Pastoral Care Of Depression

SOUTH ASIA INSTITUTE OF ADVANCED CHRISTIAN STUDIES

THERAPEUTIC COMMUNITY: AN INTEGRATED APPROACH TO PASTORAL CARE OF DEPRESSION

Submitted to

Dr. Chris Gnanakan

In Partial Fulfillment of the Requirements of the Course Theology of care and Counselling I declare that this assignment is my own unaided work. I have not copied it from any person, article, book, website or other forms of storage. Every idea or phrase that is not my own has been duly acknowledged.

Signature:______________________

By Tommy Liang Registration #0620

March 6, 2009 THERAPEUTIC COMMUNITY: AN INTEGRATED APPROACH TO PASTORAL CARE OF DEPRESSION Despite the crucial and causal role of depression in suicide has limited validity in India,1 depression has been interpreted as a stigma.2 Many Indians today continue to hold to this belief. But increasingly with the burgeoning of psychotherapy and the advent of pastoral theology, more and more religious persons struggle to maintain this belief. Depression as such no longer holds the kind of labeling effect that it once was thought to have. Indeed, particularly with our capacity to mitigate its symptoms with pastoral counseling, community of believers, and biblical images of hope, the belief that depression is a problem seems to have lost its appeal. This paper examines and challenges the underlying assumptions that continue to undergird Christian communities that depression is effectively dealt with pastoral care, especially in a faith community. To accomplish this goal I shall argue that pastoral caregivers are facing crisis themselves. Moreover, I will attempt to illustrate how biblical and theological perspectives are a fundamental dimension of understanding the individual in the community. Furthermore, I will postulate a paradigm of integration of the theological and the psychological as a process consisting of three characteristics in therapeutic community: 1) expressions of God’s presence, 2) means of salvation, and 3) priesthood of all believers. Lastly, I will suggest that several barriers must be overcome for a therapeutic community in pastoral care of depression to actualize itself. CRISIS OF PASTORAL COUNSELING Eschmann argues that there is no satisfactory integration of the various concepts of the theory and practice of pastoral care in spite of the advent in pastoral care in the past three decades, and that the tension resulting from the unclarified relationship between theology and the social sciences burdens pastoral caregivers with confusion in the practice of their ministry.3 The issue is further complicated by widely differing opinions on the theological

Lakshmi Vijayakumar, “Suicide and its prevention: The Urgent need in India,” Indian J Psychiatry 49 (2007) 81-84, http://www.indianjpsychiatry.org (accessed 25 February 2009). 2 David Kohn, “Program trains layperson to treat depression in India,” International Herald Tribune, 11 March 2008, http://www.iht.com/bin/printfriendly.php?=10918910 (accessed 27 February 2009). 3 Holger Eschmann, “Towards a Pastoral Care in a Trinitarian Perspective,” Journal of Pastoral Care 54 (2000) 419. 1

