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14 Suicide Employing spirituality and faith as a protective factor against suicide Kevin Wright outlines attitudes to suicide in the major religions

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Utilizing theoretical and practical elements from academic and Christian sources, compile an original paper of at least 8 pages of body text, in current APA style, which summarizes your understanding of the nature and causes of trauma in general, as well as Suicide and Spirituality. Address factors necessary for successfully coping with the effects of trauma, and spiritual and professional approaches to treatment.

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the Islamic suicide bomber or the challenge of those facing a disabling and agonising death to choose the time and nature of their death. There is even a suggestion of some attraction towards the act of suicide among early Christians, who associated suicide with acts of martyrdom. Christianity Christianity, which is the dominant faith of many western societies such as England, has historically proven intolerant and even punitive of those who attempt suicide and in the case of those who ‘succeed’, even after death. While there is no specific condemnation of suicide contained within the Bible, most early Christian philosophers pointed to the commandment ‘Thou shall not kill’, which they understood to cover the deliberate killing of oneself, the word suicide being literally ‘self- murder’. St Augustine (345-430AD) expressed outrage in the 5th Century at those who kill themselves, describing suicide as ‘abhorrent unto God’, though more modern commentators cannot help but notice that he did not extend this to the act of killing in war or crusades, something the Christian church has a somewhat troubled history of. A century later the Catholic church prohibited the celebration of mass for those who died by their own hand and condemned them to be buried in ‘unhallowed’ or unholy ground. St Thomas expanded on this philosophy by arguing that suicide was acting against ‘natural law’ and therefore God’s law. As a result of such beliefs those who died as a result of suicide were denied a ‘true’ Christian burial and would instead be buried ‘profanely’, often with the body desecrated. Signs of a more compassionate and enlightened approach did emerge, however, with those felt to be insane and not responsible for their actions being exempt from such terrible retribution, though in the Times newspaper, spoke of the common belief that religious societies benefit from the moral support that organised religion can offer, a benefit which translates among other positive attributes to a reduction in suicide among its members. She argues that public displays of religious conformity and devotion do not necessarily equate to a truly felt sense of faith and hope and that as a result higher rates of suicide and homicide can exist in such communities. This position is explained further by Gledhill, who argued that without a true sense of faith one can not derive the support of a truly held belief from mere public displays of worship. Such views are contrary to research evidence such as that of Kay and Francis (2006), which identifies that the core message of the Christian faith, for example, is one of hope and meaning, and that accompanying attitudes relating to the immortality of the soul and attitudes towards death are strongly influenced by this. They further argue that church attendance will have a negative impact on the act of suicide, although they attribute this to the church community providing a ‘therapeutic community’ of mutual support and understanding such as that advocated by Durkheim (1897). Dervic et al (2004) further substantiates the argument that suicide rates are lower among religious countries throughout the world. While such arguments are of interest to the academic and practitioner alike, they both neglect one important aspect of religious belief – the attitude of one’s chosen faith towards the act of suicide and whether this can act as a deterrent to some individuals contemplating death as a means of escape. It is widely accepted that the three main faiths (Christianity, Judaism and Islam) all prohibit suicide or the taking of one’s life (Rassool, 2004). Yet such directives are clearly open to interpretation in the case of 14 Suicide Employing spirituality and faith as a protective factor against suicide Kevin Wright outlines attitudes to suicide in the major religions and examines the possibility of harnessing religious belief as a method of reducing suicide attempts Kevin Wright Senior Lecturer (Mental Health) Continuing Professional Development, Edge Hill University, Lancashire Abstract This article seeks to examine the historical influence that organised religion has on the public’s attitude to suicide and its role as a preventative factor in the act of suicide. While the employment of faith and spirituality may well take mental health nurses into unfamiliar or even uncomfortable territory, this article sets out to encourage colleagues to explore the supportive factors associated with faith with the service users. Key words Suicide, religion, history, attitudes, prevention Reference Wright K (2010) Employing spirituality and faith as a protective factor against suicide. Mental Health Nursing 30(6) : 14-15. Introduction Suicide, whether as an act of hopelessness, an escape from physical pain and disability or as a weapon of violence, terror or revenge, never seems far from the front pages of newspapers or as a subject of debate on our many news and current affairs programmes. The need to address the suicide rate is the focus of much debate and the subject of constant scrutiny from the National Confidential Inquiry into suicide and homicide by people with mental illness (2010) and government strategy in the National Suicide Prevention Strategy for England (Department of Health, 2002). The influence of religion is also an often common thread whether as a motivator, justifier or as a discouraging voice. The journalist Ruth Gledhill (2005), writing in
