Future directions for the study and application of religion, spirituality, and trauma research.

Walker, Donald F. ; Aten, Jamie D.

A year ago at the international meeting of the Christian Association for Psychological Studies, I (Walker) stood in a symposium being chaired by Aten and asked if the church was really ready to respond to issues of child abuse, domestic violence, and in supporting survivors of wars or disasters. A year later, not much has changed with respect to the current state of research, training, and practice in religion, spirituality, and trauma among Christian practitioners. However, seeing the work that has been done in this special issue gives us cause for hope. In concluding the special issue, we topically review the issues that were raised by authors throughout this volume, and present our reflections on the state of research and practice in each area, with some suggestions for future research, training, and practice. In doing so, we will discuss child abuse prevention and treatment, intimate partner violence, responding to survivors of natural disasters, and integrative approaches to trauma treatment.

Child Abuse Prevention and Treatment

In presenting their call for more effective prevention and treatment of child abuse in the church, Vieth and his colleagues highlight several important issues for the Christian community to consider. First, Vieth provided a number of practical suggestions for preventing child abuse in churches and Christian organizations. We appreciate the thoughtfulness and practical nature of these policies, but question the degree to which they are currently being implemented in churches around the country. As practitioners who have treated courageous survivors of child abuse, we cannot emphasize enough the urgency with which we undertake the call to help churches prevent the abuse of children in their care. Collaboration with churches in implementing the protection policies that Vieth recommends is sorely needed. Along with that, as Vieth suggested in his article, training for clergy in responding to survivors of abuse is also needed. We are encouraged by Vieth's development of the When Faith Hurts Curriculum, and look forward to seeing its dissemination among clergy.

As psychotherapists, we also highlight the need for Christian counseling and psychotherapy training programs to comprehensively consider child abuse treatment in their training, both in the curriculum and in providing opportunities to receive clinical supervision of treatment with survivors. One of us (Walker) directs the Child Trauma Institute in the PsyD program at Regent University. The Child Trauma Institute (CTI) aims to become an exemplar for research, training, and practice in this area. Students in the PsyD program at Regent have an opportunity to take a course entitled the Psychology of Trauma and Crisis, during which they receive training in Trauma-Focused Cognitive Behavior Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006) as well as Spiritually Oriented Trauma Focused Cognitive Behavior Therapy (SO-TF-CBT; Walker, Reese, Hughes, & Troskie, 2010). As part of the course, students are also taught to assess and comprehensively treat complex trauma among children and adults using evidence based, best practice assessment and treatment methods (e.g., Courtois & Ford, 2009). In addition to learning other treatments for adults, students are also taught Eliana Gil's play therapy methods for treating abuse (Gil, 2006). A primary emphasis in the course is on reading, then seeing therapeutic models of the various approaches, followed by opportunities for practice in the form of role-plays. Students participating in the Child Trauma Institute also have the chance to participate in clinical trials of SO-TF-CBT and, as a result, to receive clinical supervision of child abuse cases. To date, no research has been conducted on the comprehensiveness of training for child abuse and other forms of trauma among Christian counseling and psychology programs. However, we suspect that training may he lagging behind our secular counterparts in this area among most programs. Research is also sorely needed demonstrating the efficacy of explicitly spiritually integrative forms of treatment for child abuse.

Intimate Partner Violence

None of the empirical research presented in the special issue focused on this issue, which is telling in itself The topic of intimate partner violence in churches is taboo, and few mental health professionals or clergy are prepared to comprehensively address religious and spiritual issues of WV from either the perspective of perpetrators or survivors. Many of the suggestions for applying the law and gospel to perpetrators and survivors of abuse in Vieth's article in this issue also apply to survivors of IPV. However, we are struck by the fact that we are unaware of any substantive, systematic research being done concerning religion and IPV at any of the APA-accredited or CACREP accredited Christian doctoral programs that we are familiar with.

One of us (Walker) has a doctoral student who presented a comprehensive review of religious issues involving IPV at the American Psychological Association this past summer. Stephens and Walker (2012) reviewed 59 studies with a total of 28,376 participants. Among the key findings from Stephens and Walker's review are the following: 1) women frequently receive mixed messages from clergy regarding how to respond to abuse in their marriage, 2) clergy typically receive little training in responding to IPV, and 3) women often receive advice from clergy to remain in abusive marriages because it is their Biblical duty to do so. In considering these findings, it is clear that several issues need to be addressed in church communities. First, survivors of IPV need to receive the clear message that physical abuse is not Biblically justified nor is it a part of a loving Christian marriage. Second, research is needed to better understand the ways in which clergy understand IPV as a theological issue and the thought processes involved in applying Scripture in responding to survivors of abuse. Third, Christian mental health professionals need to collaborate with clergy in developing counseling ministries to serve both survivors and perpetrators of abuse. In developing such ministries, it should also be noted that Stephens and Walker found far fewer research studies in which perpetrators of IPV were the main subjects of the study in the set of studies that they reviewed. The church needs to better under stand the religious thinking behind acts of abuse committed by male congregants against their wives and to actively confront that thinking as being in direct conflict with the Biblical mandates to love one's wife as Christ loves the church (Eph. 5:25), to love one's wife as one loves their own body (Eph. 5:28), and to love one's neighbor as oneself (Matt. 22:39).

