Abstract:The pastoral care situation I will be analysing is on Posttraumatic
Stress Disorder (PTSD) in a survivor from a man-made mass casualty incident. The
physical aspects associated with PTSD include a hyperarousal state and
substance abuse as an attempt to self-medicate. Emotionally, one goes through
the grief process, which involves negative emotions such as anger, guilt and
depression. There can also be excessive fearfulness. On the spiritual level,
there is disruption of the relationship with God and with people. Therefore the
pastor needs to foster spiritual wholeness through attending to both the
parishioner and the Holy Spirit. Biblical/theological concepts to aid the pastoral
care process include instigating faith, hope and love through rebiographing the
parishioner’s narrative using examples such as the story of Joseph, the prophets
in the Hebrew Scriptures, and Job’s sufferings. Humans can never understand why God
does what he does; we can only trust in faith that somehow innocent suffering
fits into a larger plan of His.
_____
The pastoral care situation I will be analysing is on Posttraumatic
Stress Disorder (PTSD) in a survivor from a man-made mass casualty incident. To
identify the physical, emotional and spiritual aspects of this situation as
well as the pastoral issues arising, we need to know the DSM-V definition of
PTSD.
Some
of the features described in the DSM-V are related to the hyperarousal state
one experiences in a fight or flight response to threat where adrenaline and
noradrenaline are released.
There
can also be a freezing response to traumatic threat, where one goes into a state
of tonic immobility
[3],
has an altered sense of time, reduced sensation of pain, absence of terror or
horror.
Once
the fight or flight has been successful, cortisol will halt the alarm reaction.
In PTSD the body do not release enough cortisol to halt the alarm reaction so
one remains chronically hyperaroused even after the threat has passed. In PTSD
there is distortion to the hippocampus, the area of the brain associated with
memory processing that gives events a beginning, a middle, and an end. One of the
features of PTSD is a sense that the trauma has not ended. The activity of the
hippocampus often becomes suppressed during traumatic threat,
and in PTSD it remains continuously suppressed and shrunken.
This is the likely mechanism of the “flashback” symptom of PTSD. The traumatic
event seem to float free in time, rather than occupying its locus in one’s
past, often intrudes into the present perception as if it were occurring now.
Functional
studies also show a significant decrease in the activity of the Broca’s area which
is related to translation of personal experiences into a communicable language.
The physical problems of PTSD are inseparable from the
emotional problems. Intrusive symptoms restrict the person’s ability to
function as reminders of the trauma they suffered may appear suddenly, causing
instant panic.
Eventually,
one can become so overcome by fear that they become extremely restricted,
fearing to be with others or to go out of his/her home.
Dissociation,
which seems to be the most severe consequence in PTSD, involves a splitting in
awareness to save the self from suffering
,
where the numbing of emotions experienced in the freeze response persists.
[12] The difficulty
PTSD individuals experience in synthesizing and assimilating a traumatic event
to produce a structured narrative
can create communication difficulties leading to impairments in interpersonal
relationships and social functioning. Other psychological comorbidities are
common: Approximately 80% of sufferers have another disorder such as
depression, substance misuse, or anxiety.
Patterns
involving self-pity, abandonment, self-victimization and self-depreciation may
intensify the negative emotions related to a traumatic memory and exacerbate
psychological suffering.
In
fact, one goes through the various stages of the grief process. Hopelessness
is a word often used by PTSD individuals to express their emotional state.
Studies suggest that an increase in hope and decrease in despair and
hopelessness may be critically important factors for better health and longevity.
A
sudden, violent, or preventable physical death is traumatic for those left
behind
,
so individuals with PTSD may describe painful guilt feelings about surviving
when others did not or about things they had to do to survive.
,[21] There can
also be a sense of anger and unforgiveness.
[22]
Trauma changes our assumptions of identity, safety, and
relationship with the world.
One
loses a sense of innocence and trust. They saw the world as dangerous, feeling
perpetually vulnerable.
In
despair, one may ask, “What kind of God would allow this to happen?”, “What kind
of world is this?”
, and
“Why me?” When the God I have cried out to for help seems to fail me, the
loneliness is devastating.
Spiritually,
there can be a severed sense of connection with God.