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general such retribution continued for many centuries, with prominent religious figures such as John Wesley (1703-1791) arguing somewhat illogically that those who failed to die as a result of attempted suicide should be put to death as a punishment. Other religions Within the other biblical tradition, Judaism, there is and remains an uncompromising condemnation of suicide based on a belief that we are merely custodians of our body rather than owners. It is inherent within this belief that one must ‘struggle to the very last breath’ to sustain this God-given body. Biblical faiths, of course, are not alone in its uncompromising position towards those attempt suicide. The Qur’an, for instance, specifically prohibits suicide ‘do not kill yourselves’ (Qur’an 4:29), with those who do being condemned to hell for all eternity. It is this historical condemnation of suicide that some would argue results in a lower suicide rate among those of the Muslim faith compared with other religions such as Hinduism (Kamal and Lowenthal, 2002). Protective capability Whatever the motivation or cause, strict adherence to a religious code, fear of condemnation either on earth or in the afterlife or through being part of a community with a strong sense of shared belonging, there is evidence to suggest that spirituality and faith can be a protective factor in eventual suicide. A recent study by Simonson (2008) validated Durkheim’s position that membership of a faith community does protect against suicide and that the religious are less likely to experience suicidal ideation (though not significantly). If one is to accept that a sense of faith, particularly a shared belief within the type of supportive community espoused by Durkheim, then perhaps one needs to ask an obvious question: why is faith and spirituality not embraced and used when offering support to the religious as a conduit of giving hope to those experiencing hopelessness (Mental Health Foundation, 2007)? Recent disciplinary action against those who wish to adorn themselves with religious ornamentation or to pray for their patients (Beckford, 2009; Wilkes and Sears, 2009) have undoubtedly caused some nurses to pause for thought before approaching the issue of faith, beyond asking their religious domination and asking if they wish to see a chaplain. An important aspect to any meaningful therapeutic relationship between a nurse and their patient is surely the provision of an environment where the respectful airing of the beliefs of those we seek to support can take place – and as such we should seek to overcome any misplaced reservation about discussing a person’s belief if the possibility exists of employing it as a protective factor against suicide (Gilbert et al, 2010). At a recent interfaith conference on faith and mental health (Mind and Soul, 2010) it was the commonly held view that if someone found themself isolated and despairing and contemplating death by their own hands, as a means of escape their faith may often be all that is left to sustain them through their period of emotional crisis. Therefore, if employed by mental health nurses it may well cause the often fleeting moment of reflection before the person decides to turns away from the act of suicide. MHN References Beckford M (2009) Christian nurse row: now teachers could be disciplined for discussing religion. The Telegraph : London: 9 February 2009. http://www.telegraph.co.uk/news/newstopics/religion/ 4557794/Christian-nurse-row-now-teachers-could-be- disciplined-for-discussing-religion.html. Accessed 10 November 2010. Department of Health (2002) National suicide prevention strategy for England . Department of Health: London. Dervic K, Oquendo MA, Grunebaum MF, Ellis S, Burke AK, Mann JJ (2004) Religious affiliation and suicide. American Journal of Psychiatry 161(12) : 2303-2308. Durkeim DE (1897) Le suicide: étude de sociologie . Felix Alcan: Paris. Gilbert P, Narinderjeet K, Parkes M (2010) Let’s get spiritual. Mental Health Today Oct : 29-33. Gledhill R (2005) Societies worse off when they have ‘God on their side’. The Times : London: 27 September 2005. http://www.timesonline.co.uk/tol/news/uk/article5712 06.ece) Accessed 10 November 2010. Kamal Z, Loewenthal KM (2002) Suicide beliefs and behaviour among young Muslims and Hindus in the UK. Mental Health, Religion and Culture 5(2) : 111-118. Kay W, Francis LJ (2006) Suicidal ideation among young people in the UK: Churchgoing as an inhibitory influence? Mental Health, Religion and Culture 9 : 127- 140. Mental Health Foundation (2007) Making space for spiritu- ality: how to support service users. Mental Health Foundation: London. National Confidential Inquiry into suicides and homicide by people with mental illness (2010) Annual report: England and Wales. The University of Manchester: Manchester. Rassool H (2004) Commentary: an Islamic perspective. Journal of Advanced Nursing 46[3] : 270-283. Simonson RH (2008) Religiousness and non-hopeless suicide ideation. Death Studies 32 : 951-960. Wilkes D, Sears N (2009) Persecuted for praying: Nurse who faces the sack after offering to pray for sick patient. 2 February 2009. http://www.dailymail.co.uk/news/article- 1133423/Nurse-faces-sack-offering-pray-sick- patient.html. Accessed 10 November 2010. 15 Spread the word! We hope you are enjoying your online journal and taking advantage of its archive, PDF and print capabilties. However, we know there are still MHNA members who are not yet accessing the journal on-line. If you have colleagues who have yet to take the plunge, then please do encourage them to start reading Mental Health Nursing again. Explain to them that reading the journal on-line is easy, convenient and can be done at home or work. More readers means that not only is the full value of membership being taken up, but it also strengthens the credibility of the journal with citation indices, colleagues and advertisers.
