Holistic Trauma-Informed Care: Integrating Spirituality & Psychotherapy by Creating a Healing Sanctuary H. Jack Perkins, D. Min., LADC Admission Director,

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
Yes No Does prayer help healing? 80% 14% Should doctors pray if asked? 63% 25% Should prayer be standard? 34% 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 NEURO-PSYCHO-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

Who or what provides the patient with strength and hope?
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. 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” Spirituality Research: Measuring the Immeasurable David O. Moberg What Has the Research Revealed? The results of studies relating spirituality to measures of health, well-being, personality, and other concerns are so exceptionally consistent in one direction that many researchers are surprised by their discoveries. 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” The results of studies relating spirituality to measures of health, well-being, personality, and other concerns are so exceptionally consistent in one direction that many researchers are surprised by their discoveries. Many of these findings have been clearly, comprehensively, concisely, and critically summarized in numerous books, especially those by Harold G. Koenig.30

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),

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.

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 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). (1) Carol Boulware, MFT, Ph.D. Los Angeles - Santa Monica & Redondo Beach, California Center for Victims of Crime (2-6) National Center for Victims of Crime

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)

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 ~

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 ~

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 (

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 It appears that many in our society have a preoccupation with individualism, some would call it narcississm. The focus of the humanistic perspective is on the self, which translates into "YOU", and "your" perception of "your" experiences. This veiw argues that you are free to choose your own behavior, rather than reacting to environmental stimuli and reinforcers. Issues dealing with self-esteem, self-fulfillment, and needs are paramount. The major focus is to facilitate personal development. Two major theorists associated with this view are Carl Rogers and Abraham Maslow. Spirituality refers to an attempt to seek meaning, purpose and a direction of life in relation to a higher power, universal spirit or God. Spirituality reflects a search for the sacred. The word spirituality is derived from the Latin word spirale which means to blow or to breathe. The Hebrew word “Ruach” and the Greek work “Pneuma” convey a similar meaning. Thus, spirituality denotes giving breath and hope to individuals, families and communities In contrast, religion refers to a form of social institution with its accompanying beliefs, practices, symbols and rituals. Viktor Frankl provided the definition that religion reflects a belief in a “final meaning.” Psuche, is translated as the sensory-self, soul or life. It is the root of the English words, psychic and psychology. The soul represents “the breath”, “the breath of life”, and is rendered “heart” in Ephesians 6:6, “Doing the will of God from your heart”. The Humanist Manifestos I, II asserts: “Ethics is automous and situational, needing no theological or ideological sanction” 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). A Psychospiritual Model of Spiritual Formation: A Review of David Benner’s Contributions Phil Howard Toccoa Falls College

4 Expressions of our spiritual essence:
Spirituality: “The response to a deep & mysterious human yearning for self-transcendence & 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) Benner, D. (1988). Psychotherapy and the spiritual quest. Grand Rapids, MI: Baker Book House. Benner, D. (1989). Toward a psychology of spirituality: Implications for personality and psychotherapy. Journal of Psychology and Christianity.

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. Fowler’s view of “faith” allows it to serve either a religious or non-religious faith. It is a characteristic of all human beings. Faith could be described as the very pattern of trust and commitment that shapes a person’s life. It is our way of making and maintaining meaning of in life. Faith is seen as a holistic orientation, and is concerned with the individual's relatedness to the universal.

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:
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 Meditation & The Brain “Think on these things…” “For God so loved the cosmos…”

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

Hyperarousal Continuum Dissociative Continuum
RESPONSES TO TRAUMA Hyperarousal Continuum ~ flight or flight ~ Dissociative Continuum ~ 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 Freezing Compliant Dissociative Fainting Opioid Response–Serotonin decreases Expressed internally (day dreaming) Heart rate decreases or stays the same Muscles become flaccid/numb Child/female response Potential for suicide increases decreases—Decrease in humans is correlated with impulsivity and aggression (Kolk, Body Keeps the Score)

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 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. 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, on-going abuse may also develop Dissociative Identity Disorder, commonly known as “multiple personalities.”

