Part 3 Counselling and Pastoral Care PDF

Part 3 Counselling and pastoral care 8 Ageing, illness, bereavement, Ageing, illness, Counselling...

Part 3 Counselling and pastoral care 8 Ageing, illness, bereavement, Ageing, illness, Counselling bereavement, and pastoral and dying care and dying QUESTIONS FOR MINISTRY Can a church full of older people still be ‘alive’? Does faith alter the experience of getting older? What special pastoral needs are suggested by older people’s psychology? How can I help people to cope with illness? How can faith be used to promote health and healing; what are the health risks of faith? How can I help someone in a major bereavement? What do people go through when they are dying? Introduction This chapter deals with four significant life issues that are perennial for pastoral min- istry – ageing, illness, bereavement, and dying. These experiences have in common a particular potency for drawing out spiritual issues and questions. In order best to help people dealing with these events, and to facilitate the role faith can play in supporting them, it is helpful to be aware of the psychological features of each. Problems of definition beset psychologists’ attempts to study ageing, illness and bereavement. How old is ‘old’ – is it not a question of being as young as you feel? Where can the line between illness and health be drawn? Bereavement is typically thought of as the process of adjustment following a death, but is it reasonable also to identify bereavement features in responses to divorce, amputations or being made redundant? Increasingly, ideas arising from the psychologies of ageing, health and bereave- ment have been appropriated for their wider potential to illuminate experiences of change, dis-ease and loss in many forms. This widened understanding of these expe- riences, seen from a spiritual perspective, offers a promising opportunity to see these issues in their widest context: ageing beyond merely getting older but as responding to the final challenge to become who God intends us to be, illness as the 142 Counselling and pastoral care challenge to discover the true meaning of healing and wholeness, and bereavement as the challenge to realise the ultimate sources of attachment and separation that give meaning to life. Ageing For my soul is full of trouble and my life draws near the grave. Psalm 88. 3 They will still bear fruits in old age, they will stay fresh and green. Psalm 92. 14 Since many churches would be virtually empty without their elderly and ageing members, the psychological and spiritual issues faced by older people must be a major pastoral concern for ministers. In today’s world, ageing issues are faced by more people and for longer, since many live on for thirty or forty years beyond their retirement. As people live longer (the number of people aged 80 and over has dou- bled in the last thirty years), the importance of addressing the heterogeneity of the ageing process increases. While psychologists can speak with confidence about some universals in the pattern of human development in the very young, the longer a person lives and the more different life experiences they have, the more varied the patterns for development become. A key issue for the pastoral ministry of the church is guarding against the unhelpful stereotypes of ‘the elderly’ that overlook their diversity and treat them as a single homogenous group. Myths about ageing It is easy for our impression of older people to be based on biased sources of data, focusing on examples such as the frail old ladies targeted by muggers, the hospitalised elderly, or caricatures from television of physically and mentally infirm and incapable older people. This sort of stereotyping is empirically inaccurate (the majority of those aged 65–80 are in good health, with mental functioning declining only slightly, and then typically only after the age of 75). Stereotyping can cause us to overlook those older people who, though mature in years, are psychologically and physically as healthy and dynamic as younger people, and can prevent us from understanding or forming good relationships with them. Myths and stereotypes can also become self- fulfilling prophecies. If we perceive and treat ‘the elderly’ as a spent force, beset with illness and intellectually waning, they will be likely to internalise all the bad press about themselves, withdraw from life, and give up on their health and abilities. Facts about ageing: changes and their consequences Losing a spouse is a dramatic change that many people face in their ageing years. However, most of the changes associated with ageing are more gradual. There are  Ageing, illness, bereavement, and dying 143 the familiar physical changes, many of which have psychological consequences. With age, our muscles become weaker, our bones more brittle, our lungs less effi- cient, our immunity is compromised and our bodies become slower to recover. These changes, together with the simple fact of looking older, can have negative effects on the older person’s sexual and social life, their employment prospects and their self-esteem. These negative changes can be offset to some extent by the rela- tively unchanging picture of cognitive function. Though cortical tissue is lost, there is often little overall change in memory; nor is intelligence affected, especially when people continue to be mentally active. The widespread notion that memory for events in the distant past improves with age, however, is without foundation. The experiences of change and loss that are part of the ageing process can be diffi- cult in themselves; they are made all the more unsettling by the shadow of death that is cast over them. For Erikson, making peace with this prospect in the light of preceding life experiences is the overriding psychosocial issue at this stage of life (see Chapter 6), though given that these days this stage of life might span more than three decades it is probably unhelpful to assume this issue has equal importance for everyone. However, the experience of minor and gradual changes as we age offers an opportunity to pre- pare in psychological and spiritual terms for dying itself, when it comes. Ageing ‘well’ may depend on seeking out anchoring points of continuity that help to put the transformations of getting older into perspective. As certain physical fea- tures change, attention is naturally drawn to the deeper characteristics that make up who we are on the inside. Indeed, a sense of the spiritual may be a primary way of identifying what is enduring. Finding this balance between change and continuity, through both psychological and spiritual awareness, may be a key feature of pastoral care with older people. Retirement For many, retirement is the life event that heralds the onset of ageing. Adjusting to retirement presents its own set of difficulties, but can also be seen as an occasion for spiritual development. The twin issues of change and loss characterise the psycho- logical challenge of retirement. Research has found that in many cases psychological distress, manifested as agitation and an anxious kind of depression, is actually worse in the period leading up to retirement, and people may benefit from pastoral support in advance of the event. In addition to the loss of work and a wage, people can experience (or dread) the loss of social status and social role that was bound up with their occupational activ- ity. They can feel emotionally vulnerable and naked without the persona associated with being ‘the doctor’, ‘the teacher’ or ‘the foreman’. In some cases, it may be appropriate to describe their anxiety in terms of an experience of ‘social death’ (Grainger 1993). The chance to voice this grief, and to overcome the taboo that surrounds admitting to it, may be important features in a process of adjustment. Retirement may be a more violent break in the pattern of life for some people, and less so for others, but those who deny feeling any sense of loss present the greatest cause for concern. In such cases, difficulties may surface in more florid ways as the 144 Counselling and pastoral care unacknowledged hurt is expressed through the irrational communication of the unconscious. Women tend to outlive men; of those aged 60 or more, one in every two women will be widowed, compared to just one in five men finding themselves alone at this stage of life. Thus, being in a minority might make male church-goers feel marginal- ised. On the other hand, women may feel uncomfortable with the tendency to nor- malise the state of sorrow associated with the more common state of widowhood. Another gender difference at this time of life is that women still tend to retire at a younger age than men, which often means retiring before their husbands. When this happens, it means a woman first has to deal with her own retirement, alone, but then also experiences her husband’s retirement at close hand – a double dose. On a social level too, husband and wife relations can be specially strained. Sometimes women may dread their husband’s retirement and his encroaching on ‘her’ domestic space. Others may have had high hopes of developing a deeper relationship once the dis- tractions of work were set aside, and feel disappointed and neglected when work is replaced not by wife, but golf or perhaps additional church activities. A Christian pastoral perspective can help older people to discover a new kind of life beyond the ‘death’ of work and occupational status. Spiritual language and imagery is ideally suited to taking hold of apparently negative experiences of change, and finding in them hope and deeply reconstructive transformation. People can experience genuine renewal in their latter years, and the increased amount of spare time may be a blessing in this respect. One study found that respondents over 50 years old accounted for more than 40 per cent of religious experiences described as ‘life changing’ (Koenig 1994) – old dogs perhaps can learn new tricks! When people retire and feel their usefulness is spent, it is tempting to suggest that they can now simply exercise their talents in the service of the church, so the retired bank manager becomes the treasurer, the teacher takes on the Sunday school, and so on; but this may prevent someone from taking time to enter that creative space that retiring makes possible, and from which a new gift or direction could emerge. People’s needs for new development should perhaps take precedence over the immediate needs of the church, though in the long run both parties stand to benefit from this enriching process. One potentially fruitful pastoral strategy would be to consider how to encourage people to explore new avenues in which they do not have existing skills. Facing up to ageing: how faith helps While there are inaccurate myths about ageing that paint an unduly depressing pic- ture, many older people do face real difficulties that can make ageing a dysfunctional process that spirals out of control. Depleted financial resources can compromise health, illness can be an obstacle to social activities, a lack of human contact can foster a sense of meaninglessness, and a low opinion of self-worth can induce guilt for continuing to live at all – some come to see themselves as a useless burden to others. For many people, faith can help divert and dispel the darker consequences of ageing.  