Addressing spiritual struggles using spiritually oriented trauma-focused cognitive behavioral therapy : an international case study.

Partridge, Katherine J. ; Walker, Donald F.

With many internationally adopted children coming from war-torn and politically corrupt countries there are a number of children coming to this country having faced nearly life-long trauma. Many of such youth experience extreme disruption in functioning that some countries have suspended the ability for children to be adopted by families outside of the country. Further, while many of these children who are adopted into Christian families may initially find some comfort from a new found faith, spiritual struggles are likely to surface. Walker, Reese, Hughes, and Troskie (2010) have developed a spiritually-oriented form of trauma-focused cognitive behavioral therapy (SO-TF-CBT) to address spiritual issues in child trauma therapy. Cultural factors further complicate the process of resolving spiritual struggles after abuse when a child is being adopted internationally.

In this brief report, we report an amalgamated case study which demonstrates some of the unique struggles that a child with complex trauma involving child abuse, who later became a Christian, may experience. First, we will provide a brief cultural backdrop and client demographics. We then provide a brief trauma history and review the client's spiritual functioning. We then conclude by providing specific considerations for using spiritually-oriented interventions within the context of TF-CBT.

Background

Demographic Information

Natalya (pseudo name) is a 16-year-old female who was brought in for treatment by her adoptive mother, Mrs. Hammond (pseudo name). Clinical interviews and assessment confirmed a diagnosis of PTSD which resulted from persistent traumatic experiences (which will be detailed below) and manifested in the form of flashbacks and nightmares, avoidance, negative cognitions, feelings of detachment, irritability, hypervigilance, trouble concentrating, and sleep disturbance. Natalya experienced stress specifically related to sleeping problems and nightmares as she would often have difficulty sleeping. In addition, when she felt threatened she was easily angered.

Cultural Context

Natalya was adopted from Russia in 2011 when Russian children were the third largest group of children to be adopted internationally by families in the United States with approximately 970 children being adopted in that year. (United States Department of State, 2011). There are reportedly over 600,000 children in orphanages in Russia though as many as 95% of them are not literally orphans in that at least one of their parents is still alive. Due to a lack of resources many families abandon them. Orphanages are not equipped to educate these children and many are turned out when they are 15 years old, resulting in a disproportionate number becoming homeless, engaging in criminal activity, or taking their own life (Lowry, 2000). At the end of 2012 Vladimir Putin banned the international adoption of Russian children. Some have speculated that this was a largely political move in response to the Magnitsky Act. This act was signed by President Obama to ban Russians with reported human rights violations from coming to the United States (Herszenhorn & Eckholm, 2012). Since that time, there has been no movement with regard to opening international adoptions from Russia to date.

Trauma History

Natalya was the oldest of three children. She lived with her biological parents until she was seven years old. Her father was an alcoholic and was physically abusive toward her mother. Natalya's father would often disappear for days at a time during which time her mother would blame her for driving him away and she would drink as well. When her father returned he would often bring presents before repeating this cycle of drinking and abuse. He would often force Natalya to watch him have sex with her mother and would tell her when she got old enough it would be "your turn." According to Natalya, there was at least one instance when Natalya's father came home so drunk that he tried to catch her to give to one of his friends for sex. She was able to run away and did not come home for three days. Shortly after this event, when her brothers were approximately 10 months old, her father died suddenly subsequent to falling down a flight of stairs while intoxicated.

Natalya's mother "fell apart" after this and could barely take care of herself let alone the children. Natalya came home after school one day to find that her mother was attempting to drown one of her brothers in the wash tub. She was able to rescue her brother as her mother left the house. Natalya reported that her mother did not come back and that she took care of her brothers for two weeks before someone from the school learned of their situation and took them to an orphanage. She never saw or heard from her mother after this point and it always bothered her that she did not know if she was dead or alive.

Natalya reported that her brothers were adopted almost immediately because they were babies. She was never told who adopted them. They were just "gone one day." After this, Natalya attempted to run away on several occasions but was always caught and returned. Typical punishments including beating, withholding food, being hit with wet towels, being forced to sit on shards of metal, glass, and pottery, verbal ridicule, and being forced to sleep on a metal box spring after having mattress privileges "revoked." Natalya also went on several hosting trips to the United States in the hopes of being adopted but she was never "chosen." When she had all but given up hope that she would be adopted and was preparing to be "turned out" of the orphanage when she turned 15, 14-year-old Natalya was adopted by a Wisconsin family.