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I Special Section: Spirituality/Medicine Interface Project Section Introduction: Spirituality, Depression & Suicide Dan G. Blazer, MD, Pho The depressive disorders, among all the psychiatric dis- orders, have been most closely correlated with ordinary spir- itual experience. And the burden of depression is increasing throughout the world.'^ Patients who struggle with depres- sion find themselves reaching to the very core of their faith traditions. In some faith traditions, even a severe depression is perceived to he an adaptive component., beneficial to the self and to others. For example, in the Christian mystic tra- dition. St. John of the Cross writes powerfully of the "dark night of the soul" as a key to spiritual growth.' One reason for the tight intertwining of depression and spirituality is the blurred distinction between clinical depression and normal problems of living. Major depression, viewed primarily as a biologic illness, has been especially challenged as a diagnosis too narrowly conceived.''"'^ While some have viewed depression as an integral compo- nent of spiritual growth, others have seen it as emotional suf- fering that is especially open to spiritual interventions. Depres- sion has often been thought to be derived from shame and guilt secondary to alienation from a higher being, generally caused by sin. and only to be alleviated by spiritual exercises, such as repentance or prayer. Though modem psychiatry has done much to temper the view that depression is a spiritual condition rather than an illness, the former view persists.^ The interrelationship between a depressed mood and spir- itual struggle/growth dates to aneient times, Job, in the He- brew Bible, cries out in the anguish of his depressed mood, "May the day of my hirth perish, and the night it was said. 'A man is bom' . . . Why is light given to those in misery, and life to the bitter of soul, to those who long for death that does not come . . .'.'" (Job 3:1-20). He challenges those who ac- cused him of some sin that separated him from God or tried to philosophically isolate him because of his severe distur- bance of mood. "But 1 have a mind as well as you; I am not inferior to you . . . What you know, I also know; 1 am not inferior to you . . . you are worthless physicians, all of you! If only you would be altogether silent! For you, that would be wisdom." (Job 12:3; 13:2-5). Job's struggle was not an ex- traordinary experience. The development of the Jewish faith as it approached suffering did not follow a simple path. A history of persecu- From Duke Unjversily Medical Center, Durham. NC. Reprint requests to Dan G, Blazer, MD, PhD, Duke University Medicat Center. Durham. NC 27710. Email: [email protected] Copyright 15 2007 by The Southern Medical Association [)()38-4348/0 - 2000/10000-0733 Dan Blazer, MD, PhD tion through pogroms, culminating in the Holocaust during World War II. has appreciably shaped Jewish thought.*^ Cer- tain elements of the Jewish response to suffering include a stark realism regarding suffering (the rclusal \o invoke a su- pernatural solution to cover or abolish the agonizing reali- ties); intense feelings of family and community: involvement in the suffering of others; and a vision of the Day of Atone- ment. In other words, for the Jewish faithful, suffering brings a more clear view of life. The belief that depression offers a clearer view of life is also observed in Islam, particulary in Shi'ism, which envi- sions tragedy and grief as religiously motivated emotions.'' Typical religious rituals help the community recollect the struggles and martyrdom of the Shi'i imams. Religious griev- ing recognizes the suppression of the righteous by the world and the sacrifice of the community in striving toward righ- teousness. Personal emotional suffering is often interpreted as a reflection of the .suffering of the entire community of mar- tyrs. Children first learn to grieve as part of a religious ac- tivity. The depressed view themselves as more sensitive to the soeial environment and especially vulnerability to the hurtful aspects of social relations or public events. This con- cept of depression in no way minimizes social concern for the depressed: the depressed, as in many other faiths or societies, seek care and condolences from the community. In Hinduism and Buddhism, the individual must detaeh himself from suffering without letting detachment turn into indifference.** A soul liberated from suffering is a soul unified. That unity extends horizontally as well as vertically, and a soul duly liberated leads to a life of submission, gratitude, forgive- ness, self-sacrifice, and self-awareness. If one's thoughts are not liberated—that is, if they continue to be attached to sinful desires and egoism—the outcome can be emotional states such as anger, resentment, shame, guilt, low self-esteem, confusion, and loss of a sense of self.'" The Hindu and the Buddhist patient is rarely self-referred for emotional suffering but usually is brought by the family to the clinician when all other resourees are exhausted. Symptoms are therefore often tied to the complex family struc- ture and the family should be included in therapy. Southern Medical .fournal • Volume 100, Number 7. July 2007 733
