotions and desires originally
associated with one person, such as a parent or sibling, are unconsciously
shifted to another person, especially to the analyst.
Counter-transference
The surfacing of a clinician’s own repressed feelings
through identification with the emotions, experiences, or problems of a person
undergoing treatment.
Proper use
of Pastoral Authority
Another
topic rich in sub-topics and nuance, this basic need is for the Chaplain to
maintain the inherited and inherent authority imbued in the title. The Chaplain
has a centuries-old tradition and mandate of sacred trust relative to the
warrior. The vet automatically assumes that the words and actions of the
Chaplain come from a higher, consecrated, and powerful place. Irrespective of
the Chaplain’s personal background, the vet has a powerful predisposition to
react to the Chaplain. In some
instances, as mentioned above, the reaction might not always be positive.
Training and professional consultation with peers helps insure this boundary
maintenance.
I have shown that the lenses acquired by
the professional, clinically trained
chaplain have value in the ability to focus on directly assessing and
addressing the spiritual needs of the patient, such as Grief, Loss, Theodicy,
disrupted spirituality, and ruptured spiritual relationship with God and one’s
faith community. I have also pointed
out some of the hazards that are inherent in the task, and the ameliorating
systems/structures that must be maintained to adequately address them. Therefore I stand by my original assertion
that further participation of clinically trained Professional Chaplains in the
treatment of PTSD is clinically indicated. There is intrinsic value added, both
to patient and to staff in having a Professional Certified Chaplain as an
integral part of the Interdisciplinary Treatment Team.
It is the deepest heartfelt desire of every
human to be heard, to be seen, to be recognized, to have some sense of
significance. Chaplains have been
called spiritual cardiologists of a sort, in that we listen to heart murmurs.
Without imposing our own inner beliefs, we also invite, encourage, and aide the
patient in naming their spiritual beliefs & wounds, and the ways in which
their beliefs are serving them or disserving them. We help them investigate and
transform their current religious or spiritual constructs into those which will
heal and transform instead of wound and oppress, without compromising the
integrity of their faith.
In honoring the uniqueness and sacredness
of each person’s spiritual beliefs, or lack thereof, we as a society have made
Spirituality a delicate and private affair. We have done so to such an extreme
that it puts an artificial constraint against the above-stated heartfelt desire
to be known. Conversely, in other situations, we have tipped the scales, and
made it into a non-focused impersonal group activity where a blending of sorts
takes place and there is no deep examination of beliefs. Circa 400 B.C. Socrates stated, "The
unexamined life is not worth living". Professional Chaplains are
clinically trained to work with the individual to help sort out the problematic
issues facing him or her. We are “authorized” to say “God”, without it being
threatening, intimidating, or disrespectful to an individual or their leanings
& convictions. When a person has a problem with diabetes or cancer, s/he
goes to a trained professional.
Chaplains are the professionals who deal with the issues of Spirituality
and Theology. Just as an Oncologist or Dietician needs to be truthful, direct
and compassionate with the diagnosis and prognosis for recovery from cancer or
diabetes in order to gain the trust and aid in the comfort of the patient, so
is the Chaplain when dealing with matters Spiritual.
As has been demonstrated, those suffering
from PTSD have issues with Spirituality that need to be addressed. Military Personnel, our patients, have been
trained to address problems directly, or obliquely, but always with Strategy,
Tactics and Logistics. We need to provide them the Chaplains for addressing
their Spiritual problems. Chaplains are
decisive and key resources in this arena.
My prayer is that this paper will be
instrumental in more tightly integrating chaplain services with
interdisciplinary care teams in the treatment of PTSD.
A
Grid for Listening:
Ten Clinical Pastoral Questions
The following questions were
developed by me in response to a Clinical Pastoral Education (CPE) Training
objective of exploring the facets of holistic ministry to patients on the PTSD
ward at the National Center for PTSD in Menlo Park, Ca. The questions are intended as a grid - to be
refined via practice, research, and consultation with my CPE Clinical Supervisor
- through which I can listen to patients, and, at a later date, develop a more
clinical Spiritual Assessment Model as part of the CPE Special Project Paper
usually executed in the third / fourth unit of CPE
A) Patient’s spiritual background / resources
1.