The Hammond family had adopted a 12-year-old girl from Russia about the same time that Natalya had been adopted the first time and felt that Natalya would be a good fit for their family because of this. The Hammonds also had four biological children, two girls ages 19 and 17 and two boys ages nine and eight. Natalya became quickly attached to her new brothers as they reminded her of the ones that she had lost. This also became a source of conflict, however, as she was attached to her new brothers and very protective of them to the point where she would check on them at night. She would also attempt to prevent Mr. and Mrs. Hammond from disciplining them and would "turn" on the Hammonds when they attempted to be close with the boys. There was also a time when a family friend, a 12 -year-old boy, was "rough housing" with the youngest brother and Natalya broke his nose trying to "protect" her brother. Overall, Natalya enjoyed being with the Hammonds. However, the way that she attempted to "take care" of her brothers frightened Mrs. Hammond and she subsequently sought therapy for Natalya.

Faith Development

Natalya reported that she never "had faith" while living in Russia. She reported that she had never been to a church except for a Russian Orthodox Church a couple of times with her grandmother when she was very young. The Hammond family was very involved in their evangelical church and immediately immersed Natalya in their church life. At the time of intake Natalya had been living with the family for approximately eight months and reported having "received Christ as her Savior" a few months before. She reported that her faith had helped her with some of her anger but that she still could not control it sometimes. Mrs. Hammond reported that she prayed with Natalya every day and that they also read the Bible together as a family. Natalya stated that she found comfort in God for the most part and that she had a "changed heart." However, she struggled with why God "gave me to so many people who didn't want me." She also struggled with thinking that her biological parents were in hell because they never talked to her about God. Additionally, she worried about her biological brothers and the fact that she does not know where they are or if they know God.

Treatment

Trauma Focused Cognitive Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006) is widely considered to be the best practice, evidence-based treatment for PTSD in children in the United States. Due to the fact that Natalya had found refuge in her new faith and was also experiencing some spiritual struggles, it was decided to utilize a spiritually oriented version of TF CBT (SO-TF-CBT; Walker, Reese, Hughes, & Troskie, 2010). Treatment components include psychoeducation and parenting skills, relaxation, affective modulation, cognitive coping and processing, trauma narrative, mastery of trauma reminders, conjoint parent-child sessions, and safety planning.

Addressing Spirituality in SO-TF-CBT

Spiritual coping. When Natalya first came to treatment she was a new believer and found great comfort in her faith. She was excited to read her Bible with her family, pray, and go to church. She initially reported that she did not have anything to "say" to God about her abuse and that God loves her. Although she reported some spiritual struggles related to her faith, she indicated that her faith was largely a source of strength for her. As a result, she chose to incorporate her beliefs in the rest of therapy.

Psychoeducation. In the psychoeducation phase Natalya was not only educated on her diagnosis of PTSD, but also on the course of treatment and the manner in which her faith might be incorporated. She was educated on some ways in which her faith may be incorporated in a way that could help her cope with what had happened. The first author, Natalya's therapist, also normalized her experience drawing closer to God on one hand while also having spiritual struggles involving questioning why God "gave her to people who didn't love her."

Relaxation. Natalya greatly enjoyed the process of incorporating her faith into relaxation training. Natalya was first taught basic relaxation skills such as deep breathing and progressive muscle relaxation. As these skills were learned and practiced she was also able to incorporate faith practices with these exercises. For example, Natalya was taught to combine deep breathing with scripted prayer such as "God be with me." Additionally, she would often use worship songs as a way to help her relax before she would go to sleep.

Affective expression and modulation. Likewise, Natalya was able to draw on faith practices in the affective expression and modulation module. Building on her relaxation training, Natalya was well equipped to incorporate her faith practices in this module. For thought stopping Natalya would often quietly sing the words of one of her favorite worships songs to distract her from distressing thoughts. Natalya also memorized several verses of Scripture that were comforting to her in times of distress such as "I have told you these things, so that in me you may have peace. In this world you will have trouble. But take heart! I have overcome the world" (John 16:33, New International Version). Natalya was excited to continue adding to her repertoire of coping skills as treatment progressed and would often report finding a new worship song or Scripture that was comforting to her while she was dealing with what happened.