Even
when the survivors thank
God for mercy, there is always a question that haunts
[28]:
what of those who were not saved? Did God choose for them to die for a purpose?
[29]
The need to find a reason for injury or survival is a defensive strategy. If
only there is a reason, or a mistake can be identified and judgment made, the
reality of lost control and powerlessness can be avoided.
[30]
The victims might go to their clergy for help with these spiritual
questions.
The
traumatic wound touches us as a whole: mind, body, and spirit
,
therefore healing from trauma is as multi-dimensional as the wound itself.
Biblical psychology
is clearly holistic psychology because the body, soul, spirit are not separate
entities.
[34]
Transforming trauma is impossible without spirituality: a belief in
something more than what is currently seen or understood.
Spiritual
issues include: “How do we pray or feel ourselves in God’s presence when one of
the fundamental elements of trauma is that trust has been ruptured?”, “How do
we make a reconnection with the God and meet God in a transforming way?”
Positive religious coping, religious openness, readiness to
face existential questions, religious participation, and intrinsic
religiousness are typically associated with posttraumatic growth
as
well as improved health outcomes.
Johnson
and Friedman
describe “spiritual emergence” as the personal integration of spiritual and
transpersonal experiences “to achieve expanded consciousness and maturity”. Whatever
the source of trauma, healing takes shape in the act of breaking out of
isolation and connecting with other people and the deeper meanings of human
experience.
Pastors are the only
counselling professionals who routinely have training in systematic theology,
biblical studies, ethics, and church history
[41],
hence uniquely equipped to foster spiritual wholeness.
[42]
The role of the
pastor is to listen, focus, and direct the process while attending to both the
parishioner and the Holy Spirit.
[43]
Pastors are also able to help their parishioner connect to support systems
through faith communities
that
can provide love and support.
[45] Pastors should never
feel that they are responsible for meeting all the needs of those who seek
their help. Instead, they carry the role of a broker, bringing those who
consult them into contact with the healing resources of the body and life of
Christ.
[46]
There is a high personal cost associated with the provision of counselling
[47],
so Benner proposes the establishment of a time-limited relationship five
counselling sessions.
[48]
Terminating the counselling relationship can sometimes get tricky.
[49]
Setting a limit discourages the formation of dependent relationships and
encourages people to continue to work on their problems.
[50]
Theologically
it is very important to address the issue of hope because hopelessness and
depression are common in people with PTSD. Despair, apathy and shame are three
attitudes where, once internalised and well established, poses a powerful
threat to the maintenance of a hopeful attitude toward life.
[51]
Therefore one needs to try and modify their narrative of the traumatic
event.
[52] One possible
meaning of repentance is that one’s sinful past is blotted out, like an erased
debt. Another is that one’s sinful past is rectified. The story of Joseph is a
biblical example of rebiographing
,
whereby he turned his brothers’ act of betrayal into a “useful event for
humanity”, a viable method of reframing because it is grounded in the boundless
mercy of God, who is able to take sinful actions that we or others committed in
the past and make them something better than we would ever have imagined.
Therefore, rebiographing makes the past as open and possibility-filled as the
future.
[54] Victor Frankl was a
psychiatrist whose work was deeply influenced by his experience in a
concentration camp. He pointed out that human beings have a fundamental need to
believe in the future, not just a hope for one’s individual future but an
embrace of future possibilities for humanity. If that belief is lost, it is impossible
to live well in the present.
[55]
The most
powerful hunger for God is known in the feeling of seeming absence.
[56]
The seeming loss of God is, in actuality, a passage into a deeper relationship
with the God. The loss of the image of a protective God carries with it the
experience of presence in the midst of the human reality of suffering.
[57]
When the prophets of the Hebrew Scriptures expressed profound grief for the
losses of their people, it invokes the memory of God’s fidelity and opens up
the possibility for a new way of understanding and living. Grief acknowledges
that a link has been severed: living into that truth frees the soul to believe
again in the future and to imagine a new possibility.
[58]
The book
of Job demonstrates that no one is exempt from suffering, even a saint like
Job, who in the face of natural evil displayed signs of social withdrawal and
complained against God. It does not explore why there is suffering but rather
the question of how a person can respond in the midst of suffering
[59]. Job’s friends
thought they were wise but they were doing more harm to Job when they tried to
explain everything away through human wisdom and self-confidence. It is not
debate but the comfort of the close human community that helps. These
sufferings lead Job to a “face to face” encounter God whereby he indicated his
complete submission to the Lord (Job 42:5-6)
[60],
and instigated a profound formation of Job into the genuinely humble wise man
of great faith who serves God simply because God is worth of such service.