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understanding of depression. Historically, depression is seen as a sin to be fled, a spiritual problem, and an affliction of the body-mind that oppresses the spirit of its victim. Despite the difficulty to know if and when a person’s depression is mainly a spiritual matter, it is later suggested that depression is the result of faulty thinking.4 Furthermore, it is clear that pastoral caregivers are also vulnerable human beings. They are even susceptible to depression that may results in either acting in or acting out behavior.5 Eventually, they can only survive by being honest with themselves to the congregation. The most important dimension of pastoral care thus is the need for communal acceptance. BIBLICAL AND THEOLOGICAL PERSPECTIVES Luke chapter 9, verses 1-4, summarizes very clearly the biblical challenge to a commitment to the understanding of and involvement in the church's healing ministry: When Jesus had called the Twelve together, he gave them power and authority to drive out all demons and to cure disease, and he sent them out to preach the kingdom of God and to heal the sick. He told them: "Take nothing for the journey - no staff, no bag, no bread, no money, no extra tunic. Whatever house you enter, stay there until you leave that town".6 Accordingly, the challenge to the church today is a three-fold one. God's people are being called to be healers, who proclaim and demonstrate a total gospel of forgiveness and healing, of the whole person, and in a healing community. Luke 9:3-4, in particular, demonstrates that the faith community cannot heal as isolated individuals because they need one another. What distinguishes any local congregation from a secular organization is a fellowship formed by the Holy Spirit, gifts of the spirit for ministry, proclamation of the gospel as the good news of grace, teaching for Christian growth, and prayer as our means of access to God.7 Eschmann suggests three dimensions of pastoral care in Trinitarian perspective orientated by the structure of the Apostles' Creed. Firstly, the pastoral care in the field of the doctrine of creation refers to blessing and healing. It is argued that in a helping relationship of true understanding healing capacities of self-realization can become effective in the individual. Secondly, reconciliation and conversion are regarded as the pastoral care in the field of the doctrine of salvation. It is concerned with enlightening M. D. Lastoria, “Pastoral Counseling and Spiritual Help,” BEPC 339-340. R. L. Randall, “Ministers and Churches at Risk,” Christian Century 1093-1095. 6 Luke 9:1-4 (New International Version). 7 E. A. Allen, “What is the church’s healing ministry? Biblical and Global perspectives.” International Review of Mission 46-50. 4 5

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the human situation under judgment and the grace of God, with the proclamation of the gospel, with human guilt, and with the unconditional acceptance of God. Finally, sanctification and fellowship fall into the pastoral care in the field of the doctrine of Holy Spirit. It reminds us that human existence retains a fragmentary character and that the whole creation yearns for their perfection and completion.8 Furthermore, Guthrie proposes another three dimensions of therapeutic alliance in Trinitarian perspective. Based on Christian doctrine of human beings and the doctrine of Trinity, human nature and destiny are understood in relation to God the Father (the Creator), Son (the Redeemer), and Holy Spirit (the Life-Giver). As a result, both the pastoral caregivers and the counselees are regarded as first, creatures in the image of God; second, sinners who contradict what they were created to do; and thirdly, people who were promised a new humanity.9 Accordingly, human individuality is actualized in human community, and human community protects and nourishes human individuals.10 In light of these observations, I would like to present my understanding of the nature of the ministry of therapeutic community in relation to depression, followed by an application involving a specific case. Following this, I will address the issues of therapeutic community in pastoral care of depression THERAPEUTIC COMMUNITY: TOWARDS AN INTEGRATED APPROACH TO PASTORAL CARE OF DEPRESSION Therapeutic community may be compared to an encounter within a divine milieu in which the group facilitates the healing of its member’s broken relationships through acts of empathic understanding, unconditional positive regard, and congruence11. Expressions of God’s presence Shelp puts it best when he conceptualizes the ministry of the congregation as a strength of the Care Team concept. The uniqueness of this approach lies in the understanding of life in Christ as a compassionate life lived together as community in which healing takes place. It is this compassion that draws members to offer care and support to others who are vulnerable and broken. By their presence and care on behalf of the community, they are expressions of God’s presence.12 This encounter allows Eschmann, “Towards a Pastoral Care in a Trinitarian Perspective,” 424-426. S. C. Guthrie, “Pastoral Counseling, Trinitarian Theology, and Christian Anthropology,” Interpretation 130-133. 10 Guthrie, “Pastoral Counseling,” 134-136. 11 It was found that psychological changes occurred in the individual only when these three conditions were present (Carl R. Rogers, On Becoming a Person (Boston: Houghton Mifflin, 1961), 60-63.) 12 E. E. Shelp, “Pastoral Care as a Community Endeavor,” 8 9