Ageing, illness, bereavement, and dying 145 Not surprisingly, one of the biggest problems many older people suffer from is fear of growing older. Proper information can help address some of the unwarranted beliefs contributing to this dread, reassuring them for example that many illnesses can be treated and pain can be controlled, or correcting some of the myths about what normal ageing involves (for a further discussion of cognitive and behavioural counselling, see Chapter 10). However, the quality of hope contained in faith offers a more comprehensive way of tackling fear of all kinds. Faith provides a way of seeing beyond even the most appalling, unalterable circumstances such as terminal illness. Koenig make the point that from an Eriksonian perspective the psychological pre- requisite for hope is trust, the earliest of building blocks in our psychosocial devel- opment (see Chapter 6). As one of the first things ‘in’, trust is arguably the last thing ‘out’, so even if our faculties become compromised through dementia or other dis- ease, faith can be an enduring support and antidote to fear. Faith provides a coherent framework of existential meaning. In obvious ways, such as a belief in life after death, faith can provide a reassuring framework in which to set the meanings and achievements of this life. Research has shown that church atten- dance is not essential for older people to benefit from the advantage religious beliefs have on their sense of well-being (Koenig 1994); the house-bound and those who prefer not to belong to the church may nonetheless rely on their religious beliefs. There are a number of ways in which faith and belonging to a Christian community can be a source of social support that keeps isolation at bay. For some the fellowship of church life may be the only regular social contact, for example if family members live at a distance and many close friends have died. Without social contact, social skills can atrophy, which further reinforces the older person’s withdrawal and disen- gagement from others. There is a natural trend for extroversion to decline, and neuroticism to increase with age. However, Christian fellowship can provide a gently counterbalancing social influence to prevent a more introverted and emo- tional position becoming disabling. The church itself has to guard against unwittingly contributing to the devalued sense of self-worth of some older people. Congregations are too often judged in terms of how many younger people they can attract. It is important to value and appreciate the contributions make by older members of the church. It is probably no coincidence that older people often take such special care to champion children’s interests – both are in danger of being overlooked as being currently ‘useless’ to the church. Dementia can affect every area of a person’s psychological make-up, disabling memory, attention, language, emotion, to the extent that it seems the core sense of self is eaten away. The appearance of what seems not much more than an empty shell where the ‘person’ once was is profoundly challenging both in terms of basic and pas- toral care. What role can faith have in these cases? Religious practices, rituals, prayers and hymns are often ‘over-learned’, that is to say they have become deeply ingrained, almost automatic patterns. When, through dementia, the ordinary, intentional access to understanding and memory is barred, these over-learned features may provide alternative routes to a rudimentary kind of knowing and feeling, perhaps the remnant of the self. There is ample anecdotal evidence (e.g. Sacks 1985) of dementia patients who have shown an unexpected quality of response to a religious service or action. 146 Counselling and pastoral care Box 8.1 Counselling needs of older people Bereavement, illness, disability, loneliness, marital problems, and prob- lems associated with being a carer (see below) are all common in older people’s lives. Often depression is not recognised as such; the symptoms of loss of appe- tite, less interest in social contact, no will to live, sadness and confusion being regarded as ‘normal’ consequences of ageing and the life events associated with it. Depression can and should be treated at any age. Adjusting to the reality of ageing (and mortality) may prompt people to seek spiritual and emotional support. There may be a need to re-examine ‘who I am’ (regardless of physical changes), or a need to deal with the changes in other’s perceptions, for instance finding that people no longer seem to recognise them as a woman or man in a sexual sense. According to Erikson (see Chapter 6) old age creates the need to come to a final evaluation of life, weighing up what has been meaningful and posi- tive and what has not. People often find this easier to do by talking, at length, about their life and their interpretation of events. Faith can be an important dimension in this process, providing the biggest kind of per- spective through which to view the various ups and downs of their lives. Christian ministry has a role not only to continue providing for the religious needs of these people, but perhaps also to encourage their carers to recognise the potential of religious stimulation to reach where other means no longer can. Counselling older people Reasons why older people might seek pastoral counselling, and approaches that are specially suited to their needs, can be easily inferred from the discussions above. A summary of these is provided in Boxes 8.1 and 8.2. QUESTIONS TO CONSIDER Think about the people you know who you consider to be ‘elderly’. What, if anything, do they have in common? In what ways do they differ from each other? Do you find yourself stereotyping older people and treating them all the same way? What particular ministries are more suited to older people? What steps should be taken to prevent older male church members feeling marginalised? What are the most effective ways that the church helps people manage the tran- sition from working life to retirement?  Ageing, illness, bereavement, and dying 147 Box 8.2 Approaches to counselling older people There can be some resistance to psychological language among older people, who can feel affronted by the implication that things are ‘all in the mind’. Counselling that adopts ideas and approaches from psychology, but employs more traditionally religious language, may be more appropriate. Reminiscence is an important way for older people to make sense of their lives. In needing to talk, at length, about themselves the older person may also be trying to connect their isolated life with others. Seeing reminiscence as an attempt to feel more of a social participant guards against our percep- tion that it is merely self-referring, ‘going on about themselves’. As older people talk and evaluate their lives, they often feel a need to make amends in one way or another. Spiritual counselling lends itself to opportunities for a more confessional expression, especially if the person wants to make peace with someone who is now dead or too far away for an actual reconciliation to happen. Illness Among Christians, the idea that sickness is not exclusively a matter of physical symptoms has been established for centuries. However, health psychology provides helpful elaboration of this understanding that body, mind and spirit collaborate in our sense of well-being or dis-ease. Illness is no longer measured solely in terms of clinical signs, but also in terms of how function is affected (headaches regularly send some people to bed, or make them extremely irritable, others can carry on). The individual’s subjective perception of well-being also can be as important as clinical and functional factors in disease (see Figure 8.1). Our psychology plays an important part in how we perceive our own and others’ ailments. A headache may be tolerated as normal by one person, an alarming sign of a brain tumour or hint of an impending epileptic seizure for another, or perceived as just desserts following a night on the town. Faith can modu- late the experience of illness. For many, faith can enhance their resistance to illness. Others turn to faith when illness strikes, as a way of coping and to seek healing. Caring for the ill can also raise its own emotional and spiritual needs. Sensitive pastoral care that contributes to healing in every sense has much to learn from a psychological understanding of the issues faced when we become ill. The interconnectedness of states of body and mind is most clearly seen in the way the psychological state of stress can lead to physical illness. Stress sets off physiolog- ical changes that can reduce our immunity to disease. It is difficult to avoid stress altogether, but reducing it is a key way of protecting health. Faith can help in a 148 Counselling and pastoral care clinical symptoms capacity to function subjective well-being Figure 8.1 Triad of components of illness number of ways to reduce the build-up of stress in people’s lives. This is borne out by evidence that religious people are on average less prone to many diseases, and that some especially religious (often conservative) groups seem particularly to attract this benefit associated with their faith (Ellison 1994). A religious perspective can alter the way we appraise stressors, for example when the delay of a traffic jam is redefined as a blessing that affords more time to listen to a radio broadcast or to think and reflect. It can also help to regulate our emotions during a stressful encounter. The risk-taking behaviours that stress can encourage (smoking, drinking alcohol, overeating, sexual promiscuity) are often prohibited because of faith, protecting the faithful from many kinds of disease. The fellowship of friends in the faith community is also a factor that is positively correlated with lower stress and higher resistance to disease. Lastly, rituals can have a relaxing effect on physical and mental tensions, combining both emotional arousal and positive cognitive feedback of belonging, and being loved or released from sin. However, we should not overlook the possibility that in some cases faith can add to our stress levels, for example when church demands encroach on time that is needed for relaxation. Religious commitment can divide and weaken marital or family relationships. Beliefs can create stress by nurturing neurotic feelings of guilt and unworthiness. Trying to conform to expectations about sexuality and gender roles can also contribute to stress, especially when these ask people to be very different from the surrounding culture. Stress is often associated with a build-up of negative and hostile emotions, which may be difficult to admit openly among Christian friends, and feeling ostracised from the worshipping community can further increase stress and compromise health. For example, if the church excludes paedophiles this may raise their stress levels and exacerbate the tendency for their condition to be ‘expressed’. When illness strikes: adjustment and coping When the body goes seriously wrong and the mind is in turmoil, a spiritual perspec- tive can offer a ‘third way’ through which to find repair and peace. Illness can prompt both religious and non-religious people alike to turn to God, in personal  Ageing, illness, bereavement, and dying 149 prayer or through the support of religious friends or professionals. However, in the crisis of becoming ill, people can find that they are burdened by as many religious questions as they have questions about their physical condition. Pastoral care needs to balance a sudden desire to question and struggle with a Christian perspective with the need for spiritual assurance and support. Ministers need to avoid simply ped- dling ‘pat’ religious solutions and explanations that overlook religious enquiry. Equally, it would be irresponsible in this sensitive period of physical and mental uncertainty to embark on a process of intensive religious education. Of paramount importance, in the short term, must be strategies that minimise stress and assist the body’s healing processes. Facing the need for medical treatment can be an additional source of stress on top of the illness itself. When an illness is first diagnosed, people need to adjust in their minds to their new status. This includes the implications of the illness for the per- son’s sense of self. For example, being diagnosed as HIV positive requires adjusting to the likelihood of suffering from various serious physical problems, and also adjusting to the disease’s impact on self-esteem and relationships. This might lead to a (potentially unhelpful) examination of whether untoward aspects of the person’s lifestyle may have contributed to their illness, introducing a heightened spiritual awareness of sinfulness. Developing one’s own illness representation model There are three important stages in the adjustment process through the course of an illness: 1 Developing one’s own ‘illness representation model’. 