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 Suggestions for Including Spirituality in Coping With Stress and Trauma Kent Drescher, Ph.D. National Center for PTSD

How can you nurture your client’s spiritual coping efforts?
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? TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D. Distinguished Professor Emeritus, University of Waterloo Waterloo, Ontario, Canada and Research Director of The Melissa Institute for Violence Prevention and Treatment Miami, Florida

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. United States Department of Veterans Affairs NATIONAL CENTER for PTSD Jack Perkins created the continuum concept

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

Beyond PTSD: Soldiers Have Injured Souls Diane Silver
Post Traumatic Soul Disorder What sometimes happens in war may more accurately be called a moral injury — a deep soul wound that pierces a person’s identity, sense of morality and relationship to society. In short, a threat in a solder’s life. Read more:

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): It must be brief. It must be easy to remember. It must obtain appropriate information. It must be patient-centered. 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. Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009

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. Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009

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 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? Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009

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?” Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009

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? Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009

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? Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009

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. T – Treatment plan: If patient is coping well, then either support and encourage or reassess at a later date as patient’s situation changes. If patient is coping poorly, then 1) depending on relationship and similarity in faith/beliefs, provide direct intervention: spiritual counselling, prayer, Sacred Scripture, etc., 2) encourage patient to address these concerns with their own faith leader, or 3) make a referral to the hospital chaplain for further assessment. The spiritual history is a genre unique from that of a spiritual screen and a spiritual assessment. Technically, FACT does not qualify as a spiritual history tool (LaRocca-Pitts, 2008ab): it is three parts spiritual history and one part spiritual assessment. In other words, it is a hybrid spiritual assessment tool that fits well the needs of a professional chaplain in an acute care setting. It also works well with other healthcare clinicians who believe the scope of their practice includes addressing spiritual needs, such as providing spiritual encouragement or prayer and making referrals to chaplains. Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009

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 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? 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? 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 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? 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? 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? 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? 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? 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? David R. Hodge and Crystal Holtrop

Security, stability, & freedom from fear or threat
Rays represent transcendence-- exceeding or surpassing in degree or excellence Self-fulfillment, realization of one’s potential, becoming fully capable of one’s potential Feelings of achievement or self- esteem & need for recognition or respect from others Social needs— friendship, affection, acceptance, & interaction with 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: Primary expression is spirituality as a search for transcendence Primary expression of human spirituality is that we inherently seek to surrender to, or align ourselves with, this self-transcendent being or thing A human desire to resolve issues of identity, to have a personal sense of meaning and to know that our existence is not accidental 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. TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum,

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 TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D. Distinguished Professor Emeritus, University of Waterloo Waterloo, Ontario, Canada and Research Director of The Melissa Institute for Violence Prevention and Treatment Miami, Florida G:\AOD COUNSELING\12 CORE FUNCTIONS\4 ASSESSMENT\Clinical Spirituality Interview.docx

Questions For Psychotherapists :
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?

Readiness for enhanced spiritual well-being
Have a desire for enhanced hope; Never _____________________________ Always Feel that there is meaning and purpose to their life; Never _____________________________ Always Have a sense of peace or serenity; 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 well-being (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. TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D.

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. TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D. “One’s faith and participation in religious rituals give a person a sense of being loved and valued, exactly as one is, despite a person’s self-image as being “damaged, sinful, abused and abandoned.” As I have discussed elsewhere (Meichenbaum, 2006a, b), a major goal of interventions is to help individuals engage in non-negative thinking and develop a coherent narrative.”

Spiritual & Religious Activities Can Act To:
Normalize reactions and internal spiritual struggles. 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.”) 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. 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. TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D. (Cacioppo et al., 2005 have reviewed the research literature that sociality, spirituality and meaning-making are central features of human beings and that relational and collective connectedness combat feelings of isolation and loneliness and that they are critical to the healing process. Socially connected individuals are more likely to meet the demands of everyday stressors by means of active coping and by recruiting help from others.)

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).” TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D.

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!” 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.” TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D. 7. “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!

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” 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. TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D. 10. The use of these spiritual forms of coping may prove most helpful for handling those aspects of stressful situations that cannot be personally controlled, nor changed, and that are not amenable to direct-action problem-solving coping efforts.

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. Psychotherapists use varied metaphors to describe these mindfulness skills. “It is like floating on a raft in the ocean and you are absorbing the warmth of the sun, noticing and accepting the rolling waves you are feeling under your floating raft.” TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D.

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. TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D See Handout

Create A Welcoming Environment

Video: “Come Unto Me You Heavy Laden…”

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. Reference and citing from: TRAUMA, SPIRITUALITY AND RECOVERY: TOWARD A SPIRITUALLY-INTEGRATED PSYCHOTHERAPY Donald Meichenbaum, Ph.D