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one to envision therapeutic community as a ministry-service to a person in need of empathic understanding. In this way, the essence of ministry is not only human in nature but also transcendent. This transcendent character of therapeutic community undoubtedly constitutes the aspect of mystery in pastoral care of depression that always remains beyond one’s full comprehension. William A. Smith, having tapped the resources of those with whom a depressed person has positive relationships and held Holy Communion with them, concludes the role of therapeutic community in pastoral care of depression in this way: “These reflections on the ministry to the depressed person have as their premise that depression (whether mild or severe) can be the basis for spiritual transformation and growth. This implies that depressive symptoms point to an inner spiritual stress where new spiritual foundations in a person’s life are being formed because of the breaking down of things previously relied upon. This suggests that depression, seen from this point of view, has within it the possibility of loss of faith and a spiritual dying, where one functions with a creed of hopelessness and survives by affirming the meaninglessness of life.”13 Nevertheless, Randall reminds us of the common problems and conflicts within congregations which are frequently rooted in the acting-in and acting-out behavior of professional and lay caregivers at risk.14 Therefore, there is always a need to attend to the self of each congregation when at-risk congregations are signaled. Means of salvation Despite the encounter with depression as a means of spiritual transformation is inspiringly significant, the balance between increasing psychosocial maturity and toward an all-encompassing spiritual integration is equally important . Lowe eloquently describes this understanding: “The therapy provided by the fellowship of the church is to be the means of salvation for its members who are estranged and cut off from meaningful relationships with God and their fellow men”.15 This description reconfirmed my strong belief that the faith community must invariably approach its member as a psychospiritual being and thus pay special attention to both psychosocial and spiritual dimensions of his or her development in order to obtain a comprehensive view of that person. Pastoral care accordingly should address both dimensions as the means of salvation. http://www.parkridgecenter.org/Page516.html (accessed 10 February 2009). 13 W. A. Smith, “Ministering to the Depressed Person,” Journal of Pastoral Care 23. 14 Randall, “Ministers,” 1094. 15 C. M. Lowe, “The Healing Community: church and mental hospital,” Pastoral Psychology 20 (1969) 55, http://www.sprinngerlink.com/content/xn24663v6g821003/ (accessed 10 February 2009). 5

Myers sees the role of congregations to be a vital venue for consciousness-raising that results in depressed persons and their caregivers getting help.16 Mindful of and respectful of a member’s striving, the faith community embraces the whole of the person indicating thereby that unconditional positive regard is essential to healing in the therapeutic community. However, Wolff gives us a word of warning: “the difference between psychiatric treatment and advice given by a religiously trained representative of a church organization should not be overlooked. Real psychiatric treatment belongs to the trained psychiatrist, who knows the physical and emotional factors involved in an emotional disturbance. Some emotional sicknesses, like psychoneurosis, require special training in psychotherapy, and treatment may last a couple of years. The more severely "mentally sick" patient should be handled by professionally competent persons only, and unrealistic or untimely experiments in treatment might do more harm than good. The psychological difference between a psychiatrist and a religious therapist can, at times, be great.”17 Priesthood of all believers James. A. Knight defines the congregation in this way: “The congregation is an instrument of therapy. The message in the Gospels discloses that an intimate relationship was taken for granted between physical, mental, moral, and religious health. Incidents are recorded in which a physical affliction was healed and sins were forgiven in one and the same act. Nobody attempted to split human health into a multiplicity of functions, and likewise nobody attempted to promote the welfare of one individual in abstraction from the salvation of the community. Each person saw and felt the spirit of God working through the religious community and knew himself to be a part of the priesthood of all believers.”18 Knight’s description of congregation as therapeutic tool certainly became real to me as I personally experienced healing of depression in the context of a small group. Pastoral care is by no means a specialized function of the professional clergyman, but rather is a task of the whole church, laity and clergy, accomplished through small groups.19 The mode of care of depression in small group is thus done within the D. R. Myers, “How can I care when they don’t care: Congregational Responses to the Caregiver with the Older, Depressed Family Member,” Journal of Family Ministry 60. 17 Kurt Wolff, “Religion and Mental Health.” Journal of Pastoral Care 43. 18 J. A. Knight, “The therapeutic opportunity of the clergyman and the congregation,” in H. J. Clinebell, Jr (ed), Community Mental Health: the Role of Church and Temple. Nashville: Abingdon, 1970. http://www.religion-online.org/showbook.asp?title=798 (accessed 27 February 2009). 19 C. H. Reid, “Pastoral care through small groups.” Pastoral Psychology 18 (1967) 14, 16