2 Action-planning and coping. 3 Appraisal (perhaps identifying the need to revise 1 or 2). An illness representation model (IRM) is the conceptual picture people form for them- selves of what is wrong, usually by answering a series of questions about their plight. It is a vital part of their attempt to make sense of their change from being a ‘well’ person to being ‘ill’. There are at least five components to consider in forming an IRM (see Table 8.1). Sometimes aspects of the model can be underdeveloped or misinformed. For example, a person might harbour illogical ideas about why they contracted the illness (cause component) or wallow in an ill-informed sense of hopelessness regarding the ill- ness’s probable course and cure. The support of other people can help in putting together a stable, helpful and realistic mental map of any illness. While the facts that make up an IRM are a matter for the medical profession, there are a number of ways in which the process of developing this model can be helped by pastoral work. Religious beliefs can modulate the answers a person feels able to accept for each of these components, and pastoral sensitivity is called for concerning how a person’s religious perspective contributes to this multifaceted mental representation. For Christians some medical subjects (such as abortion, 150 Counselling and pastoral care Table 8.1 A five-component illness representation model (adapted from Banyard 1996) Identity What is this called/like? The name I can give this illness and what I think the symptoms are. Consequences What will happen to me? My ideas about the short- and long-term effects. Time line How long before I get better/ My time frame for this change – worse? accepting long-term illness takes longer. Causes How did I get it? My own doing, external factors, chance? Cure What will make me better? My ideas about cures and healing. sexually transmitted disease, or mental illness) may be difficult even to speak about directly. Faith is especially likely to colour the components associated with cause and cure. Typically, people see God as implicated in personal more than impersonal events, and in positive more than negative events (Spilka et al. 1985). Illness is personal, but negative. A cure for illness, however, qualifies as both personal and positive – so God is especially likely to be appealed to as people address this aspect of their IRM. In other words, people are primed by their attributional mindset to regard getting better as spiritually influenced too. While ‘cause’ is ostensibly negative, though personal, there can still be a tendency to attribute the cause of medical illness to God – to paraphrase so many of the Psalm- ist’s cries: ‘Oh God, why me?’ This sense that God is behind the illness can call faith into question. A primitive sense that ‘bad things shouldn’t happen to good people’ can raise the question ‘in what respect did I not have enough faith?’ or ‘what kind of God would let this happen?’ If the illness is thought of as caused by God, it may be seen as a punishment or a test, the length of which is contingent on their spiritual record in the past and in this time of trial. People who feel convinced that God has targeted them in their illness may be redefining it as in some sense positive – a spe- cially designed communication and challenge from God just for them. So when God is brought into thoughts about cause, there is scope for faith to feel increased in some cases, while for others faith may be lost or re-examined as insufficient. Although there are many potential religious dimensions to thinking about illness, lay and ordained people who undertake visits to the sick as part of their Christian ministry will generally find the conversation is much more mundane. Simply pro- viding a listening ear for someone who wants to talk about their illness, symptoms, medication, and prognosis is one of the most valuable and important pastoral tasks. However, identifying what (and how much) is said about each of the different com- ponents of the IRM can also help the listener to recognise special issues of concern, or any that are being avoided.  Ageing, illness, bereavement, and dying 151 Action-planning and coping Much of the action-planning required during the course of an illness is negotiated by doctors on the patient’s behalf – selecting treatments, operations and tests. How- ever, anxieties and fears about these actions can significantly interfere with their intended contributions to recovery and healing. People need to have, or develop, robust coping strategies to combat the stress involved in facing illness and its treatment. Coping is how we protect ourselves, psychologically, when a stressful situa- tion such as illness occurs. Psychologists’ way of categorising these styles (into ‘avoidance’ and ‘approach’ styles) can help ministers to spot a preferred coping style, occasions when this might be unduly one-sided, and how to match spiri- tual support to this. Freud noted common ways in which people try to cope with crises through avoid- ance, using psychological defence mechanisms such as displacement and denial. When a serious diagnosis is made or a difficult operation looms, a person might bury themselves in work to distract their own attention from what is going on in their bodies. Denial obviously prohibits the adjustment afforded in developing an IRM. In general, this kind of coping offers limited protection since the use of defence mechanisms often creates secondary emotional problems, adding to the stress load. Faith can be used defensively too (see below). Approach styles of coping are more constructive and come in two forms: Problem-focused Looking for ways to sort out the problems, for example by making decisions and taking remedial actions. Emotion-focused Looking for ways to take emotional control; trying to direct thoughts and feel- ings in a constructive way. Serious illness, chronic pain or disability, bereavement or irreversible loss in many forms (e.g. hysterectomy, amputation, loss of sight) often present us with situ- ations that can’t be ‘sorted out’ with a problem-solving approach. In these cases, the emotion-focused coping style is especially useful. This is also the level on which faith-based coping seems to operate most naturally. People often turn to the church for support as they try to deal with their anxieties, not only about their illness, but also about its treatment. Ministers may be asked to ‘say one for me on Thursday when I’ve got my hospital appointment’ or find they are frequently regaled with gruesome details of tests and their results. Some spiri- tual approaches, such as a familiar ritual, can provide reassurance, whereas a conver- sational approach could explore the role of faith in God. The coping style preferred by some people might lead them to welcome the opportunity to focus on specific issues. For example, operations can raise fears about disfigurement that suggest the relevance of aspects of the spiritual tradition that deal with feeling violated or 152 Counselling and pastoral care Table 8.2 Three sorts of religious control over illness (Rothbaum et al. 1982) Interpretive control ‘Things could be worse. This cancer is part of my spiritual journey, not a roadblock.’ Predictive control ‘I’m convinced that God will make me well, regardless of medical opinion.’ Vicarious control ‘I may not know the future, but God does. I may not know how to be strong, but God does.’ damaged but subsequently transformed and whole. Others may find solace by iden- tifying a specific Biblical role-model who suffered in a similar way. Keith Pargament et al. (1988) suggest we can distinguish three kinds of religious copers among church-goers. Deferential religious copers tend to leave everything to God, perhaps to the extreme of refusing medical treatment. Collaborative religious copers engage in partnership with God in dealing with their medical problems. Self- directed religious copers use religious cognition and activity (such as prayer) much more sparingly with regard to illness. For example, they might refrain from involv- ing God in whether or not their leg ulcer heals, but rely on him to give them strength in the interim. Collaborative copers, and to a lesser extent self-directed copers, make use of their faith in a way that raises their self-esteem and well-being. Ministry with the sick often needs to steer people towards these healthier ways of relying on faith as they cope with being ill. A constructive, emotion-focused style of religious coping can be effective in low- ering the anxiety and depression associated with being ill. Religion seems to help by setting problems (pain, disability, and so on) in a bigger frame of meaning that can transcend the intractability of symptoms faced in the here and now. Religion is also effective because it can offer secondary ways in which the person can try to reclaim some control and sense of meaning. Table 8.2 identifies three ways in which people look to religion for this kind of support. Participating in religious ritual can also be a valuable way of supporting coping. Ritual can focus and order all kinds of powerful, ambiguous emotions (see Chapter 2). It is also something the person can do at a time when they feel otherwise incapaci- tated. Prayer can also give this feeling of doing something positive about one’s situation. SUMMARY OF KEY THEMES Measuring health and illness by the triad of clinical symptoms, capacity to function, and subjective well-being. The connection between stress and illness. The risk-taking behaviours that stress can encourage (smoking, drinking, over- eating, sexual promiscuity). How Christian fellowship can reduce stress and improve health.  Ageing, illness, bereavement, and dying 153 Developing an Illness Representation Model: thinking about the identity, con- sequences, time-line, causes, and cure of one’s illness. Avoidance and approach styles of coping with illness. Deferential, collaborative, and self-directed forms of religious coping. The need to care for carers. QUESTIONS TO CONSIDER How have you coped with illness in the past? What part did your faith play in this? How could you stop church-related stress contributing to the stress–disease cycle? Box 8.3 Pastoral care for carers Those who find themselves caring for the sick, especially a family member, can themselves have a number of special psychological needs in which pastoral support can help. Becoming a carer usually entails a role adjustment. The relationship between a married couple, when one of them falls ill, can become more like a parent–child relationship, in which the carer loses his or her sexual partner and mutual support. Carers can experience an emotional cocktail of love, anger, guilt and exhaustion. The context of faith (e.g. in prayer or through fellowship) may offer opportunities to express this in a safe way, if it is made clear that negative emotions are not necessarily ‘unchristian’ all of the time. Carers can develop too thick a skin as a defence to protect themselves from the reality of their patient’s suffering. Learning to be indifferent in this way may prevent the carer experiencing their own vulnerability. Framing suffering in a spiritual perspective may help to overcome this ‘defensive’ caring style. Respite from being a carer is vital but, interestingly, carers often find comfort in opportunities to be supportive to others, such as contribut- ing to self-help groups. This seems to work by providing them with a source of appreciation that is perhaps lacking from their incapacitated spouse, or is of a different order given that care in sickness and health is expected in marriage. Providing help and support to other carers or suf- ferers maximises the carer’s sense of being useful and active rather than feeling passively at the mercy of the home situation. 