Cognitive coping and processing I. Teaching Natalya the cognitive triangle and self-talk was completed in a typical fashion through the use of stick figure drawings with thought bubbles. Natalya was able to quickly catch on to the process of changing thoughts to change feelings and behavior. Although it was easy for Natalya to play out confabulated scenarios on paper, she was reluctant to engage examples from her own life even related to basic behavior. For example, right before one session she had an argument with her adoptive mother and she yelled at her. She had difficulty processing that very personal example. In addition, this module was the first point in which Natalya began sharing some thoughts that she had related to God and her trauma. One example was "If God loves me why did He give me to so many people who didn't love me." Because this module comes so early in treatment, these thoughts that are potentially related to abuse are not cognitively processed until after the trauma narrative is complete. Therefore, Natalya was encouraged to keep a journal and write down those thoughts so that they could be processed later in treatment.

Trauma narrative. The first author spent an entire session preparing Natalya for the trauma narrative in addition to mentioning it several sessions before starting the process. It was very important to Natalya that she would feel that she had enough distance between her and her trauma by the end of each session so that she would be able to sleep that night. We also discussed moving her sessions to later in the evening at this point in treatment so that she could make sure to have completed all of her homework and dinner before she came to session. This way she would be able to do a non-stressful activity when she got home. Natalya was also very adamant that she pray before each session would start. Therefore, it was decided that Natalya would pray before we would begin discussing the trauma narrative and she would ask God to help her "be strong enough to talk about the bad things" and to help her to have "understanding" about what happened. Natalya also liked to end the trauma narrative portion of each session by listening to a worship song and we would often find a worship song with religious imagery in the music video to watch on YouTube.

In discussing Natalya's experiences, there were many spiritual struggles that arose for her. Natalya struggled with feeling "unwanted" and with why God would allow her to experience being "unwanted." Natalya also greatly struggled with wondering if her biological parents were in hell or if they were going to hell because they never talked about God. In addition, she worried about her biological brothers being taken care of and whether they knew about God. Natalya also wrestled with the concept of forgiveness because she felt like she kept "messing up" and she knew that God would always love her but in the back of her mind she was always afraid that God would turn away from her if she did not "shape up." These thoughts, in addition to others related to her experiences were very important for Natalya to discuss in cognitive processing.

After completing the trauma narrative the first author was able to have a session with Natalya's adoptive parents to share some of her experiences with them and to allow them the space to process their reactions. While they were aware of her basic history, she had not shared with them some of the more difficult stories such as watching her mother attempt to drown her brother. In the conjoint session with Natalya we proceeded much like we had during the creation of the trauma narrative and Natalya's parents were able to pray for her to start the session and Natalya was able to share some of her struggles with her parents. This experience helped to create a sense of bonding within the family. Natalya felt better able to talk with her parents about her struggles after seeing them receive her stories in such an encouraging way.

Cognitive coping and processing II. In this module, it was very important to take a collaborative approach when exploring her spiritual struggles. We were able to sign a release to speak with the pastor at Natalya and her adoptive family's church. This was helpful to provide a theological perspective on these struggles that was consistent with her beliefs and the theology of the church that she attended. With having this support Natalya was able to be pointed to Scripture and other Biblical truths that helped her process what she had been through. For example, Natalya was encouraged by learning about general and special revelation and the fact that people do not necessarily have to "go to church" to learn about God and that there are a lot of ways that God reveals Himself to people from His creation to His word. Therefore, she was able to come to peace with the fact that it was not a certainty that her parents were in hell and that only God really knows a person's soul. She was also able to process in session and pray to God for insight about why he allowed her to live with so many people that did not want her. For this, Natalya was able to find great comfort in the story of Job in the Old Testament who lost everything as a testament to God's sovereignty (unbeknown to him) and she was able to decide that God might have bigger plans for her than she could know.