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Special Section: Spirituality/Medicine Interface Project Suffering and melancholy is viewed with ambivalence in Christianity. Although religious melaneholy has been an integral part of spiritual growth tliroughout much of Western Christian history, at the same time it has often been undemtood as a symptom of stalled spiritual growth. Depression was understood as not merely the self turning inward due to a painfiil and self- absorbed temperament but was seen as inextricably derived from one's experience with God. Such an understanding led to the search for explanation for suffering and, subsequently, to the problem of theodicy (the difficulty of defending the justice and righteousness of God in the face of suffering)/ Stress and fear often lead to depression. One of the an- cient interpretations of a depressed mood was weariness in doing good works, or acedia. The Apostle Paul encouraged the Thessaionians to "never tire of doing what is right" (2 Thessalonians 3:13) for fear of slipping into acedia: in other words, sometimes the depressed withdraw from the world out of weariness from its stresses. People suffering from acedia might see the world clearly enough, yet lose hope in God; they would fear God. Jonah, for example, was weary and became angry with the world and with God because the Ninev- ites repented, and, in so doing, had "cheated" the wrath of God: "It would be better for me to die than to live," he said while watching and waiting upon the city (Jonah 4). The stress of preaching to this sinful nation drained whatever fervor Jonah felt for his godly mission; his anger and depres- sion wearied him; acedia overtook him. and he withdrew from the city. For many, the answer to acedia was the hope found in the events of Jesus's life and Resurrection. Hope in Jesus did not abolish suffering and depression, however., and the Christian mystic tradition describes its own profound understanding of melancholy, most poignantly put in the '"dark night of the soul."'' This period of desolation and fatigue reflects a disharmony between the self and the world as one grows spiritually. The dark night reflects an exhaus- tion of the old state and the "growing pain" to the new state of spiritual consciousness. The greatest pain comes from the sense of God's absence (the Divine Absenee), whieh in turn leads to a redoubled desire to unite with God. This sense of God's absence is accompanied by a heightened sense of sin, the loss of old passions for the world, and the recognition that peace and joy cannot be found in the world. Depression serves as a purification of the will and defeat of the person's rebel- lion against God. To put it more simply, the dark night builds character for the faithful Christian. In this issue, the focus of the Southern MedicalJournaVs Spirituality/Medicine Interface Project is on Spirituality, De- pression and Suieide. My colleagues and I will address these delicate connections. First, I provide an overview of spiritu- ality and depression from a eross-eultural perspective. Harold Koenig then reviews the empirical studies which assess the assoeiation of religious belief's/activities and depression. Bob Cloninger then reviews the emerging psyehobiologie studies that inform us regarding our innate spirituality and happiness. Next, the relationship between spirituality and depression will be addressed from a developmental perspective by Alan Jo- sephsen (adolescents), Michael Bostwick and Teri Rumnians (midlife), and David Steffens (the elderly). Susan Dunlap complements the physicians who have contributed to the see- tion with a view from pastoral care. John Peteet focuses spe- cifically on suicide and spirituality, and Diane Meglan, a social worker, follows this with a review of resources for clirJcians facing issues of suicide and depression. In the Eye on Religion subseetion, Phil Petersen and Alan Nelson present practical guidelines for working with patients from the faith traditions of the Monnons (Latter Day Saints) and Seventh Day Adventists, respectively, The section is brought to a close with the Selected Annotated Bibliography, which fo- cuses on books that, in my view, provide a most helpful perspective to clinicians. References 1. Kessler R. Berglund P, Demler 0, et al. The epidemiology of major depressive disorder: results from the National C'omorbidily Survey Rep- lication (NC"S-R). JAMA 2003:289:3095 3105. 2. World Health Organization. World Health Report 2001: Mental lleallh. New Understanding, New Hope. Geneva, World Health Organization, 2001. 3. St. John of the Cross. Darii Night of the Soul. New York. Image Books, 1959. 4. Blazer DG. The Age of Melancholy: Major Depression and ils Social Origins. New York, Routledge, 2005. 5. Parker G. Beyond major depression. Pxyehol Med 2OO5;35:467-474. 6. Horowitz AV. Creating Mental Illness. Chicago. University of Chicago Press, 2002. 7. Adams J. Competent to Counsel. Grand Rapids, Bilker Book House, 1970. 8. Bowker J. Problems of Suffering in the Religious World. Cambridge, Cambridge University Press, 1970. 9. Good B. Good M. Moradi R. The interpretation of depressive illness and dysphoric affect. In: KIcinman A, Ciood B, eds. Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatiy of Affect and Disorder Berkeley. University of California Press, 1985, pp 369--428, 10. Juthani N. Hindus and Buddhists. In: Josephson AM, Peteet JR, eds. Handbook of Spirituality and Worldview in Clinical Practice. Washing- ton, DC, American Psychiatric Press, 2004, pp 125-138, 11, UnderhitI E. Mysticism. New York. Dutton. 1961. pp 380-395, 734 © 2007 Southern Medical Association