Responding to Survivors of Disasters

The impact of disasters can be far reaching, from individuals and families to entire communities and nations, as evidenced by the article and work of Leavell and colleagues on clergy coping following Hurricane Katrina. Disasters over the last decade have brought a considerable amount of attention to the role of clergy and congregations following disasters. As highlighted in the Leavell article, many victims of disaster seek out help and care from clergy. However, this article reminds us of the importance of understanding how faith can help or hinder coping among disaster caregivers. The shared lived experiences captured in this study also provide glimpses into research and practice issues that warrant further study. For example, in the last 25 years there have been several studies that suggest that religion and spirituality can help buffer negative psychological, physical, and spiritual health outcomes. However, in most cases that make up this current body of literature, most have come about a priori. That is, several studies were underway prior to a disaster so they lacked sophisticated measures of the disaster or disaster consequences and just catch a "glimpse" to how catastrophe had affected their participants. Or there have been studies that are more sophisticated in their approach to studying the disaster or disaster consequences itself, but were lacking in terms of religious or spiritual measurement.

However, because of the scope and prolonged recovery timeline of 9/11 terrorist attacks and Hurricane Katrina, a few researchers have been able to include more in depth studies that delve deeper into both the impact and religious phenomena of disasters. Thus, current findings would seem to suggest that it is not if or how religious a person is that determines post-disaster outcomes, but rather how one utilizes religion. For example, imagine two people going through a similar disaster and have similar religious background and levels of religiosity. However, the first survivor views that God was "out to get them" and the second survivor views God was "on my side through it all". The second survivor, who practiced more adaptive religious coping practices, will likely fair better than the first survivor.

Overall, we need more collaborative research, or researchers, that are capable of bringing together the best of disaster mental health and psychology of religion researchers if we are going to more fully capture the complexity of psychology of religion and disaster phenomena. We also need more longitudinal research so that we can better map the path of how religion and spirituality either helps or hinders recovery. Additional community-based research is also needed that will help leverage the infrastructure and capacity of congregations and other faith-based organizations to better prepare, respond, and recover from disasters. Research has already demonstrated that a significant percentage of disaster survivors turn to faith, faith leaders, and faith communities in times of disasters. Additional research that will help inform the ways in which mental health providers collaborate with clergy in times of disasters, as well as tools and resources to enhance clinical and community psychology interventions which focus on disaster spiritual and emotional care is also warranted.

Training Recommendations

In our view, Christian training programs have two broad considerations in preparing student therapists to work with trauma. On one hand, students should be prepared to utilize secular best practice models for treating trauma and should apply those models. Examples of best practice, evidence-based treatments include TF-CBT (Cohen, Mannarino, & Deblinger, 2006) for child abuse, Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2008; Resick & Schnicke, 1993) for intimate partner violence and combat related trauma, Psychological First Aid (e.g., Brymer et al., 2006) for first responders in combat situations and in global contexts after wars and natural disasters, and modified approaches for complex forms of trauma (e.g., Courtois & Ford, 2009). At a minimum, students in Christian psychology and counseling programs that are preparing students to work with trauma need to be taught these treatment models.

In addition to being prepared to use secular best practice models, student therapists should also be trained how to competently address religious and spiritual issues and to utilize spiritual interventions within the context of these and other trauma models. In training Christian therapists to treat trauma, training programs need to consider multiple competing tensions. Some students will work in secular settings, others will work in explicitly Christian ones, and some professionals will eventually work in both treatment settings. Preparation for both types of practice setting requires related but slightly different skill sets.