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context of the genuine relationship between members. In this way, the condition of personal change is seen to lie in the congruence of the congregation. Anderson offers more heuristic insights into the dynamic relationships between congregation and mental health. Ten theological principles are extracted: (1) The health of the congregation and the mental health of its members are reciprocally related; (2) Health is never an end in itself; it is always a penultimate goal; (3) A congregation may work toward health, but that is not its primary purpose; (4) Christian congregations cannot avoid the obligation to be agencies of healing; (5) Sickness is not a private matter, and neither is healing; (6) Because health is never fully possible, the ministry of healing is always an ongoing necessity for Christian communities; (7) In order that a congregation might maximize its potential as a healing and sustaining human community, some shift is necessary in the practice of ministry; (8) The congregation is a natural mental health resource because it is a bridge between the individual and society; (9) The relationship between the congregation and mental health is an instance of the larger theological question of the relation between salvation and health; and (10) This emphasis on the congregation as a community of care presupposes that human nature is communal as well as individual.20 In the perspective of therapeutic community, we accordingly learn how to be and function as a reality of the priesthood of all believers. By receiving basic trainings in mental health, laypersons are more able to develop therapeutic alliance that is truly analogous to a specialist’s role in providing for a patient’s needs and experiences with depression.21 It may be deduced from my earlier statements regarding spiritual and psychosocial interdependency that one may talk about the pastoral care of depression within the faith community. However, the fact that clinical ministries are also part of the pastoral care should not be overlooked. Anderson puts it right when he urges us to give more attention to fostering an organic connection between congregations and clinical ministries: “The support of persons providing pastoral care in specialized settings is an expression of the congregation’s ministry of healing insofar as these persons continue to function in the place of a local congregation to provide pastoral care for those life crises necessitate special treatment.”22

http://www.springerlink.com/content/w4846385j2372965/ (accessed 10 February 2009). 20 Herbert Anderson, “The Congregation: Health Center or Healing Community,” Word & World 126128. 21 Kohn, “Program,” 1. 22 Anderson, “Congregation,” 129. 7

The conceptual framework just presented can be seen in my personal experience: I am reminded here of my failure to concentrate in my work and be passionate with people for nearly six months before I came to India. As an infant aged six months, I was abandoned by my divorced parents and was sent to my adoptive father and my maternal aunt. It was until the age of fifteen that my adoptive father married my mother and we lived together. As an adolescent, I had experienced an upsetting disagreement with my mother and struggled and anguished over this before I went to college. Later I told myself that I had forgiven my mother and at the same time kept a distance from her. Since my adoptive father passed away one year ago, I started to get more in touch with my mother. Although I perceived and empathized with her loneliness, I realized later, through the similar struggle of a Christian friend, that I had also failed to acknowledge the repressed anger towards my mother even though I had worked very hard. What I had missed was my hatred towards her; I did not let go of my frustrations in my adolescence. As I became conscious of this, I chose to share my struggle in a small group of believers. In reflecting back over the experience, I realize it was their empathic understanding, unconditional acceptance, and congruence which led me to the experience of God’s presence, the transformation and maturation resulting from salvation, and the involvement of a part of the priesthood of all believers. SOME ISSUES OF THERAPEUTIC COMMUNITY IN PASTORAL CARE OF DEPRESSION In spite of the fact that the community of believers is one of the overlooked resources of pastoral care,23 the role of Christian social support in coping with depression is open to criticism. White and others identify attributions as the key to determining the depression-buffering role of faith community.24 As a result, obstacles to the comprehensive interpretation of meanings are to be removed in order for a therapeutic community to actualize itself. I have identified three sources of the obstacles. Inadequacy of psychospiritual education Earl D. Bland summarizes his attempt to overcome the barriers between psychology and church: “The role I play is not of an expert or consultant who dispenses guidance from a distance; rather, I strive to be a participant in the ongoing development of a community of believers of which I am a part.”25 The strong sense of humility and passion in the relationship between religion and social sciences allows one to find a R. W. Fairchild, “Sadness and Depression,” DPCC 1105. S. A. White and others, “Christians and Depression: Attributions as Mediators of the DepressionBuffering Role of Christian Social Support,” Journal of Psychology and Christianity 49-57. 25 E. D. Bland, “Psychology-Church Collaboration: Finding a New Level of Mutual Participation,” Journal of Psychology and Christianity 302.. 23 24