154 Counselling and pastoral care Bereavement Death is the one point in our secularised lifestyle where the influence of the church is still sought, through funeral services and attendant pastoral care; indeed, it is esti- mated that 90–95 per cent of funeral services in the UK are led by a Christian minister (Brierley 1999). Thus, the role of ministers and the wider church in helping the bereaved is crucial. When a vital relationship has been severed through death, we are faced with the full extent of our vulnerability as humans. The loss of spouse, parent, child, sibling or friend, devastating in itself, also entails changes in the wider network of relation- ships. There may also be changes to a person’s world view; perhaps their faith has been undermined or shattered through this tragedy. As noted above, bereavement can come in many forms. The loss of a limb, physical illness, disability, divorce, mis- carriage, job loss, moving house, changing schools, and old age all involve radical change and a sense of diminishment, and so can produce a sense of bereavement. Such experiences of loss also have the potential to revive emotions connected to pre- vious unresolved losses. Grieving is a process; it is not humanly possible to deal with its devastation all at once. Researchers have observed various stages through which grieving persons need to pass. Elisabeth Kubler-Ross’s book On Death and Dying (1970) helps us to understand the emotional stages that terminally ill patients experience in their approach to their own death, the ultimate loss. These stages have been found to be broadly relevant to the grieving process as well. In practice, stages may be cyclical, and some might be skipped. Bereavement may progress upwards as a spiral stair- case, or zig-zag unpredictably. There is some question about how universal these stages are, as different cultures emphasise different aspects of the grief process. Thus, in caring for the bereaved, the map laid out in Box 8.4 needs to be applied flexibly. Other aspects of grief described by C. Murray Parkes (1986) are an alarm reaction (anxiety, restlessness and physiological accompaniments of fear), searching (an urge to find the person in some form), feelings of internal loss of self (even of mutilation of the self), and identification (the adoption of traits, mannerisms or symptoms of lost person) (Parkes 1986: 202). These are normal features of the lengthy process of grieving, a process which should not be expected to last less than two years (and may in fact last longer). Yearning and searching for the deceased can be so real that the person can get glimpses of the dead person, and may even think they are going mad. It is now accepted as normal to feel the presence of the other, a phenomenon which can bring comfort, especially in the early stages of grieving. However, a person can get stuck in seeking comfort through continued contact of some sort with the deceased. Churches can offer a valuable ministry to their communities by offering periodic services of remembrance, where the dead are valued and remembered within a Christian context. Bereavement raises many important theological issues. Obviously, the fact that many people have a sense of the continued presence of the deceased can be  Ageing, illness, bereavement, and dying 155 Box 8.4 Kubler-Ross’s six stages of grieving 1 Denial ‘It’s not true’, ‘This isn’t really a fatal disease’, ‘Even though she has died, this won’t really affect me’. Denial and isolation. Shock, numbness. Removing oneself from realities that challenge denial. Whether the news of an impending death is sudden or gradual, there can be numbness and denial, a normal feature of shock, which protects the person from being overwhelmed too suddenly. Pastoral advice Don’t get into arguments or challenge denial strategies directly. On the other hand, don’t collude with the denial. Offer plenty of opportunity for the truth to be explored gradually. Provide time to talk, do not leave the bereaved in iso- lation. Convey the message that there are no taboos, anything can be said. Gently ‘steer into the distress’. 2 Bargaining ‘If you cure my husband I will be a perfect wife...’, ‘I promise to go to church if only you will...’. Bargaining is an attempt to alter the terrible reality. Pastoral advice Listen, but do not actively collude with unrealistic hopes or with a view that God can have his arm twisted. It is normal that we try to manipulate God in times of crisis, but eventually we need to acknowledge this. Bargaining takes up a lot of energy, and eventually the person may be glad to give it up. 3 Anger ‘Why me? What have I done? It’s so unfair, so bloody unfair’. Anger indicates a fight, an effort to refuse the terrible reality; the person may still be fighting to maintain hope for recovery. Pastoral advice Allow the person to express feelings of anger, even anger against the person dying (or who has died) for abandoning the living. Anger at God is often pro- jected onto the clergy or other church members trying to help. Allow the expressions of anger and rage to be expressed. Do not try to defend yourself (or God, or the church), but do find someone outside the situation with whom you can work through your own pain. 4 Guilt ‘Is there something I could have done to prevent this? If only I had...’. Feeling guilt and remorse for the loss, or for what was unresolved in the rela- tionship. Relationships that have been difficult often leave a legacy of guilt. 156 Counselling and pastoral care Pastoral advice Allow space for the person to talk through regrets and a sense of failure and sin. Do not try to make a person feel better by encouraging them to avoid their sense of guilt. Rather help people gain a realistic picture of what comes from real, objective guilt, and what comes from false, subjective guilt. Children in particular may feel responsible for a death of a sibling or parent, and need help to see that this was not their fault. (See also the section on confession and for- giveness in Chapter 2.) 5 Depression ‘There is no purpose in living now...’, ‘I will never stop grieving...’. Feeling a profound sense of loss and sadness is the beginning of accepting the loss of the other’s life. Depressive and painfully sad feelings are normal, and it is to be expected that despair, hopelessness, or intense grief will surface unbidden and, at times, feel overwhelming. Pastoral advice This is part of the vital ‘griefwork’. It is hard work, intensely absorbing and energy draining; do not encourage people to be falsely cheerful or to look on the bright side too soon. Anniversaries and birthdays can often kindle intense feelings of loss. Some people seek to avoid their feelings, or feel ashamed of them, and thus need encouragement to express their sorrow. If the person appears to be stuck for some length of time, or the depression is severe, the help of a GP (who can refer onwards to more specialist help if needed) should be sought. 6 Acceptance As with a person nearing their own death, in grieving, eventually a period of quiescence comes. This acceptance precedes a gradual re-integration with life, and a gradual forming of new ties; a letting go but not a forgetting. Pastoral advice People may need to be reassured that it is not disloyal for them to accept the death of the other, and to begin to let go and to say good bye. Reliving memo- ries, going through the photos, talking about and owning what has been good and precious will be helpful. Adjusting to the new reality, hope for the future, and gradual re-entry to social life in time will follow. The social support of a church, involving the bereaved in the normal round of activities, can provide a caring, albeit altered, network of relationships. interpreted in terms of Christian thinking about immortality and the communion of saints, though these beliefs should not be used in way that obscures the fact that an earthly life has ended. Biblically, the grief of the disciples at Jesus’ death is an inter- esting case study in bereavement. Indeed Jesus’ attempt to prepare the disciples for  Ageing, illness, bereavement, and dying 157 his death (John 14-16) touches many bereavement themes, including loss, glorying, and presence (Harvey 1985). The loss of the relationship is the primary, major stressor in bereavement: the break- ing of the affectional bond. But primary loss is often followed by secondary loss. Sec- ondary loss for a widow could be having to sell the house and living on a reduced income. She may have to face doing taxes for the first time, and to learn to take control of the finances at a time when she is least able to do so. A surviving spouse with children will need to cope with the grief of the children and the grief of in-laws at a time when support is keenly needed. Many families rally at a time of bereavement, but equally, the strain of family members grieving in different ways can exacerbate old wounds. ‘No one ever told me that grief was so physical’. The stress of bereavement on the physical body is enormous. The immune system and endocrine functioning are under fire. Eventually the body can become exhausted, and more prone to disease. It is not surprising that many studies show that in the first six months after a major bereavement, especially for men, there is approximately a 40 per cent increased chance of death, either through illness or accident (Stroebe and Stroebe 1993). People with greater social and family ties are more protected from this general increase in the risk of mortality. The importance of the church as a place of re-weaving supportive relationships cannot be overestimated. Sex differences Men and women tend to adopt different coping strategies in bereavement. In gen- eral, women tend to focus on dealing with their emotions, while men prefer to focus on problem-focused coping strategies such as attending to the practicalities of the changes in their life. In the case of a couple who have both been bereaved (e.g. through the loss of a child) it is easy for partners to feel that the other is not grieving in the right way, and to feel unsupported by their spouse. For parents who have lost a child, the secondary loss may be the strain on the couple’s relationship: the woman feels and expresses intense grief; the man bottles it up and, pragmatically, tries to cope. The woman may feel her husband is not really grieving as much as she is. Mar- ital discord could lead to a whole swathe of losses: divorce or separation, loss of the marital home, separation from surviving children, all of which are losses that can be as crippling as the primary loss. Despite some of the structural inequalities in society that disadvantage women, making for greater secondary losses (smaller pensions, lower incomes, fewer employment prospects especially if juggling child-care), research indicates that, overall, men have a more difficult time than women in coming to terms with spousal bereavement. This has been understood in terms of our culture’s taboo on the expression of emotion for men, whereas women are allowed to ‘have their cry’. This is certainly one feature. Another, perhaps even more salient feature, is that women tend to be the couple’s initiator in terms of other social relationships. Women are more likely to seek out other support networks. Men, when widowed, can withdraw into isolation (a tendency which is exacerbated as men get older). Many women turn to the church after a bereavement and find it a place of spiritual strength and social 158 Counselling and pastoral care support. The need for the church to learn to reach out effectively to grieving men, especially older men, is apparent. Complicated griefs The shock of a sudden unexpected death can prolong and complicate the grieving process. An unexpected loss can be so much harder to make sense of; bewilderment and protest can endure for years. If the death was traumatic and was witnessed by the survivor, dealing with the traumatic memories of the death may require special- ist help. Stigmatised deaths such as suicide, or death through AIDS, add a burden of shame and social isolation for the survivors, as well as continual rumination over guilt. Church practice has historically added to this burden; as recently as the 1950s a suicide was not allowed a Christian burial. The church is now in a position to assuage some of the social stigma of such bereavements. The termination of a difficult relationship through death tends not to bring a blessed release, as one might wish for, but rather a legacy of unresolved anguish, anger and guilt. Working through the various stages of anger and guilt may require the help of a trained counsellor. At the same time the church has much to offer in helping a person work towards forgiveness of self and other, but this must not be rushed, lest it serve as a bandage over a festering wound (see also the section on con- fession and forgiveness in Chapter 2). Death of a child It is unnatural for a child to die before their parents, at any age. The intense affectional bond between children and parents, and parents’ feelings of responsi- bility for the child make this perhaps the most difficult bereavement. Mothers especially can find it almost impossible to separate themselves from their child, even long after the child’s death. At conscious and unconscious levels, parents can feel responsible for the death of their child, as well as suffering from frustration and helplessness that their child could not be saved. To work through the grief of such an intense loss can seem unbearable, and such mourning is often truncated. For instance, sometimes parents turn a sibling into a substitute for the dead child, to both the parents’ and surviving child’s detriment. Support groups involving other bereaved parents can help a person begin to unravel the chronic grief and irrational guilt that is common among bereaved parents. Certainly, a deceased child is never forgotten; ‘the death of a child is forever’ (Weiss 1993). Stillbirth and miscarriage, at any point in the pregnancy, are also bereavements. A child of whatever stage of development is of infinite value to the parents, and the church should not gloss over these early losses. Initial research shows that how par- ents are treated by hospital staff is an important factor in the grieving process, and hospitals are becoming more sensitive and supportive at this critical time. Parents find it helpful to have the option to spend time with the body of their child, however brief the life, and to say goodbye. Even a procured abortion can be a bereavement, and will also involve guilt, regret and anger. Memorial services which allow parents  Ageing, illness, bereavement, and dying 159 to remember, love, and grieve for an unborn child may help them come to terms with what is often a silent grief (Smith 1993). Abnormal grief Although grieving is a normal, inevitable process, it seems that the process can go awry in several ways. Categories of abnormal grief include: 1 Chronic grief Grief that is stuck, endless, or inconsolable. 2 Absent grief Grief that is being denied. 3 Inhibited grief Grief that is not able to be expressed. If a person has had good previous attachments and separations (and has an internal model of surviving a loss), it will be easier to survive a major bereavement. If a person has not had the benefit of prior secure attachment, the loss will be much harder to bear (and may require counselling to unravel the earlier problems). In such cases, it may be necessary to get specialist help, either through a professional coun- sellor or a specialist bereavement counsellor (through organisations such as Cruse). Churches and ministers can provide valuable ongoing spiritual and social support while the complicated, critical issues are being pursued with professional help. Loss-oriented and restoration-oriented coping The standard assumption about bereavement, which has been tacit in what has been said here so far, is that healthy grieving involves confronting and coming to term’s with one’s loss rather than hiding from it and denying one’s feelings. However, recent research shows that it is not possible to face the devastation of one’s loss and grief head-on and continuously during bereavement. Rather, it is normal and healthy to oscillate between loss-oriented coping (confronting the loss, ‘griefwork’, and breaking the bond to the deceased) and restoration-oriented coping (seeking distraction from grief, avoiding grief, doing new things, attending to life changes) (Stroebe and Schut 1999; see Figure 8.2). Just as approach and avoidance coping techniques each have their place when deal- ing with illness, so loss-oriented and restoration-oriented coping styles each have a place in the grieving process. In each case, the avoidance and problem-focused styles more common in men, as well as the expressive and emotion-focused styles more associated with women, have a place in dealing with experiences of loss. Another assumption of the classic approach to bereavement is that in contemporary Western culture there is no possibility of having any meaningful relationship with the dead. However, a new model suggested by Tony Walter (1996) proposes that one of the purposes of grief is to go on living with the dead, acknowledging that the person is a continuing member of the family and the friendship network, albeit in a changed way. Although we should not deny the reality of their death, there needs to be a recog- nition that we are who we are, in part, because of who the other person was to us. We 160 Counselling and pastoral care everyday life experience restoration- loss-oriented oriented grief work attending to life changes intrusion of grief doing new things breaking bonds/ distraction from grief ties/relocation denial/avoidance of grief denial/avoidance of new roles/identities restoration changes /relationships Figure 8.2 Loss-oriented and restoration-oriented coping (Stroebe & Schut 1999) are denying psychological reality if we try to leave that person entirely behind. In Shona tradition, for example, there is a straightforward and simple burial. There is no attempt to deny that the person has physically died. This is a necessary preliminary to inviting the deceased back into life as one of their ancestors. The dead person is lost and then re-found. It is worth pondering what kinds of church practices might help Christians to maintain a healthy connection with their dead (a need perhaps more pro- nounced within Protestantism than within Catholicism). In this new model, the process of grief is not centred so much on working through painful feelings, but leads to an emphasis on talking about the deceased with people who knew them well. In this way the grieving person will be able to develop a more accurate picture of the deceased, and to integrate others’ understandings with their own memories and images. This sort of ‘reality testing’ with others, who may have known different aspects of the deceased, and seen them from a different perspective, can be a very valuable part of the grieving process. The traditional Jewish Shiva, a seven day period when friends and relatives sit in the house to talk about the dead person, seems very suited to this task. Funerals can also contribute to the important task of working out who the deceased really was, drawing from several persons who knew them well. Finding the time to share reminiscences about the person is psy- chologically very valuable. Within a church, meetings between the bereaved and people who knew the deceased could be encouraged. Rituals and commemoration services can be ways of achieving an ongoing dialogue concerning the deceased, and of honouring the reality of the communion of saints. For Christians, it is the eternal perspective that makes sense of our ongoing relationship with the dead.  Ageing, illness, bereavement, and dying 161 SUMMARY OF KEY THEMES The stages of a major bereavement: 1 denial 2 bargaining 3 anger 4 searching 5 guilt 6 depression 7 acceptance Pastoral tools for supporting someone through bereavement: 1 one-to-one bereavement visiting (clergy or lay) 2 a team of bereavement visitors 3 initial training in bereavement counselling 4 remembrance services 5 providing contacts for professional bereavement counselling 6 practical advice (e.g. on financial matters) from those in congregation with relevant expertise 7 including the bereaved in social events 8 church bereavement self-help groups Being aware of how grieving affects every area of life: practical, financial, family relationships, social relationships, and physical health. The differences between ‘female’ (loss-oriented) and ‘male’ (coping-oriented) forms of grief. The importance for the bereaved person of talking to people who knew the deceased person well. When it is appropriate to turn to a trained counsellor in addition to Christian pastoral support. QUESTIONS TO CONSIDER What is your own experience of bereavement? Was your church able to offer support to you? What was helpful? Was anything unhelpful? What kind of support would you have ideally liked? Was support readily offered in the early stages (perhaps when shock was still numbing the reality) but tailed off later when depression was setting in? In the light of research mentioned, what might a psychologically helpful funeral (or remembrance) service, sermon or eulogy be like? 162 Counselling and pastoral care Dying Facing one’s own death is the final bereavement, the ultimate goodbye. When work- ing with the dying, we are helping people to come to terms with the loss of self. Fear of death (and of the process of dying) is a natural, biologically based feature of human life. Death involves not only the prospect of physical pain and trauma (often now somewhat assuaged with good palliative care) but a very real and primitive fear, possibly first experienced in infancy, that our own self will be annihilated and will cease to exist. These fears can gain an unhealthy power in our life, holding us in life- long ‘slavery [through the] fear of death’ (Hebrews 2. 