Spirituality and Trauma Treatment: Suggestions for Including Spirituality as a Coping Resource
By: the National Center for Post Traumatic Stress Disorder
Religious beliefs and practices (spirituality) are traditions through which many people develop personal values and their own beliefs about meaning and purpose in life. Among mental health professionals, there is increasing recognition that many patients view spirituality as a primary human dimension. Indeed, current concepts of coping strategies are evolving to include spiritual beliefs and practices, along with other social, emotional, physical, and cognitive aspects, as important coping resources. The military has a long tradition of providing for the spiritual needs of its troops through Chaplains representing Jewish, Catholic and Protestant religious traditions. In his review, Donahue (1) found many studies which show generally positive relationships between religion and both mental and physical health. In particular, regular religious practices (as opposed to specific beliefs) such as church or synagogue attendance, prayer and scripture reading, have been shown to be related to positive mental and physical health.
Traumatic events often lead to dramatic change in survivors' world views so that fundamental assumptions about meaningfulness, goodness, and safety shift negatively. For those whose core values are theologically founded, traumatic events often give rise to questions about the fundamental nature of the relationship between the Creator and humankind. How can belief in a loving, all-powerful God be sustained when the innocent are subjected to traumatic victimization?
In a recent study (2) it was suggested that religiously committed women who are battered suffer less severe PTSD symptoms than women without such commitment. However, research also indicates that battered women attend religious services less frequently than maritally distressed controls (3). This finding is consistent with research related to combat veterans which suggests that those experiencing psychiatric problems or PTSD attend religious services less frenquently than controls (4).
The goal of this article is to provide suggestions for incorporating spirituality as a core component in coping resources assessment or relapse prevention work for traumatized populations. Over the past year we have been studying veterans in treatment at the Menlo Park and Brentwood PTSD inpatient treatment programs. To date we have studied the responses of about 100 patients to the 14 item Age Universal Religious Orientation Scale (5). What we found is consistent with earlier findings. Vietnam combat veterans with PTSD score lower than average on measures of religious orientation (6). It also suggests that they are less likely to use religion as a way of getting social support when they need it. We also inquired about other aspects of their religious faith. Table 1 shows these items and mean response rates.
These results show that most patients had difficulty reconciling their religious beliefs with their experience in combat. However, about 26% of patients said that combat experiences made their faith stronger. For these particular patients, this statement was strongly associated with current church attendance. To summarize, current spiritual practices appear to be heavily influenced by two factors: childhood religious participation, and combat-related religious conflicts. For those individuals who want to work on their religious participation as a means of improving their coping resources, we have developed several intervention strategies which might be incorporated into existing group treatments.
Guidelines For Incorporating Spirituality Into Group Activities
To institute a spiritual component, two ground rules are critically important: strictly voluntary participation, and mutual respect for divergent views. Patients' views of spirituality can be highly personal and emotionally charged, ranging from seeing spirituality as unimportant to it being a central focus of life. These factors make it essential that participation be voluntary. Discussion of sensitive and delicate issues must allow for wide ranging differences in attitudes and beliefs. Thus maintaining a tone of interest in and mutual respect for the views of others is a necessity. Emphasis is placed on aspects that varied religious traditions share, rather than on those which separate. Acknowledgment of the varied contributions of each religion and culture represented should be made and a tone of acceptance set by group leaders. As with all trauma groups, it should provide a safe environment for emotional expression and self-disclosure.
Table 1. Responses Of PTSD Inpatients To Items Related To Religious Faith
Religious faith was an important part of my life during childhood.
I have had difficulty reconciling my religious beliefs with the traumatic events that I saw and experienced in Vietnam.
I abandoned my religious faith in Vietnam.
Experiences in Vietnam made my faith stronger.
I have abandoned my religious faith since my return from Vietnam.
Experiences since I left Vietnam have caused my religious beliefs to grow stronger.
Feelings of guilt about things I experiences in Vietnam have caused my religious faith to diminish.
While I was growing up, I attended church or religious services: (> 2X per month)
In Vietnam, when it was possible, I attended church or religious services: (> 2X per month).
I currently attend church or religious services: (> 2X per month)
A Menu of Possible Group Activities
A variety of spiritually based activities are possible: a spiritual autobiography, discussion of key existential issues, silent prayer and meditation, guided imagery, practice in religious ritual, use of selected readings, ad attendance at religious services.