[61] The greatest act of
faith for those encountering grief is to stand in its presence and make no
attempts to explain it away.
[62]
Humans
can never understand why God d
oes what he does; we can
only trust in faith that somehow innocent suffering fits into a larger plan of His.
Such faith in God
begins to free one from grief so that other imaginative possibilities start
revealing itself, including hope for the future and the desire to love again.
Person’s situation
|
PTSD in a survivor from a
man-made mass casualty incident.
|
Major needs for the person
|
Physical:
l
Reduce anxiety/hyperarousal symptoms, eg. irritable
behaviour, reckless behaviour, hypervigilance, exaggerated startle response,
poor concentration, and sleep disturbance.
l
Reduce intrusion symptoms, eg. recurrent intrusive
memories, dreams, flashbacks
l
Get off any addictions
Emotional: Guide the person through
the grief process.
l
Reduce negative emotions (anger, guilt)
l
Reduce numbing/depression (the inability to
experience positive emotions).
l
Lead the fearful individual into trusting again.
Relational:
l
Restore intimate relationship with God
l
Restore interpersonal relationships.
Social:
l
Enhance integration into community and social functioning
Spiritual:
l
Forgive self and others through the change of
narratives
l
Strengthen faith in God
l
Reinstigate hope in those who lost a sense of innocence
and trust
l
Regain the ability to love again
|
Support Network (who
are all the providers of care in this person’s life? What role do they have?)
|
Family/relatives: provide love and support,
need indepth understanding of PTSD due to proximate contact.
Friends: provide love and support.
Pastor: foster spiritual wholeness[1]
through listening, focusing, and directing the process while attending to
both the parishioner and the Holy Spirit.[2] Help
their parishioner connect to support systems through faith communities.[3] Enhancing parishioner’s awareness of God’s
grace and faithful presence.[4]
Congregation: provide love and support.[5]
Health Professionals: GP is usually
the first place to start. Subsequently, community psychiatric nurse,
psychologist, or psychiatrist might be involved.[6]
|
Major Overall Objectives
for Pastoral Care Plan
|
Foster spiritual wholeness[7]
|
Length of plan and how it
will be reviewed (how long will this
plan be used, how will it be assessed for effectiveness?)
|
Set five-sessions first
because those who need more sessions should be referred to someone who is
appropriately qualified.[8]
The exception to this rule is a situation which a parishioner is facing a
significant crisis at the end of the five sessions, and there are no other
available resources to provide the necessary support.
|
Pastoral Care Plan – specific steps
|
Identified
problem or issue
|
Specific
Objectives/goals
|
Specific
Skills or Activities that will be utilised
|
Support
Providers
|
Specific
Resources that will be used
|
Anxiety/hyperarousal
symptoms.
Intrusion symptoms.
Addictions.
|
Reduce
these physical symptoms and stop harmful “self-medication” methods such as
substance abuse.
|
Teaching:
The person and his family/carers need to be educated so they understand the
condition and its symptoms. He needs to be fully informed about all available
treatment options.
Training:
The person needs to be trained to perform relaxation techniques,
incorporating healthy lifestyle, and ways of staying off addictions.
|
GP: initial assessment and referral.
Psychologist/Psychiatrist: treat through
psychotherapy or medications.
Family: understand and cope in living with a PTSD
individual.
Pastor, congregation, friends: be understanding
when these physical symptoms arise.
|
Psychotherapy:
CBT or EMDR.
Antidepressant
medication might be needed.
|
Negative
emotions: anger, guilt.
Numbing/depression:
the inability to experience positive emotions.
|
Forgive
self and others through the change of narratives.
Regain
the ability for positive emotions such love and joy.
|
Listening
skills: one needs to be a good listener to detect the anger and guilt, which
can be hidden.
Genuineness:
people don’t always voluntarily express negative emotions unless it’s
somebody they trust.
Empathy:
to be a good listener, one has to be empathetic. The person feels safer about
telling their story.