In conducting integrative trauma treatment, practitioners are left with multiple competing models for treatment. Psychotherapists might choose to (1) use secular models for spiritual goals, (2) use secular evidence based practices and incorporate spiritual content, or (3) use spiritual practices for treatment of trauma and other presenting problems (Aten, McMinn, & Worthington, 2011). The guest editors' approaches to integration in trauma treatment have both varied depending on the setting in which we have practiced. One of us (Walker) prefers to use secular evidence based models as a starting point and to adapt those models to incorporate spiritual content. Our initial work in Spiritually-Oriented TF-CBT represents an exemplar model for efforts in this area (Walker, Quagliana, Wilkinson, & Frederick, in press; Walker, Reese, Hughes, & Troskie, 2010). My (Walker) rationale for beginning with secular, evidence based models is a pragmatic one. Students working in secular settings are taught to begin with a model that most of their non-religious supervisors will be familiar with, and are then given a language for addressing religious and spiritual issues as a diversity variable. In secular settings, I have found that this often reduces supervisor concerns about considering religion and spirituality in case conceptualization and treatment. Conversely, in Christian practice settings, I have found that clinic owners are typically happy to be utilizing evidence-based treatments on the grounds that many Christian therapists are not trained in such treatments.

However, other Christian approaches to treating trauma have begun with developing spiritual interventions as a foundation, independent of secular treatment models. For example, I (Aten) am collaborating with the American Bible Society's She's My Sister program which is an example of this approach. The mission of this program is to engage gender-based violence survivors in the Democratic Republic of the Congo with Scripture and healing practices through local churches. This program's missions are being accomplished by equipping church leaders in a paraprofessional community-based group intervention accomplish these goals. This program has "grassroots" origins, has evolved out of shared community experiences, and is grounded in Christian scriptures and teachings. These Bible-based practices and teachings later evolved into a book (Hill, Bagge, & Hill, 2004), and then a more formalized treatment intervention. In contrast to the approach outlined above, it was the community's leading and religious foundations that came first. Then, groups of professionals were gathered together to form a trauma advisory board to evaluate the intervention and to strengthen the psychological processes. The intervention is currently undergoing piloting and evaluation.

Christian therapists should have adequate knowledge, awareness, and skills related to trauma. This can be done in several ways. One approach is to take steps to ensure faith and trauma are discussed and incorporated when applicable across the curriculum. This should also include clinical and practicum training, and should be explored through consultation and clinical supervision. More informal approaches outside the classroom for introducing students to issues of faith and trauma, include advising, mentoring, modeling, and research labs or projects. Other possible options might be to consider developing a certificate or specialization within training programs, as well as postgraduate certificate offerings. Professional organizations also represent great potential, and readers are encouraged to consider presenting on religion and spirituality topics focused on trauma at meetings. Likewise, specialty tracks and working groups could be formed which focus on religion, spirituality, and trauma.

Reseach Recommendations

In this section, we provide a series of general recommendations for advancing integrative research that focuses on religion, spirituality, and trauma. For one, there is a need for greater clarity and consistency of religious, spiritual, and trauma taxonomies. Though there has been a great deal written about all three constructs, there is still opportunity for greater agreement among researchers and practioners alike. The majority of this conversation has taken place outside of the trauma context, and that which has is often lacking a strong psychology of religion underpinning. Overall, there is a need for more: (a) consistency across definitions, (b) recognition of the nuances of various traumas, (c) cultural contexts of study, (d) international perspectives on trauma, (e) community-based definitions of faith and trauma, (f) clear definitions of spiritual trauma, and (g) research on post-traumatic growth and post-traumatic spiritual growth.

Future efforts should also focus on developing more sophisticated measurement and research design. For example, more sophisticated clinical assessments are needed that account for spiritual facets of trauma. The measures also need to be more inclusive of diverse clients, communities, and faith traditions. Similarly, work needs to be done to foster more developmental and age appropriate measures. As more Christian mental health professionals engage in international work, so does the need for internationally normed and standardized measures of religion, spirituality, and trauma. Measures are also needed that will capture phenomena that appear to link faith and trauma, such as resilience. Again, this is needed at both the individual level and community level of understanding. Furthermore, greater diversity of study design is needed, including more: (a) clinical trial, (b) qualitative, (c) mixed method, (d) comparative, (e) epidemiological, (1) moderating and mediating modeling, and (g) longitudinal studies.

It is recommended that more be done to bridge the present "gap" between research and practice, as well as between religion/spirituality and traumatology. This means we need researchers thinking more about clinical applications and we need clinicians thinking more about research applications. We also need researchers and clinicians to come together in dialogue. Possible goals for these collaborations might focus on topics such as integrative best practices and identification of core competencies. Ideally, we would begin to see more research being used to inform and guide practice, as well as lessons learned in practice being shared to inform and guide future research on religion, spirituality, and trauma.

Christian accommodative trauma therapies and practices also warrant greater attention. There is a need for more solid clinical trial studies of Christian approaches to treating trauma, particularly in the areas that we have highlighted--child abuse treatment, treatment for intimate partner violence, both domestically in the United States and in international settings.

