Sunday, December 28, 2008

Spirituality and Disaster Psychiatry - Toward a Framework for Understanding

During disasters people experience disruption of what is normal and predictable. Spirituality is one important dimension among the many facets of human experience which are temporarily turned upside down by a disaster. Furthermore, in today’s global culture, spirituality is highly complex, at least as complex as disasters and mental health are themselves, creating a challenging juxtaposition for consideration. It is useful to have a simple framework to address the complex issue of spirituality in disasters.

The disaster psychiatrist must be prepared to address spiritual issues in individuals and organizations – though addressing spirituality may be less familiar for some traditionally trained psychiatrists. There are two main reasons why it is wise to attend to spiritual matters as a disaster psychiatrist: first, spirituality and religion are important parts of resilience which are altered during disaster, and second, faith-based practitioners such as clergy and chaplains will invariably be involved in all levels of disaster response, usually prior to mental health involvement. Clients will often omit to mention religion and spirituality to mental health providers for a variety of reasons – however, whether or not we are aware of it, we are collaborating with our faith-based colleagues, as may be constructively revealed by a few well-timed and well-formulated inquiries.

I will focus on two key themes to sketch out how I approach spirituality in disaster psychiatry: the theme of public and private, and the theme of belief systems. I briefly will discuss a neuroscience perspective on spiritual experience which is independent of formal religious beliefs, and give two illustrative clinical vignettes, with details altered to preserve confidentiality.

In a broad sense, we divide ourselves into public and private. Some things we never share with anyone; other things are on display for all to see. In between, there is a continuum of boundaries and relationships among which we share our thoughts and feelings. For many, spirituality is kept private, while others may be quite open. Likewise, religious practice ranges across the same continuum. When approaching clients, it is important to attend to whether or not they are religious and/or spiritual, and what their aesthetics are of public vs. private around spirituality, in order to approach assessment without being inadvertently clumsy. It is important to formulate questions tactfully and with caution, to avoid damaging rapport with clients. Oftentimes, questions about spirituality may arise during social history, developmental history, and sometimes trauma history – it is important to listen with an ear for spiritual themes, to guide more directive questions. There is a cost-benefit balance between obtaining useful information earlier, and waiting to get information when the time is ripe and not before.

What I have found to be helpful are the following theoretical perspectives, which frame both the way I listen and interact, and the stance I take. First is the basic perspective of countertransference awareness, if you will. My own beliefs and feelings contextualize my experience and approach with clients. I make it a point to be aware of what my own stance is in order to contextualize my work appropriately. I do not believe in the supernatural in general or deities in particular – however, I also do not reject belief – I recognize that there is very little I understand. The position I’ve found myself most comfortable with is that we may lack the capacity to meaningfully formulate such questions, which leads to a lot of problems when we try to do so, which are beyond the scope of this piece.

Regardless of belief, however, I do undergo cognitive, somatic and affective experiences which we commonly observe in ourselves and others: feelings of the uncanny, feelings of awe and wonder, cognitions about meaning and purpose, the feeling of heightened reality and meaning, and so on. These sorts of experiences are common across different cultural groups, regardless of whether they are labeled as “spiritual”, “philosophical”, “religious”, “literary”, or what have you. It is of particular interest that some individuals vehemently state they are “not spiritual” – suggesting a possible prejudice against spirituality, which I’ve found to be prevalent among mental health providers, of which it is advisable to remain aware. I suspect that regardless of how one labels the above human experiences of awe and so on, they would produce similar patterns of brain activity on functional neuroimaging, suggesting a common denominator underlying those who are spiritual and those who are not spiritual, and providing an empirically-based stance from which to work.

A parallel line of reasoning provides another base I use to approach spirituality in disaster work: We all make assumptions at every moment of every day, consciously and unconsciously - things that we take for granted will be relatively enduring and constant. Beliefs about the rules or “axioms” of our lives create a framework which holds us and permits us to function. These axioms can be religious and secular, spiritual and not, pragmatic and more ethereal – some people can contain mutually exclusive beliefs; others tolerate paradox less well. Regardless, we all require ways to deal with uncertainty and anxiety – different belief systems to varying degrees provide a sense of either certainty (certainty about uncertainty perhaps), and ways to live with uncertainty and its uniquely individual consequences.
I would like to offer two brief clinical illustrations. They illustrate examples of how to get into issues pertaining to spirituality in clients who, among other issues, have survived disasters and who are having difficulties on the spiritual level which are not readily apparent and difficult to address.