In-vivo desensitization. Natalya had several "triggers" for PTSD symptoms. The primary trigger that impacted her functioning in her adoptive family, however, was anytime her attachment with her adopted brothers was threatened. The most traumatic experiences revolved around her brothers (i.e. watching her mother attempt to drown her brother, being taken to the orphanage and separated from them, and the day she found out they had been adopted). Understandably, when she can to live with the Hammonds, she became quickly attached to her adoptive brothers and was always trying to "take care" of them. As mentioned previously, she would wake up multiple times a night to "check" on them, she would attempt to "protect" them from discipline, and she injured someone who was playing with her brothers. The Hammonds were incredibly frustrated by this as they felt they could not function "normally" because of it. Therefore, we did several sessions of "family" practice where we would role-play one of her parents disciplining one of her brothers and we would practice her response to decrease her automatic defensiveness. In order to address the "checking" behavior at night, Natalya learned to replace the behavior with a quick prayer for her biological and adoptive brothers and when she felt the "urge" to check on them at night she would say a quick prayer for them instead. Natalya found comfort in the fact that even though she did not know where her biological brothers were, she could still pray for them. As she began engaging in this process she was able to eventually sleep through the night, especially if she prayed for her brothers before she went to bed because it helped to get her "worry about them out of my head."

Safety planning and future development. In regard to basic safety planning, the discussion had to be constructed very carefully as Natalya had the tendency to overreact when she felt something threatening was happening, such as with "protecting" her brothers. Therefore, we were concerned that she might use methods, such as calling 9-1-1 inappropriately. Her parents were very helpful in this discussion and we were able to come up with rules for the family related to different safety skills. For example, only using a weapon if someone were to come at her with a weapon and getting the attention of a "safe" adult if she felt her brothers were in danger. In collaboration with Natalya's pastor we were able to discuss the probability of spiritual struggles in the future, but we were also able to emphasize the fact that she now knew several important tools and had resources to be able to manage those. Likewise, her ability to use positive coping skills to manage future problems was emphasized.

Ultimately, Natalya left therapy a much different young woman than when she came in. While initially very angry and guarded, she became better able to share her experiences and to make meaning from them. Further, she was genuinely able to use her new found faith to help her cope with her experience. Moreover, while she experienced spiritual struggles while in the process of attempting to reconcile her faith and her traumatic experiences, she was ultimately thankful that she experienced those struggles right after becoming a Christian because she thought she could handle anything if God could help her through that. At post-treatment, she no longer met diagnostic criteria for PTSD. Natalya and the Hammond's were very thankful to have been able to address their common faith in therapy because they felt that the process helped them to grow closer as a family.

References

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating traumatic grief in children and adolescents. New York, NY: The Guilford Press.

Herszenhorn, D. & Eckholm, E. (2012). Putin signs a bill that bars U.S. adoptions, upending families. The New York Times. Retrieved from: http://www.nytimes.com/2012/12/28/world/europe/putin-to-sign-ban-on-us-adoptions-of-russian- children.html?pagewanted=all&_r=0

Lowry, J. (2000). Inside Russia's orphanages. The Magazine of the International Red Cross and Red Crescent Movement. Retrieved from: http://www.redcross.int/EN/mag/magazine2000_1/voyage_en.html

United States Department of State (2011). Pursuant to Section 104 of the Intercountry Adoption Act of 2000 (IAA) (Public Law 106-279), the U.S. Department of State submits the FY 2011 Annual Report on Intercountry Adoption. Retrieved from: http://adoption.state.gov/content/pdf/fy2011_annual_report.pdf

Walker, D. F., Reese, J. B., Hughes, J. P., & Troskie, M. J. (2010).Addressing religious and spiritual issues in trauma-focused cognitive behavior therapy with children and adolescents. Professional Psychology: Research and Practice, 41, 174-180.

Katherine J. Partridge and Donald F. Walker

Regent University

Authors

Katherine J. Partridge (M.A. in Clinical Psychology, Regent University) is a doctoral candidate and scholar assistant with Child Trauma Institue at Regent Univeristy. Her primary research and clinical interests include early childhood intervention, parenting, child trauma, and cultural adaptation of evidence-based parenting and trauma interventions.

Donald F. Walker, Ph.D., is an Assistant Professor and Director of the Child Trauma Institute at Regent University. His research interests include spiritual issues involved in recovery fom childhood abuse, spiritual interventions in child and adolescent psychotherapy, and interventions to address childhood trafficking.

Correspondence regarding this article should be addressed to David F. Walker, Ph. D., Regent University, 1000 Regent University Dr., Virginia Beach, VA 23464; dfwalker@regent.edu