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Running Head: Suicide and Spirituality 1 Suicide and Spirituality Krystal Giordano Liberty University Abstract
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Suicide and Spirituality 2 Introduction: o Thesis Statement Body I. 1.Nature and Causes of Trauma in general
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I Special Section: Spirituality/Medicine Interface Project Suicide and Spirituality: A Clinical Perspective John Peteety "O Over 30.000 people eommit suicide each year in the United States. While the reasons in eaeh ease may be eom- plex. the deeision that life is not worth living is an expression of existential despair. Most studies show an inverse relation- ship between religious involvement and suicide.'"'' Tliis paper reviews ways that clinicians can take into account a patient's worldview and existential concerns when assessing suieide risk, can bring spiritual resourees to bear in dealing with these concerns, and can assist families and friends with spiritual healing in the aftermath of a completed suieide. Suicide Assessment and Preventive Intervention Many individuals who kill themselves saw a clinieian shortly beforehand,"' suggesting that they were reaching out for help. Assessing spirituality in addition to suicidal thoughts, plans, means and prior attempts can help determine suicide risk. What does the person believe happens after death (reunion, punishment)? Important dimensions of existential concern for depressed individuals include identity, hope, meaning/purpose, guilt, and connection. Consider ways that clinicians can assess and help patients bring spiritual resourees to bear on core eon- cems in eaeh of these areas: Identity A public scandal may cause a respected businessman to consider suicide, and a disabling accident may put an athlete at risk. Such patients often need help to look more deeply at what has defined their sense of themselves. What core com- mitments have shaped who they are and want to be? What is the spirituality, or connection to something larger., in which these commitments are rooted? If it has been abstract or static, how can they find a spirituality that is engaged, and a re- source for transformation? Narrative approaches, such as Viederman's life review, can assist patients to see more clearly what their lives have been about within a bigger picture.** If they have lost this perspective, or if faith for them is what researchei-s call "extrinsic" rather than "intrinsic," a clinieian can try to help them understand why, and to engage again their deepest re- sources of inspiration tliat have sustained their identity. Breit- From the Dana-Farber Cancer Instilutc. Boston, MA. Keprinl requests to .lohn Pctect, MD. Dana-Farber Cancer Institute, 44 Binney Sn-eet. Gossman 411. Boston. MA 02115. Email: [email protected] harvard.edu Copyrighl 'C 2007 by The Southern Medical Association 00384348/0-2000/10000-0752 John Peteet, MD bart's meaning-centered therapy, which draws on Victor FrankPs logotherapy, is an example of this kind of work.'' A 60-year-old retired Unitarian minister with colon can- cer said he wanted to die because he could no longer be of service. He explained, "If I believed that there were an au- thority out there taking care of things to whom 1 was respon- sible. I would feel differently but I don't. I simply believe in service. When 1 can't continue to improve things, what's the point of going on?" His therapist explored why his recent ineapacitation seemed to have invalidated a life of service and his worth io family and friends, as well as how he could continue to give to others in the form of the opportunity to serve him. Hope Sinee hopelessness strongly predicts suicide,'* the clini- cian of a seriously depressed patient would want to know: What has made the patient's life worth living?^ How does s/he see the future? Do disappointments in achieving valueil goals mean that these goals need to be reassessed, and if .so what resourees does he have for putting unrealistic hopes into a larger context? A 30-year-old Asian graduate student explained that she- had taken an overdose of pills because she had given up on meeting the expectations of her parents to excel academi- cally. In assessing her risk of making another attempt, her clinician focused on whether she eould engage in family work. and in therapy aimed at clarifying and affirming her own core values that might transcend fulfilling parental expectations. Her relationship to her faith and her church community were important elements of this assessment. Patients otkn lose hope because vital relational source.s of confidence have failed them. Trauma at the hand of early caregivers can leave them vulnerable to disintegration of ba- sic trust, particularly when reminded by a subsequent loss or betrayal. They may then lose hope in themselves. A clinician can help patients who have lost basic triisi and hope by fostering a spirituality that is integrated rathct 752 2007 Southern Medical Association