What
are this patient’s strengths & resources (community (family and extended),
past & present experiences, skills & gifts) / beliefs
2.
Where
does this patient get consolation / peace / joy / confirmation /
encouragement?
3.
What is
this patient’s current view of: “God”, “church” “prayer”, “meditation”,
“spirituality”, “afterlife”, and “community”
4.
Does
that differ from his youth, and, if so, why?
5.
What
defining “transcendent moments” has this patient had? (Awe-some) how did they impact the patient’s life –
(meaning, strength, etc.)
6.
What
kind of God-image (or combination of images) does the patient carry?
Predominant?
·
None
(if “none”, explore 1-5 more)
·
Condemning
/ judging
·
Loving
/ supportive / personal / beckoning / inclusive
·
Aloof
·
Appeasable
/ unappeasable / no need to appease
B) Patient’s spiritual trauma
7.
What
defining “transcendent moments” has this patient had? (Awe-full) How did they impact
the patient’s life – (jagged raw wound, cauterized, numb.) Did it have physical
manifestations? (injury to body) or is it invisible / internal?
8.
What is
the “heart murmur” / “heart scream” saying? (grief, fear, rage, impotence,
isolation, lack of trust)
C) Patient’s current spiritual needs / outlook
9.
What is
the spiritual need here? What kind of teaching / truth-telling / consolation /
support / clarification is necessary?
D) What tools do I have that are appropriate to the need?
A) Position of Chaplain: Viewed by Military Personnel as “go to” person
for all things spiritual; in many
cultures as “God’s representative” in all things emotional / social / spiritual
/ societal / communal.
B) Self:
1) Formal training
Theological / Seminary
training
Clinical Pastoral Education (CPE) - Hospital Chaplaincy
Experience: Clinical training / Pastor as diagnostician / Interdisciplinary
Consultation / Spiritual Assessment
Model & Practice / Pastoral Care and Counseling skills / 1-1 visits / team treatments / Interfaith Perspective /
Active Listening / ministry of presence
2) Ancillary aspects
Personal Spiritual
Practice Pastoral / Ministerial skills
Scriptures / Classic literature US / World / Military History
Eclectic musical repertoire Current events / films as metaphors
Extensive and intensive world travel
17 years recovered substance abuse
USMC Vietnam Vet (can be 2-edged sword. Explored in above-mentioned CPE
Special Project paper)
[i] As defined in the Diagnostics and Statistical Manual of Mental Disorders (DSM-IV) http://www.psychologynet.org/dsm.html
[ii] National Center for PTSD Annual Report for Fiscal Year 2000 http://www.ncptsd.org/about/annual_report/ar00.html
[iii] The Therapeutic Community Model and PTSD Services http://www.ncptsd.org/publications/cq/v6/n4/networki.doc.html
[iv] The Mental Health Provider's Role http://www.ncptsd.org/wsah_booklet/32_the_mental_health_pr.html
[v] Spiritual Healing and PTSD Philip G. Salois, M.S.
NCP Clinical Quarterly 5(1): Winter 1995
http://www.ncptsd.org/publications/cq/v5/n1/salois.html
[vi] a “The Comparative Efficacy of Religious and Nonreligious Cognitive Behavioral Therapy for the Treatment of Clinical Depression in Religious Individuals” L..Rebecca Propst, et al. Journal of Consulting and Clinical Psychology 1992, Vol. 60, No. 1, 94-103
[vii] “Faith and Healing” Claudia Kalb Newsweek November 10, 2003, 47-48
[viii] ibid Salois (iv)
[ix] Some
Theological Perspectives On PTSD, William P. Mahedy NCP Clinical Quarterly
5(1): Winter 1995 http://www.ncptsd.org/publications/cq/v5/n1/mahedy.html
[x] Marines Find Faith Amid the Fire – L. A. Times 4/29/04
http://www.latimes.com/news/nationworld/iraq/la-fg-baptize29apr29.story
[xi] Surprisingly Few Adults Outside of Christianity Have Positive Views of Christians http://www.barna.org/FlexPage.aspx?Page=BarnaUpdate&BarnaUpdateID=127