The first vignette is about a woman in her late 20s with a history of chronic interpersonal abuse and strong Christian belief. She presented for psychiatric evaluation in crisis, work teetering on the edge of falling apart and her long-term relationship in ruins. I learned she had strong trauma exposure during 911, and although she reported multiple symptoms then and now, she was unable to acknowledge the potential impact, directly, and complained to her therapist I was making more of 911 for her than was the case even though from my point of view I had not strongly emphasized this element. Apparently any emphasis was perceived as a strong emphasis, which was itself telling. As our meetings progressed and she appeared to be doing only marginally better, she quoted the Bible, a favorite passage from a wall-hanging in her home elicited when I inquired about her home environment. I wondered silently if going to church might be an effective intervention for her. Though I thought of this question in a prescriptive way (“It is good to build social support and church can be an avenue for that so I’ll recommend going to church if it fits for a given person”) I asked, with a sense of spontaneity and intuition borne out of surprise and emotion engendered by the vehemence of the quote, “Do you ever go to church?” To my surprise she became very animated, and described how she’d gone to church weekly up until 911, when she had abruptly stopped. She had been severely shocked, having always had fervent religious belief in Christ, that another group could believe in a different faith with such powerful conviction that they would commit the World Trade Center attacks. This both crushed her prior perspective, yet opened up new vistas which she had not fully integrated even after several years – for instance, she said she never would have been able to marry her spouse, from a different faith background, had 911 not happened. I did not press her to return to church at that time, at variance with the prescriptive model, but suggested she explore this further with her (spiritually oriented) therapist.

The second illustration is of a man in his early 30s who came to therapy after 10 or more years of “knowing I would eventually have to deal with my issues”, also with a chronic history of interpersonal abuse and several short and apparently ineffective efforts to start therapy over the last several years. His disaster was of the personal, life-long variety, which for some people appears to eclipse singular large-scale events.. He noted a feeling of intense shame and anger preventing him from connecting with people, including therapists, and had been unable to maintain personal relationships or satisfaction in jobs. He would change jobs and geographical location when things got rough, but this time for as yet unclear reasons related to a growing sense of desperation and frustration decided to stay. A relevant aspect of his history is that he did not feel safe within his family of origin - the one safe group was a church study group of peers from his early teens – unfortunately, he was ripped from this group when his family moved, and never recovered from, or really addressed, the loss. A parallel current complaint was that he could not return to church – though he longed to go back, he could never find a church he liked. After some time in therapy, learning more about the loss of this spiritually-supportive religious surrogate family (one might say), I asked spontaneously and with some concern the question might be taken as an intrusion, “What do you envision when you imagine God?” Surprised by the question, he looked up toward the ceiling and started to describe an inner experience of a bright white light, accompanied by feelings of heightened awareness, and security. I found this description remarkably similar to my own introspections on the experience of consciousness, though I do not tag these experiences for myself as being spiritual or religious. I did not share my reflection because I felt that might interfere with the patient’s private revelry and the process my question may have set in motion. Some weeks later, the patient, doing better, reported returning to church for the first time, and while it was not “perfect” it was a very good experience and a first step.

In conclusion, the main points I have hoped to elucidate are that experiences of heightened meaning, awe, uncanny-ness and the like, are a common overarching part of human experience. It is not necessary to accept belief in supernatural or theistic forces to relate with spiritual experience, or to even necessarily label such experiences as “spiritual” – but it is imperative to find a way to address spiritual issues in working with disaster-affected clients. Nurturing these clinical skills allows us to work collaboratively with a diverse group of clients and other providers. The stance we take up should be done with care and thoughtfulness because our stance will influence the quality of our work and how it unfolds with different people in different contexts. Just as we try to understand countertransference in other areas and make use of this understanding clinically and theoretically, we are more effective when we understand our own countertransference in relation to religion and spirituality, especially in the tumultuous context of disaster work. It is important to take care not to allow our own beliefs to interfere with the care we strive to provide, but to use our beliefs in order to be more effective.


  1. Do lack of posts so far say something about how hard it is for people to focus on disasters when they are not occuring?

  2. Quite so, quite so. That is a great topic for a whole other post!