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new level of mutual participation. Nevertheless, the collaboration between church and psychology is still under construction. White and others believe that education about the nature of depression and its symptoms and providing a Christian attribution about the cause and nature of depression that helps elicit supportive behaviors from significant others are the crucial components of treatment.26 Myers also sees the role of empathic ministry approaches to be that of a psychospiritual education for caregivers, in which effective helping skills are learnt so that emotion-sensitive atmosphere can be cultivated and emotionally intelligent elements in existing programs can be developed.27 Yet without collaboration, any promise remains empty. Lack of a missiological mindset On the one hand, despite many psychiatrists are seeking collaboration with religious representatives and are firmly convinced that faith is an important factor in problems of emotional health,28 there is still a gap between mission and renewal of the church.29 It is thus argued that mission should have a priority for renewal of the church. On the other hand, although the churches of many developing countries have experienced prayer-healing movements and some become healing churches, all of them are still not widely accepted for their particular kind of witness and for their way of doing theology within the ecumenical fellowship.30 What I believe is that the church has lost the awareness of engaging its social millieu missionally and of witnessing against injustice. Challenge of cultural barriers All of the above are important but each falls short of what is required. Authentic integration will demand effective engagement of its culture. Peoples have always had ways of responding to life transitions, but each ethnic group had its own method. Ullrich discovers that depression is an appropriate response for the widow who was regarded as responsible for her husband’s death in South India.31 Webster also shows that fifty-six out of 175 Dalit Christians tend to turn their anger inward under adverse circumstances.32 If we are to think constructively about the pastoral care of White and others, “Christians and Depression,” 57. Myers, “How,” 56-63. 28 Wolff, “Religion,” 41. 29 W. R. Shenk, “The Priority of Mission for Renewal of the Church,” Direction 102. 30 C. H. Grundman, “He Sent Them Out to Heal! Reflections on the Healing Ministry of the Church,” Currents in Theology and Mission 372-373. 31 Helen E. Ullrich, “Widows in a South India Society: Depression as an Appropriate Response to Cultural Factors,” Sex Roles 169. 32 John C. B. Webster, The Pastor to Dalits. (Delhi: ISPCK, 1995), 133. 26 27

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depression, we need to recognize the cultural factors of therapeutic community. CONCLUSION In the light of the biblical and theological perspectives, I have sought to provide a conceptual framework by which to understand how faith community can be of help to the pastoral care of depression. It is my belief that it is crucial to understand the role that conditions of change have in the lives of depressed individuals. This framework further provides an explanatory rationale for how depression is regarded as a solution to the disintegration between an adequate theological understanding of human nature and a psychological efficacy of change within the church and among the community. I believe that the proposed framework provides directives that might be followed in future investigation within the field of theology and psychology. For both pastoral caregivers and depressed individuals, the proposed framework suggests the crucial need for clinical ministers to educate the congregation and the community about theological understanding of human nature, psychological foundation of depression, and social skills of helping. Within the church community, I believe it is important to provide a missiological understanding about therapeutic community and to develop a culture-sensitive approach to the care of depression. I believe that empowering the faith community to develop an integrated approach to pastoral care of depression is a crucial component of treatment that might enhance the patient’s recovery and prevent the patient from collapse.