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 Office: You may have a water feature. Following a story I shared at MBTS that had started out as an illustration for a sermon, a student called me sobbing uncontrollably. The story had touched a button and she insisted she needed to talk with me. She poured out her heart. Even though she was studying to become a minister and was married with children, she had been having an affair. I met with for several sessions to process the events of her life and the impact of the experience. Confessional in a Baptist church was not a direction she could take. I encouraged her to go home, while alone, put on soft music, light candles in her bathroom, put bubble wash in her bathtub, and meditate on the cleansing aspect of the “water that swells up from within” as Jesus forgives and restores. The origins of separation and alienation: The village of Sychar where Jesus meets the Samaritan woman was by Jacob's Well and was located near Mount Gerizim, the site of the Samaritan temple, Samaria's holy place. Passages which provide a perspective on the historical racial hatred and tensions between the Jews and the Samaritans are: II Kings 17:21-41; Ezra 4; and Nehemiah 4. Passages which provide a glimpse of Jesus' attitude towards the Samaritans is provided in the following passages: Luke 9:51-56; Luke 10:30-37; and Luke 17: Samaria was the northern kingdom of Israel. The "Jews" were descended from the returned exiles of the southern kingdom of Judah. I and II Kings provide the history and story of these two kingdoms which developed after the death of Solomon. NOTE: Jesus himself was accused of being a Samaritan and having a demon in another passage in John - John 8:48. Clues to be gleaned: Two times this woman is called the "Samaritan woman" or, in other translations, a "woman of Samaria". (John 4:7, 9) Twice she is labelled. Twice her nationality and her religion were emphasized. Then there is the fact that she is not exactly well-to-do. Women of influence and affluence did not draw water from wells in those times. (John 4:7) Then there is the inescapable hint of a disreputable life - "you have had five husbands and the one you have now is not your husband". (John 4:18) Further, this woman is somewhat unique in that she had not sought out this meeting either by prayer (like Anna in the temple) or by going out to find him (like the Syro-Phoenician woman). Jesus in relation to women: Historically and traditionally, Jewish men did not speak in public to women, even their own wives. For a rabbi this would have been an even greater restriction. Women were not publicly taught the Law. A woman's place in that society was not remotely similar to our own. But Jesus never treated women in the expected ways of his culture. He talked with them. He taught them. He expected and trusted them to be able to proclaim the Good News. He told stories using women as his characters. He even gave an illustration of what God was like using the image of the woman searching for the Lost Coin. Jesus acted and spoke as if women and men were equal before God and his eyes.

Explore the value of using metaphors in Christian counseling
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” Trinity Evangelical Divinity School 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). ETHICAL ISSUES IN SPIRITUAL ASSESSMENT Linda Openshaw Cynthia Harr Presented at: NACSW Convention 2005 October, 2005 Grand Rapids, Michigan

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. ETHICAL ISSUES IN SPIRITUAL ASSESSMENT Linda Openshaw Cynthia Harr Presented at: NACSW Convention 2005 October, 2005 Grand Rapids, Michigan

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) Counselors must first resolve and clarified prior to carrying them into their professional practice. ETHICAL ISSUES IN SPIRITUAL ASSESSMENT Linda Openshaw & Cynthia Harr Presented at: NACSW Convention 2005 October, 2005 Grand Rapids, Michigan

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. An underlying theme of a strength based therapist is this … “most people are very good at articulating their problems and their faults… they are seeking my help to acknowledge and to understand their strengths and potential solutions… it is my job to ensure that the therapy session balances problems with solutions and perceived faults with perceived strengths.” Strength based interventions are particularly important to couples and family therapy interventions – hope encourages change and clients don’t tend to feel very hopeful if an entire session is spent on articulating faults and problems… everyone has strengths and a solution is always available… the more that the clients can believe this the more hopeful they will be and the more likely they will be to do their part in creating meaningful change.

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” SPIRITUAL ASSESSMENT: A REVIEW OF COMPLEMENTARY ASSESSMENT MODELS David R. Hodge and Crystal Holtrop

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 It has been nearly two decades since the term "vicarious trauma" entered the lexicon of psychological conditions. In early descriptions by Karen Saakvitne, PhD and Laurie Anne Pearlman, PhD in 1990, the co-authors of numerous articles on the subject, defined vicarious trauma (VT) as a "pervasive effect on the identity, world-view, psychological needs, beliefs, and memory systems of therapists who treat trauma survivors."

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.

How does your spirituality help you when hearing story after story?
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 kitty- corner 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

Holistic Trauma-Informed Care: Integrating Spirituality & Psychotherapy by Creating a Healing Sanctuary H. Jack Perkins, D. Min., LADC Admission Director,

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Holistic Trauma-Informed Care: Integrating Spirituality & Psychotherapy by Creating a Healing Sanctuary H. Jack Perkins, D. Min., LADC Admission Director,

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Presentation on theme: "Holistic Trauma-Informed Care: Integrating Spirituality & Psychotherapy by Creating a Healing Sanctuary H. Jack Perkins, D. Min., LADC Admission Director,"— Presentation transcript:

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