Spiritual Autobiography: Patients are asked prior to group to write a description of their spiritual journey from childhood to the present. This highlights key experiences and decisions which were made regarding their religious faith and describes the context in which they occurred. This exercise allows patients to clarify and see more objectively their current religious beliefs and practices and reflect on directions they would like to pursue. Autobiographies are presented in turn by group members during sessions and help to identify and begin discussion of relevant themes and issues.
Discussion of key issues: The group focuses on the discussion of key theological and existential issues. A portion of each group session is devoted to exploration of issues which are relevant for the group. Facilitators need to be able to inform the group how various traditions have resolved these issues but leave it to group members to wrestle the questions through toward their own individual solutions. Issues might include reconciling the existence of God with the presence of evil and suffering in the world, processing feelings of anger at perceived abandonment of betrayal by God. Additional issues might include shame, forgiveness, guilt, and self-blame. Participants are asked to reflect about their own religious upbringing and what they learned as children about these issues.
Spiritual exercises: A variety of experiential exercises involving meditation, guided imagery, and silent prayer are appropriate. These should include a relaxation component which will build upon existing stress management skills already learned and used by the patients. Exercises are drawn from a variety of religious traditions. In addition, outside "practice" of prayer and meditation exercises experienced during group sessions is encouraged.
Selected readings and religious ritual: A varied collection of suggested readings is compiled by group members and a file maintained by facilitators. Reading is assigned as homework and members are asked to keep a journal recording their thoughts about the readings and other group experiences. Throughout the sessions the importance of religious rituals is emphasized. Many theological traditions have made use of rituals to communicate meaning through imagery and metaphor. Leaders can encourage group members to discover meaningful rituals in churches they visit. In addition, the group can create a unique ritual which might express something of the issues explored during the course of the group. The group should then enact the ritual at some point, perhaps near the end of the group meetings.
Religious participation outside group: Group members are encouraged to attend a religious service of their choice. The purpose is to desensitize this experience for members for whom this is difficult and it may facilitate development of an outside network of social support in the community.
The ultimate goal for the individual participants is the recovery of a sense of hope, and a more realistic balanced view of the world as a place of both danger and safety, evil and good. Facilitating patients' re-connection with the roots of their childhood faith or discovering new avenues of religious expression may provide ongoing meaning and comfort. Patients may also identify spiritual practices which ultimately provide release from guilt, comfort for pain and loss, and support for the struggles of healing which lie ahead.
By Kent D. Drescher, M.Div., Ph.D. and David W. Foy, Ph.D.
NCP Clinical Quarterly 5(1): Winter 1995
1. Donahue, M.J. (1985). Intrinsic religiousness: Review and meta-analysis. Journal of Personality and Social Psychology, 48, 400-419.
2. Astin, M.C., Lawrence, K. J., & Foy, D.W. (1993). Posttraumatic stress disorder among battered women: Risk and resiliency factors. Violence and Victims, 8, 17-28.
3. Ogland-Hand, S.M. (1992). Post-traumatic stress disorder and religiosity: Comparisons between battered and maritally-distressed women. Unpublished doctoral dissertation, Graduate School of Psychology, Fuller Theological Seminary, Pasadena, CA.
4. Watson, C.G., Kucala, T., Manifold, V., Juba, M., & Vassar, P. (1988). The relationships of post-traumatic stress disorder to adolescent illegal activities, drinking, and employment. Journal of Clinical Psychology, 44, 592-598.
5. Gorsuch, R.L., & McPherson, S.E. (1989). Intrinsic/extrinsic measurement: I/E revised and single-item scales. Journal for the Scientific Study of Religion, 28, 348-354.
6. Kennedy, K.A. (1989). Gallup poll on religion: Social demographics for intrinsic and extrinsic religious orientation. Unpublished doctoral dissertation, Graduate School of Psychology, Fuller Theological Seminary, Pasadena, CA.
Kent D. Drescher, M. Div., Ph.D. is a health scientist who works as the assessment and data management coordinator for in the inpatient programs of the National Center for PTSD, Menlo Park, CA. He is also an ordained Presbyterian minister.
David W. Foy, Ph.D. is a professor of psychology at Pepperdine University, Graduate School of Education and Psychology. He has served as a research consultant for the National Center for PTSD since 1991.