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Special Section: Spirituality/Medicine Interface Project than ambivalent, or painfully torn [Judith Herman points out in her book Iruiitmt cwJ Recovery'^ that a trauma survivor often needs help to reeonstruct her fragmented view of the world]. A hope-sustaining spirituality is one that is accessible and real to the individual not only when he is in a comforting (for example, a religious) setting, but when he is in the middle of the stress of his everyday life. The theologian Paul Tillieh called this the "courage to be."" Many traditions have "spir- itual disciplines'" (such as prayer, worship, fasting, or giving to others) that help believers to maintain a consistent and coherent connection to their faith. A clinician can inquire about a patient's use of these as she might inquire how a patient in AA is "working the Program." A 30-year-old occupational therapist with a history of childhood sexual abuse cut herself during episodes of feeling numb and hopeless, many of which were triggered by work- ing with young female patients. Therapy involved months of estahlishing trust in her therapist, and in God. to whom she had turned ibr healing. Several appt'oaches helped her to in- tegrate her spirituality and her experience of trauma: honest prayer with her pastor and with members of a weekly small prayer and sharing group; having friends from church accom- pany her from difficult therapy sessions when she did not feel safe alone; and participating in a religiously-based month- long program for other survivors of similar trauma. These gave her the perspective of other people on her whole self and on how her faith included grace for her failures. Meaning/Purpose Chronically suicidal individuals struggle with whether life has any meaning, or if it has enough to outweigh their suffering. Some patients may even pose these ultimate ques- tions in therapy: Why is life worth living? What could it mean for (iod to allow suffering? Rather than intellectual responses, they usually want to be joined in their quest for spiritual answers. Clinicians ean encourage sueh patients to foster a spiri- tuality that is contemplative and attuned to larger realities, rather than distracted by proximate distress or impulses. Ac- tive appreciation of music, art, or nature, as well as prayer and worship, ean all help maintain self transcendence., or a center of gravity outside the self, whieh as Cloninger notes is a central feature of a mature personality.'" Mindfulness, ac- eeptance, and meditation are now taught not only by Buddhist practitioners but increasingly in psychiatric treatments such as Dialectical Behavioral Therapy (DBT). addiction treat- ment programs., and to patients in general hospital settings." A 50-year-old, bright administrator with borderline per- sonality disorder often felt demeaned at work and regularly declared her intention to kill herself because her life was meaningless. Though as an atheist she had always regarded Ihc spiritual practices of faith communities absurd, she found a sustaining sense of spaee. historical perspective, and a shared experience of beauty in her Renaissance literature classes. Guilt Is the patient feeling so guilty that s/he deserves to die? Does s/he show a pattern of blaming self-blame in the face of adversity? Is s/he capable of using insight from therapy, or from a pastor that his/her guilt may be irrational? Or is an overwhelming sense of guilt uneharaeteristie, fixed and per- haps even a delusional symptom that requires pharmacolog- ical intervention, and/or electroconvulsive therapy (liCT)? What ultimately grounds the psychotherapy patient's sense of worth? Does s/he have a way of llnding forgiveness? How effective are these? in other words, what is the nature of his/her spirituality? What does the person believe about the morality of taking one's life and what happens after death''? Does he believe that he will be punished (or rewarded in the case of a terrorist) for suicide in the next life? The irrational guilt that makes patients feel that they do not deserve to live is frequently embedded in an immature moral and spiritual perspeetive^a patient may for example fee! guilty for something of which a childhood parent, or a Sunday school version of Ciod might have disapproved. Cli- nicians can sometimes help such patients who are otherwise mature to see that their faith development [as described by James Fowler, in his book Stages of Faith''] has lagged be- hind and begin to "cateh-up," both in their appreciation of what is wrong, and of what God could forgive: As he approached retirement, a 65-year-old Protestant minister with obsessional traits developed an agitated depres- sion marked by feelings that he had committed a sin that would send him to hell. He gradually improved with a com- bination of medication, psychotherapy suppoiiive of his need for time to recover, mature theological responses from cler- ical friends, and appreciation by his wife and church of what he could still do for God. Connection Suicidal individuals often feel alone, misunderstood, and rejected by everyone, including God. At the same time, they may be drawn to die by fantasies of reunion in an afterlife.'