Many readers may be thinking to themselves, "but I don't have the resources" or "I don't have access to the right clientele." That is where the above comes into play. If researchers and practioners are collaborating, then such research becomes more feasible and sustainable. Other related foci should include investigation into what spiritual disciplines are most advantageous for use with trauma clients. On the whole, more applied research is called for with individual, couples, groups, psychoeducation, and community samples. We also need to recognize that traditional psychotherapy models may not be best suited for some populations, such as in a community shortly after a large scale disaster or in an international settings where there may be limited (if any) professional mental health professionals. Therefore, we also need to explore Christian trauma interventions, including: (a) lay counseling, (b) peer support, (c) prevention, and (d) church-based interventions.

The "roadmap" above will be challenging if we are not preparing future and current Christian mental health professionals. Therefore, as a field, we need to take steps to properly prepare students as well as seasoned therapists to integrate religion and spirituality into trauma focused practice. Statistically, a majority of clients that will find their way to psychotherapists' offices will have experienced some form of trauma over the course of their lives. Yet, most students receive very little training in treating trauma survivors in Christian psychology training programs, and there appear to be even fewer Christian-focused trauma continuing education opportunities available to those already in the field.

Conclusion

In concluding this special issue, we are struck by the Biblical story of Job and the suffering that he experienced. As Christian mental health professionals, it is our goal to become wise counselors who avoid simple platitudes in the face of profound pain. In responding to Job, at one point the Lord asked Job if he knew the way to the abode of light, and where darkness resided (Job 38:19). We are reminded that the mysteries of the world belong to God alone, including the mystery of trauma and suffering. We look forward to the day when "Every valley shall be raised up, every mountain and hill made low; the rough ground shall become level, the rugged places a plain" (Isaiah 40:4, NW). Until that day, we are encouraged by the growing number of Christian professionals across the disciplines of counseling and psychotherapy, divinity, and law, who are taking up the call to carry the cross of Christ with survivors of traumatic experiences.

References

Aten, J., McMinn, M., & Worthington, E. L., Jr. (2011) (Eds.). Spiritual interventions for counseling and psychotherapy. Washington, DC: American Psychological Association.

Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P. (National Child Traumatic Stress Network and National Center for PTSD). (2006). Psychological First

Aid Field Operations Manual (2nd ed.). Available on: www.nctsn.org, and www.ncptsd.va.org.

Cohen, J., Mannarino, T., & Deblinger, F. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press.

Courtois, C., & Ford, J. (2009). (Eds.). Treating complex traumatic stress disorders. New York: Guilford Press.

Gil, E. (2006). Helping abused and traumatized children: Integrating directive and nondirective approaches. New York: Guilford Press.

Hill, H., Bagge, R., & Hill, P. (2004). Healing the wounds of trauma: How the church can help. Paulines Publications: Africa.

Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park CA: Sage Publications.

Resick, P. A., Monson, C. M., & Chard, K. M. (2008). Cognitive processing therapy veteran/military version: Therapists manual. Boston, MA: VA Boston healthcare system.

Stephens, R., & Walker, D. F. (2012). Religion-related intimate partner violence: A comprehensive review Paper presented at the 120th annual convention of the American Psychological Association, Orlando, FL.

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.

Walker, D. F., Quagliana, H., Yother, M., & Frederick, D. (in press). Christian accommodative trauma-focused cognitive behavioral therapy for children and adolescents. In J. Aten, E. Johnson, E. L. Worthington, Jr & J. Hook (Eds.), Evidence-based practicesfir Christian counseling and psychotherapy. Downers Grove, IL: Intervarsity Press.

Author Information

WALKER, DONALD E. PhD. Email: dfwalker@regent.edu. Title: Director, Child Trauma Institute, and Assistant Professor, Regent University. Degrees: PhD in clinical psychology--Graduate School of Psychology, Fuller Theological Seminary. Specializations: spiritually-oriented approaches to child abuse treatment, spiritual interventions in child and adolescent psychotherapy.

ATEN, JAMIE D. PhD. Address: Department of Psychology, Wheaton College, 501 College Avenure, Wheaton, IL 60187-5593. Email: Jamie.aten@wheaton.edu. Tide: Founder and Co-Director of the Humanitarian Disaster Institute and Dr. Arthur P. Rech and Mrs. Jean May Rech Associate Professor of Psychology at Wheaton College (Wheaton, IL). Degrees: PhD (Counseling Psychology) Fuller Theological Seminary; M.S., Counseling Psychology) Indiana State. Specializations: psychology of religion and disasters, disaster spiritual and emotional care, and faith-based relief and development.