15). Instinctively we feel that death is a violation and an outrage, a view held also by Jesus, whose eschatological mission is to defeat this final enemy. Thus death is the ultimate challenge to the meaningfulness of our lives as humans. At the same time, dying is the final stage in our growth in this life. It puts all our relationships in a new perspective and invites us to see ourselves in the context of eternity. Review, repentance and forgiveness are its special tasks. One is also called, if one has time, to put one’s affairs in order, so that the living can go on ‘living well’. One of the difficult pastoral issues raised by people who are dying is to what extent they are aware of the fact. Sometimes the person concerned is well aware of this, but maintains the fiction that they are going to get better to avoid upsetting their families. The minister may then be valuable as someone with whom they can be  Ageing, illness, bereavement, and dying 163 honest. Sometimes they may not be fully aware of it themselves; in which case the minister may play a useful role in helping them to come to terms with it, though on occasion they may be so deeply defended against the idea that they are dying that it would be counterproductive to try to help in this way. The minister needs to tread carefully, being as sensitive as possible to how far people have gone in accepting the fact that they are dying. The stages of bereavement discussed earlier are based upon Kubler-Ross’s (1970) research into the stages of dying. A dying person is being forced to separate from the fullness of this life and human interactions. It is normal for a dying person to respond with vehement feelings, in various stages of: denial, isolation, bargaining, anger, guilt, depression, searching, withdrawal, acceptance, and finally, finding hope. Pastoral care which enables people to move through the various stages of dying will share similarities with the advice given above regarding the stages of grieving. In each of the stages, in whatever order they arise, the dying person needs the freedom to explore and express their feelings, and to face any issues that need repentance or forgiveness. A person may also need to ‘forgive’ God, especially if their life is ending well before its time. To live through these stages within the context of family and pastoral care is, in some measure, a victory over death’s separating, isolating power. Continued meaningful social interaction demonstrates that death brings radical change, but not an end, to our relatedness to others. In addition, there can be a restless seeking for the meaning of one’s life, a yearning to find that one’s life has been appreciated. Perhaps the minister may help the person find a safe place from which to reflect on the ways they did or did not find what they were looking for in life. What is helpful is to gain a realistic picture of one’s life, and some sense of how this fits into a larger context of ongoing life, and for Christians, the ongoingness of God’s kingdom. However, our culture tends to disempower people for this final life task. Dying is largely kept hidden from view, as if it were unnatural, something that shouldn’t happen. Christians should not collude with this cultural norm by putting on a cheery face that avoids the reality of death, when in fact, the Christian faith provides the resources for this ultimate challenge. Psalms, hymns, poems and scriptures, shared in small doses, (perhaps left at a person’s bedside, or shared in a pastoral visit) may enable a dying person to explore creatively, even playfully, the significance of this journey from life, through death, to a continuation of life in eternity (van Gennep 1977). An opportunity for confession to a priest, a final Communion, or last rites, are important ways the church helps people prepare for death. Yet pastoral care is not a one-way street. Ministering to the dying often means allowing them to minister to us. Many who work with the dying in palliative care speak of the gener- osity of the dying, the way they bestow a sense of the sacredness of life upon those around them. Near the end of their life, a dying person may tend to withdraw from social con- tact. At first this is from more casual relationships, later it may include even close family. It is not necessarily a failure for a person to die just when family members have slipped out for a meal or some much needed rest. The dying need to feel the 164 Counselling and pastoral care security of being loved and cared for up to and beyond the point of death, but within that, they may need privacy as well. When a person has moved through separating from this life (with its attendant denial, bargaining, anger, depression, guilt and fear), and is moving through that liminal, transitional stage in which self is begin- ning to be dissolved in order to be reformed, what a dying person may most wish for is the silence that marks the journey towards God. We are dying, we are dying, so all we can do is now to be willing to die and build the ship of death to carry the soul on the longest journey. A little ship, with oars and food and little dishes, and all accoutrements fitting and ready for the departing soul. Now launch the small ship, now as the body dies and life departs, launch out, the fragile soul in the fragile ship of courage, the ark of faith......upon the flood’s black waste upon the waters of the end. D. H. Lawrence ‘Trust in God; trust also in me. In my Father’s house are many rooms; if it were not so, I would have told you. I am going there to prepare a place for you.’ John 14. 1b-2 Further reading Ageing Grainger, R. (1993) Change to Life: The Pastoral Care of the Newly Retired, London: Darton, Longman and Todd. Levin, J. (ed.) (1994) Religion in Aging and Health, London: Sage. Twining, C. (1988) Helping Older People: A Psychological Approach, Chichester: Wiley. Illness Banyard, P. (1996) Applying Psychology to Health, London: Hodder and Stoughton. Hood, R., Spilka, B., Hunsberger, B. and Gorsuch, R. (1996) The Psychology of Religion: An Empirical Approach, 2nd ed., London: Guilford Press, chapter 11. Levin, J. (ed.) (1994) Religion in Aging and Health, London: Sage. Pargament, K. I. (1997) The Psychology of Religion and Coping: Theory Research and Practice, New York: Guilford Press. Bereavement Bowlby, J. (1980) Attachment and Loss, Vol. 3, Loss, Sadness, and Depression, London: Hogarth. Davies, D. (1997) Death, Ritual, and Bereavement: The Rhetoric of Funerary Rites, London: Cassell.  Ageing, illness, bereavement, and dying 165 Grainger, R. (1998) The Social Symbolism of Grief and Mourning, London: Jessica Kingsley. Harvey, N. (1985) Death’s Gift: Chapters on Resurrection and Bereavement, London: Epworth Press. Lewis, C. S. (1961) A Grief Observed, London: Faber and Faber. Parkes, C. M. (1986) Bereavement: Studies of Grief in Adult Life, London: Penguin. Raphael, B. (1984) The Anatomy of Bereavement: A Handbook for the Caring Professions, New York: Basic Books. Saunders, C. (1983) Beyond All Pain: A Companion for the Bereaved and Dying, London: SPCK. Stroebe, M., Stroebe, W. and Hansson, R. (eds) (1993) Handbook of Bereavement, Cambridge: Cambridge University Press. Walter, T. (1990) Funerals and How to Improve Them, London: Hodder and Stoughton. Dying Cook, A. and Oltjenbruns, K. (1998) Dying and Grieving: Life-span and Family Perspectives, 2nd ed., London: Harcourt Brace. Kastenbaum, R. L. and Aisenberg, R. (1974) The Psychology of Death, London: Duckworth. Kubler-Ross, E. (1970) On Death and Dying, New York: Macmillan. Kubler-Ross, E. (1975) Death, the Final Stage of Growth, Englewood Cliffs NJ: Prentice Hall. van Gennep, A. (1977) The Rites of Passage, London: Routledge. Organisations to contact for information (UK) Cruse (Bereavement care and resources) Cruse House, 126 Sheen Road, Richmond, Surrey, TW9 1UR Tel 020 8940 4818 for nearest of 200 local branches. SANDS (Stillbirth and Neonatal Death Society) 28 Portland Place, London, W1N 4DE Tel 020 7436 5881 E-mail: [email protected] Web: www.uk-sands.org 9 Emotional problems Counselling Emotional and pastoral problems care QUESTIONS FOR MINISTRY Many people in the church are hurting. How can we help? What are the signs that someone is suffering from a serious emotional problem, such as depression or anxiety? When is psychological counselling needed? When is a more explicitly religious approach to emotional problems appropriate? Are there moral as well as psychological dimensions of emotional distress? When should emotional problems be considered as potentially sinful? Which emotions are constructive and which destructive of spiritual growth? Emotional problems such as depression, anger, and anxiety are ubiquitous in our society. Most people experience them at some time, and within any Christian con- gregation there will be a significant proportion of people experiencing emotional problems. Before considering specific emotional problems in more detail, this chap- ter will elucidate the general reasons why Christian ministers need to be concerned with them, and briefly consider some basic psychological approaches to emotional reactions and problems. Christian ministers and emotional problems There have been historical changes in the ways people handle emotional problems. The cultural norm used to be to suffer in silence. Now it is increasingly common to seek help, though this trend has not gone so far in Northern Europe as it has in America. When Christians experience emotional problems, they may well turn to their minister or pastor for help. This raises the question of where normal emotional reactions become emotional problems.  Emotional problems 167 It is, of course, normal and almost universal to feel sadness, anxiety, or anger from time to time. However, these reactions are sometimes so intense and continuous that they become a severe problem. To respond appropriately to life’s circumstances, people need to be able to show some light and shade, and variety, in their emotional reactions. If emotional reactions become jammed in one position, that variety and that appropriateness are lost. When people are in the grip of emotional problems, they often want to take the opportunity to understand themselves and their situation better. The question ‘why am I feeling this?’ raises itself insistently. This reflects one of the basic functions of emotional reactions. Psychologists such as Keith Oatley (1992) have proposed that one of the basic functions of emotions is to convey information. For example, anxi- ety draws our attention to the fact that we are in danger of some kind, and provides the energy to respond appropriately. In a similar way, depression can signal the fact that someone’s basic emotional needs are not being met, and provides the impetus for a fundamental change in lifestyle. Given this basic understanding of the function of emotions, it is natural that people experiencing intense and prolonged emotions should ask the question, ‘what is wrong? Why am I feeling this?’ This leads on to the question of whether there is any distinctive Christian approach to emotion. Here it is necessary to take notice of the history of the concept. As Thomas Dixon (1999, in press) has pointed out, though the word was an older one, it was only in the nineteenth century that the very broad concept of ‘emotions’ became an established psychological category. Before that time there had been an older tradition of thinking about what we would now call emotions that was more in harmony with Christian theology and that divided these states into the ‘passions’ and ‘affections’ of the soul. The passions of the soul were seen as being signs of and punishments for the original sin of Adam and Eve. The way that lower appetites and desires disobey the will when we are in the grip of passions mirrors the original dis- obedience of Adam and Eve to God in the garden of Eden. The affections of the soul, on the other hand, were the more refined, spiritual, and aesthetic movements of the soul towards things of truth, beauty, goodness – in short, towards God. The all- encompassing term ‘emotions’ was introduced as part of a secular psychology that gave much weight to scientific method and much less to the Christian tradition. During the nineteenth century, emotion theorists increasingly stressed the impor- tance of mechanical physical processes at the expense of the will and the mind. So, in asking whether there is a specifically Christian approach to emotions, we are effec- tively asking whether what was originally a secular concept can be re-integrated into a Christian framework. There is no reason why this should not happen. SUMMARY OF KEY THEMES The trend away from suffering in silence towards seeking help and advice. The problem of prolonged or jammed emotional reactions. Emotions as sources of information about needs not being met. The traditional Christian distinction between passions and affections. 