Bibliography Allen, E. A. “What is the church’s healing ministry? Biblical and Global perspectives.” International Review of Mission 90 (2001) 46-54. Anderson, Herbert. “The Congregation: Health Center or Healing Community.” Word 10

& World 9 (1989) 123-131. Bland, E. D. “Psychology-Church Collaboration: Finding a New Level of Mutual Participation.” Journal of Psychology and Christianity 22 (2003) 299-303. Eschmann, Holger. “Towards a Pastoral Care in a Trinitarian Perspective.” Journal of Pastoral Care 54 (2000) 419-427. Fairchild, R. W. “Sadness and Depression,” in R.J. Hunter and others (eds), Dictionary of Pastoral Care and Counseling. Nashville: Abingdon, 1990. 1105. Grundman, C. H. “He Sent Them Out to Heal! Reflections on the Healing Ministry of the Church.” Currents in Theology and Mission 33 (2006) 372-378. Guthrie, S. C. “Pastoral Counseling, Trinitarian Theology, and Christian Anthropology.” Interpretation 33 (1979) 130-143. Knight, J.A. “The therapeutic opportunity of the clergyman and the congregation,” in H. J. Clinebell, Jr (ed), Community Mental Health: the Role of Church and Temple. Nashville: Abingdon, 1970. http://www.religiononline.org/showbook.asp?title=798 (accessed 27 February 2009). Kohn, David. “Program trains layperson to treat depression in India.” International Herald Tribune. 11 March 2008. http://www.iht.com/bin/printfriendly.php? =10918910 (accessed 27 February 2009). Lastoria, M. D. “Pastoral Counseling and Spiritual Help,” in David G. Benner & Peter C. Hill (eds), BEPC. 2nd edn. Grand Rapids, Michigan: Baker, 1999. 339-340. Lowe, C.M. “The Healing Community: church and mental hospital.” Pastoral Psychology 20 (1969) 55-59. http://www.sprinngerlink.com/content/xn24663v6g821003/ (accessed 10 February 2009). Myers, D. R. “How can I care when they don’t care: Congregational Responses to the Caregiver with the Older, Depressed Family Member.” Journal of Family Ministry 14 (2000) 46-66. Randall, R. L. “Ministers and Churches at Risk.” Christian Century 108 (1991) 10931095. Reid, C.H. “Pastoral care through small groups.” Pastoral Psychology 18 (1967)1421. http://www.springerlink.com/content/w4846385j2372965/ (accessed 10 February 2009). Rogers, C. R. On Becoming a Person. Boston: Houghton Mifflin, 1961. Shelp, E.E. “Pastoral Care as a Community Endeavor.” http://www.parkridgecenter.org/Page516.html (accessed 10 February 2009). Shenk, W. R. “The Priority of Mission for Renewal of the Church.” Direction 28 (1999) 101-112. 11

Smith, W. A. “Ministering to the Depressed Person.” Journal of Pastoral Care 26 (1972) 15-25. Ullrich, Helen E. “Widows in a South India Society: Depression as an Appropriate Response to Cultural Factors” Sex Roles 19 (1988) 169. Vijaykumar, Lakshmi. “Suicide and its prevention: The Urgent need in India.” Indian J Psychiatry 49 (2007) 81-84. http://www.indianjpsychiatry.org (accessed 25 February 2009). Webster, John C. B. The Pastor to Dalits. Delhi: ISPCK, 1995. White S. A. and others. “Christians and Depression: Attributions as Mediators of the Depression-Buffering Role of Christian Social Support.” Journal of Psychology and Christianity 22 (2003) 49-58. Wolff, K. “Religion and Mental Health.” Journal of Pastoral Care 14 (1960) 39-43.

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