Encouragement:
use the Scriptures to shift the focus to the love and promises of God.
|
Family,
friends, pastor, congregation: give the person time and
space to heal, don’t take his negative emotions personally. Intercession
prayer.
Heath
professionals: listen, counsel, provide psychotherapy or medications as
needed.
|
Pastoral guidance through
Scriptures: One possible meaning of
repentance is that one’s sinful past is blotted out, like an erased debt.
Another is that one’s sinful past is rectified. The story of Joseph is a
biblical example of rebiographing.[2]
Psychotherapy:
Past-focused approaches include exposure therapy and psychodynamic recall
therapies.[3]
Antidepressant
might be needed.
|
Lead
the fearful individual into trusting again.
Restore
intimate relationship with God.
|
Instigate
hope in those who lost a sense of innocence and trust.
Strengthen
faith hence trust in God, thereby re-instigating faith,
hope, love.
|
Genuineness:
the person need to encounter enough genuine people to be able to trust again.
Listening skills: to both
the parishioner and the Holy Spirit.
Teaching:
using Scriptural examples to teach about faith, hope, love, and God.
|
Pastor:
to listen, focus, and direct
the process while attending to both the parishioner and the Holy Spirit.[4]
Family,
friends, congregation: spiritual time together.
|
Pastoral
guidance through Scriptures: “…faith, hope and love. But the greatest of
these is love (1Corinthians 13:13)”. The prophets of the Hebrew Scriptures
and Job’s story as illustrations.
|
Restore
interpersonal relationships.
Enhance
integration into community and social functioning.
|
To
trust and love others again.
Restore
meaning and purpose in life and find a vocation that fulfill these.
|
Recognition
of abilities: to identify suitable vocations and community activities.
Training:
for interpersonal skills and the vocation of interest.
Teaching:
biblical wisdom applicable to interpersonal relationships and social
functioning.
Encouragement:
be patient as the process can be slow and frustrating.
|
Pastor:
Setting a limit discourages
the formation of dependent relationships and encourages people to continue to
work on their problems.[5]
Psychologist:
provide interpersonal skills training.
|
Pastor:
help parishioners connect to
support systems through faith communities during and after treatment.[6]
Psychotherapy:
Interpersonal skills training.
|
“Post-traumatic stress disorder (PTSD): the treatment of PTSD in adults
and children,” last modified March 2005,
https://www.ranzcp.org/Mental-health-advice/guides-for-the-public/PTSD-Public.aspx
Pastoral Care Plan –
biblical, theological and theoretical foundations
|
Biblical, theological or theoretical
perspectives/evidence
(that are relevant to this situation and the
care plan that has been developed)
|
Ways that this perspective/evidence informs
the pastoral carer
(link your response to specific problems,
objectives, skills or resources in your plan)
|
Psychotherapies
have been considered the mainstream treatment for PTSD cognitive behavioural
therapy (CBT) and eye movement desensitisation and reprocessing (EMDR).[1]
When
there’s sufficient
benefit from psychological intervention alone[2],
medications have been shown to be helpful in the management of core symptoms
of PTSD.[3]
|
These physical symptoms need
to be managed and are not signs of spiritual weakness.[4]
|
Joseph
turned his brothers’ act of betrayal into a “useful event for humanity”, a
viable method of reframing because it is grounded in the boundless mercy of
God, who is able to take sinful actions that we or others committed in the
past and make them something better than we would ever have imagined.[5]
|
Help the person re-narrate
his story.
|
When
the prophets of the Hebrew Scriptures expressed profound grief for the losses
of their people, it invokes the memory of God’s fidelity and opens up the
possibility for a new way of understanding and living.[6]
From
Job we see humans can never understand why God does what he does; we can only
trust in faith that somehow innocent suffering fits into a larger plan of
His. This faith allows other imaginative possibilities start revealing
itself, including hope for the future and the desire to love again.
|
Do not try to explain
everything away theologically. Let the Holy Spirit lead the process.
|
Human beings have a
fundamental need to believe in the future, not just a hope for one’s
individual future but an embrace of future possibilities for humanity. If
that belief is lost, it is impossible to live well in the present.[7]
|
Carry
the role of a broker, bringing those who consult them into contact with the
healing resources of the body and life of Christ.[8]
|
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