168 Counselling and pastoral care QUESTIONS TO CONSIDER How do you let people know that you are available to talk about their emotional problems? If you have experienced emotional problems, was there something valuable that you learned as a result? What are the relative roles that friends, a minister, or health professionals can play in dealing with different emotional problems? How can you help people to learn from their emotional problems? Which emotions could be thought of as troubling passions and which as gentler affections? What are appropriate reactions to passions? And to affections? The nature of emotions Emotions are inherently difficult to define, because they have a number of different aspects, and no one aspect seems to be fundamental. There are three particularly sig- nificant aspects of emotions: physical reactions, thought processes, and behaviour. Thus, an anxious person will have a faster heart beat, and other signs of increased activity in the autonomic nervous system, will be thinking anxious thoughts, and will want to run away or in some other fashion avoid the situation. Though there has sometimes been a tendency to claim that one of these reactions is fundamental and that the others are secondary, this has never been convincingly maintained. It seems that emotions are so inherently systemic, that no one response system is fundamental. In the late nineteenth century, William James tried to argue that the physical aspect of emotions was the fundamental one, but that argument quickly ran into problems. More recently, there has been an attempt to argue that thought processes are fundamental. These have led to cognitive approaches to therapy that have been of great practical value, and these are discussed in Chapter 10. However, it would equally be a mistake to argue that thought processes are the fundamental component in emotional reactions. As well as these three basic response systems in emotions, there are various broader sets of factors, that shape our emotional reactions. There are three such that need to be briefly considered here: social factors (the influence of our relationships and general social context); cognitive factors (the influence of how we interpret our experience); and developmental factors (the influence of our past history). Among social background factors, close relationships are particularly likely to produce emotional reactions. For example, people are more likely to get angry with those they are close to than with strangers. The greater the investment in a rela- tionship, the more risk there is of it going wrong in a way that will produce a strong emotional reaction. However, relationships also provide resources that help people to cope with their emotions. For example, as will be seen in more detail later in the chapter, how well people can cope with difficult circumstances largely depends on whether they have a confidant(e) with whom they can share their problems.  Emotional problems 169 However, there is a certain skill involved in eliciting the social support that is poten- tially available. One of the reasons why normal reactions can turn into prolonged emotional problems is that people are not good at eliciting the social support they need to cope with events. As so often in psychological matters, it is important to avoid the extremes. If people have a low view of themselves, it is hard to bring them- selves to seek the social support that is potentially available and would be helpful to them. On the other hand, if people do seek support, they can make such excessive demands that potential helpers ‘run a mile’. The skill that people with emotional problems need to learn is to make prompt use of the emotional support available to them but not to overuse it. Of course, this has implication for carers too. It is good to be sensitive to when people need emo- tional support to help with potential problems, and an investment of limited time and effort at the right stage can prevent an emotional problem getting out of hand. On the other hand, it is seldom helpful to try to provide excessive emotional sup- port. On the contrary, keeping support within bounds helps a person with emotional problems to contain those problems himself. Whether or not events produce strong emotional reactions also depends to a large extent on what sense we make of them or, to put it another way, on what cognitive processes are involved. For example, as was mentioned in Chapter 1 in connection with thanksgiving, it makes a great deal of difference how we attribute events. Thus, an experience of failure will produce a more severe emotional reaction if we see it as arising from an inherent lack of ability than if we put it down to fleeting, chance fac- tors. Also, a frustrating event will produce a different, more extreme, emotional reaction if we think it was done on purpose rather than just arising accidentally. 170 Counselling and pastoral care The general background assumption here is that we are all the time making sense of our experiences, and there is considerable variety in how we do this. Emotional reactions arise not from ‘pure’ events, but from events interpreted in a particular way. Some emotional reactions, such as disgust, seem to arise with more immediacy than others. Some, like guilt, depend on an elaborate set of interpretations of self and society. This is the essence of the distinction between ‘primary’ and ‘secondary’ emotions. Particular interpretations of events are also important in turning immedi- ate emotional reactions into prolonged emotional problems. People have a tendency to talk to themselves about upsetting events and this ‘self talk’ tends to be heavily laden with how the event is interpreted. That can set up a vicious circle that main- tains the emotional reaction. Particular modes of interpretation fuel emotions, and emotions in turn fuel maladaptive modes of interpretation. The third set of background factors are developmental ones. Freudian psy- chology has been particularly important in elucidating the influence of our earlier personal history on our adult emotional reactions. Though there is currently a lot of psychological research on the development of emotional reactions in children, the important contribution of the Freudian tradition is still that it links childhood experience and adult reactions. However, the basic point is a very simple one, that whether or not events in adulthood produce strong emotional reactions depends very largely on whether they are echoes of painful and difficult events in childhood. SUMMARY OF KEY THEMES The many aspects of emotions: physiological, behavioural, and cognitive. The social, cognitive, and developmental factors that shape emotional reactions. How to make use of emotional support but not overuse it. How problems can be fuelled by patterns of attributions and ‘self talk’. Childhood experiences and adult emotional reactions. QUESTIONS TO CONSIDER Who (or what) in your life arouses powerful emotions in you? What is the appropriate amount of support to offer to someone with emotional problems who seeks your help? Do you know people whose interpretations of their lives serve to fuel negative emotions and emotional problems? Do you know people whose childhood experiences have made themselves evi- dent in emotional problems in adulthood? Depression It is time now to consider some specific forms of emotional problems, beginning with depression. The point was made in the last section that emotional reactions  Emotional problems 171 have various different manifestations, and this is especially true of depression. For example, thoughts become negative, there are feelings of sadness and a loss of interest and pleasure, behaviour becomes lethargic, cognitive func- tioning is affected, with problems especially in concentration and memory, and biological functioning is also affected with impairment of sleep and appetite. It seems that all of these aspects of depression may affect one another, producing a comprehensive and mutually reinforcing depressive system that is difficult to break out of. Six per cent of the population will go through a major depressive episode at some point in their lives, making it an illness of relevance to every church congregation. Depression can take a variety of forms. For example, a distinction is sometimes drawn between ‘reactive’ and ‘endogenous’ depression. The basic idea is that one form is a response to stressful life events, and the other to some kind of biochemical imbalance, though many authorities have concluded that there is no clear-cut dis- tinction to be made here. The problem is that it is hard to find features of so-called reactive depression that are not also present in endogenous depression. So-called endogenous depression may just be a more severe form of depression in which bio- logical symptoms such as disturbances of sleep and appetite are more prominent. The practical significance of this lies largely in its implications for treatment by medication. Not all forms of depression respond equally well to anti-depressant medication; the best guideline is that where biological symptoms are prominent, treatment by medication is likely to be most appropriate. A distinction is also made between ‘unipolar’ and ‘bipolar’ forms of affective dis- orders. People with bipolar depression show a slow and fairly predictable oscillation between depressive and manic phases. (This is certainly not to be confused with people who feel bright on some days and down on others.) Bipolar depression is a relatively rare but serious condition, calling for expert treatment, including medica- tion. Unipolar depression, in contrast, has no manic periods. It is beyond the scope of this chapter to deal fully with all aspects of depression. In what follows, we will focus mainly on the social context and negative thought processes. Social aspects There has been much excellent research on the social context of depression over the last thirty years, most notably in the research programme of George Brown (Brown and Harris 1978). First, it has become clear that in the six-to-twelve months before an episode of depression there are often threatening life events. To some extent, what counts as a threatening life event varies from one person to one another, and it is only when you know a certain amount about a person’s circumstances and back- ground that you can tell whether a particular event will be sufficiently threatening to be likely to produce an episode of depression. However, there are some recurrent themes, including episodes of failure, in which hopes and plans in which the person has invested a good deal come to nought, and episodes of loss, in which key relation- ships and social roles come to an end. 172 Counselling and pastoral care A threatening life event of this kind is not necessarily enough to produce an epi- sode of depression – many people experience failure and loss without