^ Assessing both what they believe happens after death, and how concerned they are about the impact of their death on survivors, ean be important information in evaluating their risk. A clinician can often help a patient who feels alone to look at the possibility that others are more welcoming of him than he expects. In a similar way, he may be able to help him look at whether God. like the father of the prodigal son rather than being an authority ready to judge him. is more ready to receive his lost son back than the son believes. A 35-year-old Christian mother of two felt overwhelmed by her emotional limitations as a parent, and more aware of Southern Medical Journal • Volume 100. Number 7. July 2007 753
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Trauma, Attachment, and Spirituality: A Case Study Lauren E. Maltby and Todd W. Hall Rosemead School of Psychology ±e goal of this article is to illustrate the interaction be- tween trauma, attachment, and spirituality, and to dem- onstrate how to address this interaction in long-term attachment-based psychoanalysis. Toward that end, this article brie²y summarizes the convergence of attachment theory and psychoanalysis, and then reviews literature on attachment to God and trauma, including complex trau- matic stress. We then present an in-depth case study of a patient with symptoms of complex traumatic stress that was treated from a long-term attachment-based psychoan- alytic modality. Finally, based on the case that is presented, recommendations are made to practitioners about dealing with trauma and spiritual issues from an attachment-based perspective. In developing what came to be known as attach- ment theory, John Bowlby (1973, 1980, 1982) set out to update psychoanalytic object-relations theory with contemporary biology and ethology. In his research observations and clinical work, he saw the importance of real interactions in shaping personality and psy- chopathology. His emphasis on real interactions rather than the internal world, the sine qua non of psycho- analysis, caused the psychoanalytic community to re- ject his ideas (Holmes, 1993). As a result, attachment theory developed independently of the relational strand of psychoanalysis from the 1940s until the past few decades. ±is state of a²airs led to attachment the- ory focusing more on research and less on applied clin- ical interventions. In recent years, the ri³ between the trajectories of attachment theory and psychoanalysis has begun to converge, resulting in a more clinically focused theory of attachment. ±ere are several in´uential factors in this development. ±is convergence was sparked by Mary Ainsworth’s work on secure and insecure attach- ment types, which emphasize the subjective meaning of an infant’s behavior (Ainsworth, Blehar, Waters & Wall, 1979). ±en, a turning point occurred in the mid-1980s, when attachment theorists shi³ed from a focus on infant behavior to a focus on the dynamic in- ternal representations in the infant and parent, partly as a result of the development of the Adult Attachment Interview (Fonagy, 2001; Main, Kaplan & Cassidy, 1985; Bretherton & Waters, 1985). Main, Kaplan & Cassidy (1985) moved from infant attachment behav- ior to the level of mental representation in adults by us- ing the Adult Attachment Interview (AAI). In the past decade in particular, a number of clinical theorists have further developed the applications of attachment the- ory (Fosha, 2001; Mitchell, 2000; Wachtel, 2010; Wallin, 2007). Attachment theory, broadly construed, is based on the belief that “what is believed to be essential for men- tal health is that the infant and young child should ex- perience a warm, intimate and continuous relationship with his mother (or permanent mother-substitute) in which both µnd satisfaction and enjoyment” (Bowlby, 1982, p. xxvii). ±is caregiver-infant bond serves to meet not only the biologically instinctual drive for in- fants to maintain physical proximity to caregivers in or- der to sustain life, but also serves the second purpose of regulating emotional distress. ±rough processes such as attunement (Siegel, 1999) and the dyadic regulation of a²ect (Fosha, 2001; Tronick, 2007) caregivers are able to function both as a secure base from which in- fants and young children can explore the world, as well as a safe haven to which they can return when they face overwhelming challenges or feelings of distress. In dyadic relationships where this occurs, infants are Copyright 2012 by Rosemead School of Psychology Biola University, 0091-6471/410-730 JOURNAL OF PSYCHOLOGY & THEOLOGY 2012, Vol. 40, No. 4, 302–312 302