becoming clin- ically depressed. Also relevant are background social circumstances, and in particular having a close confidant(e), though there are other relevant factors such as being in employment and having adequate financial resources. It seems that people can cope with stressful events provided they have good support, and equally that people can manage without good support provided nothing too stressful occurs. It is the combination of stressful events and lack of support that often results in depression. There is also often a close relationship between depression and marital problems, and once again there can be a vicious circle here. A dysfunctional marriage quite often results in one party becoming depressed, equally when someone is depressed it often puts their marriage under strain. Bereavement is probably the life event that produces depression more commonly than any other (see Chapter 8). Cognitive aspects Aaron Beck (Beck et al. 1979) has described a triad of negative thoughts in depres- sion; when people are depressed they have negative views about themselves, the world, and the future. They see themselves as relatively worthless, they see the world as a bleak place, and are pessimistic about the future. These negative thoughts often take a stereotyped and repetitive form, so that people are constantly and almost ‘automatically’ thinking particular negative thoughts. In addition, Seligman (1975) has elucidated the feelings of ‘learned helplessness’ that characterise depression. Through a series of failure experiences, people can be reduced to a state of helplessness in which they believe that they cannot change their circumstances for the better. In more recent formulations of this theory of depres- sion, the focus has been on how people attribute events such as failures or losses in their lives. Depression is associated with a tendency to attribute negative events to oneself rather than to external factors, or to stable factors that are unlikely to change, and to see them not as isolated events but as examples of a global and pervasive prob- lem. So, for example, while a non-depressed person who fails a maths test might attribute her failure to not having had her coffee in the morning, not having revised sufficiently, or to the test being too hard, a depressed person is likely to attribute fail- ure to being useless at maths in particular and her stupidity in general. Not everyone who has this depressive mind-set is necessarily in the grip of a full state of depression. However, such a mind-set is more likely to lead to full depression when circumstances become adverse. Depression is almost always characterised by this negative frame of mind, and it seems that this plays a key role in maintaining the depression. Thus, in a similar manner to the self-pity spiral most people have expe- rienced, depression gives rise to negative thoughts and modes of interpretation, which in turn consolidate the depression. Depression is also associated with biases in what people attend to and what they remember. Selective memory is often particularly marked in depression, with people selectively recalling the bad times and having difficulty recalling the good  Emotional problems 173 times. Similarly, when depressed, people pay more attention to negative experi- ences, and gloss over the good things that may happen to them. From what has already been said, it is not surprising that depression is often asso- ciated with guilt. Sometimes this takes the form of insistently recalling some bad experiences from the past for which the depressed person feels excessively to blame. The topic of guilt forms a convenient bridgehead between the psychological and religious perspectives on the negative mind-set of depressed people. It has often seemed that there is a clash between the two traditions over guilt. Psychologists have been aware of the harm that excessive guilt can do, and have been concerned to alle- viate it. Christians, in contrast, have sometimes highlighted the value of a sense of guilt in leading people to repentance. In fact, however, there may not be as much of a clash here as at first appears. It is helpful to make a distinction, as Freud among others did, between realistic and neu- rotic guilt. Neurotic guilt is excessive and pervasive, and it is this that has been the concern of psychologists and counsellors. It is a completely different matter for people to have a bad conscience about genuine wrong-doings. (For a further discus- sion of the role of guilt, see Chapter 2.) The fact that depressed people take a more negative view of things does not nec- essarily mean that they are less realistic. Indeed, they often claim that life really is bleak, but most people go around with a ‘rosy glow’ ignoring the fact. There is a certain amount of research evidence that supports this claim of ‘depressive realism’. For example, depressed people may be more accurately negative in estimating their popularity than are non-depressed people. There is nothing in the Christian tradition that would seek to encourage a facile optimism as a defence against depression. It is relevant here to consider the nature of Christian hope, and to distinguish it from optimism (Watts 2000). It can be argued that hope, far from denying bleakness, comes into its own when circumstances are too hard to permit mere optimism, and provides the inner resources for continued constructive engagement even in the most dire of circumstances. Psychologists have sometimes said that depression is characterised by a position of ‘hopelessness’. However, when you look at the details of this claim, it seems that depression is being equated with a lack of optimism rather than a lack of what the Christian tradition would understand as hope. It may well be that hope, because it is more realistic, would be a more effective antidote to depres- sion than optimism, and that is something that could be an interesting focus of research. SUMMARY OF KEY THEMES The distinction between ‘reactive’ and ‘endogenous’ depression. ‘Unipolar’ and ‘bipolar’ affective disorders. The role of threatening life events in triggering bouts of depression. Episodes of failure and of loss. Marital problems and depression. 174 Counselling and pastoral care Depressed people’s negative thoughts about themselves, the world, and the future. Biases of attention and memory in depression. The phenomenon of ‘depressive realism’. QUESTIONS TO CONSIDER How many people in your congregation have experienced bouts of depression? Have they talked to you about them? Do you know how to recognise signs of depression? Is it wrong for a Christian to seek medical treatment (e.g. drugs) for emotional problems? How can depression be exacerbated by negative thought processes? How might Christian disciplines (such as confession, thanksgiving, prayer and fellowship) help with depression? Anxiety One helpful initial subdivision of anxiety problems is into specific and general anxi- eties. Whereas depression tends to be an all-pervasive emotional problem that affects almost everything, people can suffer from highly specific anxieties and show no other emotional problems. The most common are phobias of animals such as spi- ders, though there is considerable variety in the focus of specific phobias. Such highly specific fears are often not unduly incapacitating. However, if they are, they generally respond to ‘behavioural’ treatment methods in which, in effect, the person gradually practises getting used to whatever they are frightened of. More serious and incapacitating are anxieties involving other people. These can also take various different forms. For example, there are anxieties about having to perform in public, of which public speaking anxiety is the most common. There are also anxieties about having to meet people in official positions or people with intimidating personalities. Yet again, there can be anxieties about having to make conversation, which largely arise from the person’s own lack of social skill, rather than from the personality or position of the other person. Finally, there are anxi- eties about crowds, which often have an element of ‘social claustrophobia’ in which the person dreads being trapped in a social situation. Another specific anxiety that causes considerable problems is agoraphobia. Though etymologically it means a fear of open spaces, the central anxiety is often of not being able to return to a place of safety. It frequently develops in the context of depression, and is associated with acute and unpredictable attacks of panic. Panic attacks are so alarming that they often themselves become a focus of anxiety, and a familiar kind of vicious circle develops. Being anxious about having a panic attack makes it more likely that one will occur, and each attack reinforces the anxiety. In addition to these various specific anxieties, there is also ‘generalised anxiety disorder’, which is characterised by worry about almost everything. Pervasive worry  Emotional problems 175 can take up a huge amount of mental energy, and because it saps confidence, it makes everything very demanding. Like depression, anxiety affects people’s thought processes, behaviour, and phys- iological state, as well as their feelings. Once again, the mind-set is one of the most fruitful things to focus on. In pathological anxiety, judgements about what may go wrong become distorted. This has two aspects; there are both exaggerated estimates of the risk of something going wrong, and an excessive catastrophising of the feared eventuality. Once again, people often attend selectively to what is threatening in their circumstances. This, in turn, is exacerbated by the sense that one will not be able to cope and by the fear that other people will be hypercritical or unsupportive. Just as depression is characterised by a lack of hope, so anxiety is characterised by a lack of trust. Needless to say, it is inappropriate to make things worse by accusing people of a lack of trust. The point is rather that, for whatever reason, they have found trust peculiarly hard to develop. The escape from anxiety often involves the opportunity to ‘test reality’ and discover that things do not turn out anything like as badly as they had feared. It is also helpful to contain anxious thoughts, so that they are not continually exacerbating an already anxious state. There will be more discus- sion of these approaches in the following chapter. SUMMARY OF KEY THEMES The distinction between specific and general anxieties. Anxiety about public performances and social occasions. Generalised anxiety disorder; worrying about everything incessantly. Anxiety as lack of trust. QUESTIONS TO CONSIDER Who do you know who is prone to excessive or debilitating anxiety? Is their anxiety specific to certain situations or more generalised? What thought processes fuel their anxiety? Do they form unrealistic appraisals of the likelihood of things going wrong? How can you encourage anxious people to be more trusting? What Christian disciplines might help to relieve anxiety? Meditation on scrip- ture? Prayer support from others? A confidant(e) or soul friend? Anger The final emotional condition that we will consider in this chapter is anger. It is less handicapping than either depression or anxiety, but it is a subject about which Christians have found it difficult to know what to say. There are specific theological difficulties concerning anger (Campbell 1986), such as the relationship between human anger and the anger of God, a subject that received one of its first explicit treatments by Lactantius in the early fourth century. The Bible, especially the Old Testament, is full of references to God’s anger. This 176 Counselling and pastoral care