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likely to develop a secure attachment style (Ainsworth et al, 1979). Unfortunately, caregivers are not always e±ective at consistently providing attunement. In the absence of consistent attunement, infants and young children develop organized strategies of maintaining the at- tachment relationship. In the 1970s, Ainsworth de- vised the strange situation, which resulted in the now– ubiquitous classi²cation system identifying these other organized, but insecure attachment styles (i.e., anxious and avoidant ). A fourth attachment style, disorganized , was identi²ed in 1980’sby Main and Solomon (1986). In cases where caregivers are both terrifying and the only source of comfort in the face of terror, as in the case of trauma, no organized strategy can be developed. ³e disorganized attachment style, marked by dissocia- tion and the inability to develop an organized strategy for managing the attachment relationship, has been signi²cantly related to traumatic experiences, par- ticularly traumatic experiences involving caregivers. A wealth of empirical literature has demonstrated that at- tachment styles are clearly identi²able by 12 months and persist into adulthood (Brown, 2009; Main, Ka- plan & Cassidy, 1985; Sroufe, Egeland, Carlson, & Collins, 2005). ³e infant’sstyle of relating, whether it is an organized or disorganized strategy,becomes inter- nalized; at times, this pattern of relating to others has been called an internal working model . Internal Working Models and Ways of Knowing ³e dynamic relationship between attachment the- ory and neuroscience has been highly in´uential, both in empirically con²rming the theoretical underpin- nings of attachment theory and in providing numerous rich directions for the continued re²nement of attach- ment theory. One of the most signi²cant concepts to emerge from this relationship has been that of two dis- tinct ways of knowing, or processing systems. ³e explicit system (Siegel, 1999), also called the verbal (Bucci, 1997), cool cognitive or “know” (Metcalfe & Mischel, 1999), C , and re´ective (Lieberman, 2007) system, processes information serially, slowly, and con- sciously; it is responsible for intentional behavior, propositional knowledge, and episodic and semantic memory.In contrast, the implicit system (Siegel, 1999), also called subsymbolic and nonverbal symbolic (Bucci, 1997), hot emotional, or “go,” (Metcalfe & Mischel, 1999) X, and re´exive (Lieberman, 2007) sys- tem, processes a massive of amount of information in parallel, rapidly, and unconsciously. ³is system is par- ticularly responsible for processing social-emotional information; that is, for computing the meaning of re- lational experiences for a person’s well-being. Attachment-related information is encoded largely by the implicit system. Implicit knowledge about our- selves-in-relation-to-others has been termed implicit relational knowledge , (Stern et al., 1998), representa- tions that are generalized or RIGS (Stern, 1985), emo- tion schemas (Bucci, 1997), mental models (Siegel, 1999), and internal working models (Bowlby, 1973). Regardless of what it is named, one’s implicit knowl- edge of how to be with an attachment ²gure is at the core of one’s attachment style. Implicit memory has been referred to as an attachment ±lter because it oper- ates outside of conscious awareness (Hall, 2007). ³e ²lter itself is not experienced; rather, relationships are experienced through the ²lter. By its very nature, people struggle to identify their implicit attachment ²lters; instead, they are communicated “between the lines” so to speak in the way people tells their story, rather than the content of the story per se (i.e., explicitly). It did not take long for attachment theory to make its way into the psychology of religion. Parallel to Ana- Maria Rizzuto’s prior work applying object relations theory to understand people’s experiences of God (Riz- zuto, 1979), researchers quickly realized that people ex- perience God as an attachment ²gure, and subse- quently began applying attachment-based categories to describe attachment to God. Research in the area of at- tachment to God has clustered around two distinct hy- potheses, termed the correspondence and compensa- tion hypotheses, respectively. ³e question, as posed by Kirkpatrick and Shaver (1990), is whether one’s reli- gious and spiritual experiences correspond to their in- ternal working models of human attachment ²gures, or whether they in fact compensate for the lack of secure attachment relationships with humans. Both the corre- spondence and compensation models of attachment to God have received empirical support (correspon- dence—Beck & McDonald, 2004; Brokaw & Ed- wards, 1994; Hall, Brokaw, Edwards, & Pike, 1998; Hall & Edwards, 2002; Merck & Johnson, 1995; Rowatt & Kirkpatrick, 2002; compensation—Gran- qvist, 1998; Granvist, 2002; Granqvist & Hagekull, 1999; Kirkpatrick, 1997, 1998; Kirkpatrick & Shaver, 1990), creating a rather inconsistent picture of how one’s attachment to God relates to one’s attachment style with close human relationships. Hall, Fujikawa, Halcrow, Hill, and Delaney (2009) suggested that this inconsistency was due to lack of clarity regarding the correspondence and compensa- MALTBY and HALL 303
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