4.0 Clinical Vignettes
4.1 Clinical Vignette - Laying Down the Structural Foundation
Imagine a 31 year-old unmarried female, currently living with her parents and suffering financial difficulty. She relates her presenting complaint to the clinician as follows: "I am miserable. My living situation is becoming totally unbearable. There is constant turmoil between my parents and I usually end up being put in the middle of it. I have so many troubles of my own that I can't deal with life. I don't handle stress well anyway, and I have plenty of that with school and my "toxic" family. I have no money and no income, and therefore no way of moving out. I'm in school trying to create a career that will fit with my physical capacity. I just can't seem to find a job I'm qualified for that doesn't involve lifting, prolonged standing, or prolonged sitting. I have pinched nerves in my lower back as well as spinal arthritis. I just feel completely overwhelmed because I have no escape from either school stress or turmoil at home. To top it off, I'm having some trouble with my relationship with God."
Where would a clinician begin? First, the clinician would perform psychometric assessment such as the Beck Depression Inventory (BDI), Suicidal Ideation Scale (SIS), Beck Anxiety Inventory (BAI), and Novaco Anger Scale NAS to establish a baseline current and future reference. For this patient, her scores for the BDI are in the clinical depression range and clinical anxiety range of the BAI.
Psychotherapeutic Objectives consisted in helping the patient accept that her cognitive interpretations of life events were actively triggering her emotional reactions. Furthermore, a series of interlocking scenarios were preventing her from considering other choices. Helping her restructuring her distorted perceptions could lead to more functional emotional reactions and realistic choices, which would likely establish functional behavior. Her treatment also included a program of bibliotherapy, focusing on the reading of D. Burns's Feeling Good.
As her treatment progressed, she began to note favorable changes in her perception and behavior as exemplified in the following quote: "Things on the home front are going okay for now: no major blow-ups. I'm still working on what to do about my financial situation, as well as the addressing with my past school transcripts."
The patient, being very religious, wanted her life centered on God. At the same time she was dealing with the previously discussed issues, she was troubled with her current relationship with God. Psychospiritual clinical interventions would provide her with the necessary steps to address this problem and she could begin using her spiritual commitment to enhance her Cognitive-behavioral treatment.
Clinically, one of my responses to her was: "I am happy about the lack of "blowups." As children of God, can decide to bring peace to those around us. One way is to make a conviction that no matter what anyone around us says or does, we say to ourselves: "I will not get angry." I reminded her of what St Seraphim of Sarov said: "Acquire the spirit of peace and a thousand souls will be saved around you, for this is truly the peace of Christ, which you can immediately bring into your family."
4.2 Clinical Vignette – Treatment Plan
- Rule out harm to self or others
- Complete all necessary assessments
- Obtain medical and psychiatric consultations as needed
- Establish therapeutic relationship
- Provide bibliotherapy
- Normalize treatment process
- Begin reading assignments
- Educate about psychospiritual issues
- Reduce negative symptoms
- Enhance spiritual meaning with self/family
- Strengthen relationship with God
- Explore dysfunctional passions
- Use Christian verses to challenge cognitive distortions
- Process cognitive distortions
- Strengthen sense of spiritual self
- Strengthen relationship with family
- Process psychospirutual connection with God
- Address and process spiritual meaning of life enjoyment
- Prepare for termination
- Model a healthy goodbye
- Explore and process feelings related to termination
- Extend visits as necessary
- Leave option open for future treatment
4.3 Clinical Vignette – Psychospiritual Focus
The patient made a profound statement typifying her challenge in the spiritual domain:
"Father, I'm having some trouble with my relationship with God. I'm mostly having trouble reconciling these three things: First, that God loves me, second, that Christ defeated the power of sin and death, and third, that we cannot know if we will be saved in the end. Despite all our best efforts to serve God, He may very well label me a goat and send me to hell at the Judgment."
Her struggle was deep and profound. We began addressing the fact that God loves her. I reminded her that Jesus revealed to us so much more about God: "God is Love" He said. The three persons of the blessed Trinity relate together in Love. Jesus came to this world to save sinners. He wants all to love God. He wants all to love each other as He has loved us. He is the Good Shepherd. He is the one who forgave the adulterous woman. He is the one who called the children to Him. He is the one who cured, healed and forgave sin. He is the one who gave us the parable of the Prodigal Son. I invited her to process the following: "If you think of it, it is only to the unrepentant hypocrites He chastises. Yet a repentant Pharisee: Joseph of Aramithea became a saint. Remember that he was one of the greatest Pharisees and persecutors of Christians. Saul became Paul, one of the greatest of all saints. I reminded her: "Be a spiritual child, strengthen your trust in God, and say the greatest prayer of all. Lord Jesus Christ, have mercy on me a sinner." Act as St. Gregory Palamas did when he trusted God, not in presumption of salvation, but in trust of a merciful Lord.
My psychospiritual interventions could be summarized in the teaching that Jesus gave to His Church and passed down to us from the Apostles and Church Fathers. We can summarize these as follows:
If we go to confession and sincerely confess our sins, desire not to sin again and then receive the prayer of absolution, we are guaranteed forgiveness and salvation. We are reminded of this in the prayer I invoke: "May Our Lord Jesus Christ forgive you your sins and transgressions, and I, an unworthy priest, absolve you from your sins in the name of the Father and of the Son and of the Holy Spirit." This is one of Christ's great gifts to His Church, one of the "pearls of great price." This is a great assurance to every Christian. Even if we remember immediately after confession and absolution a specific sin we forgot to mention, it does not matter to Jesus. He has forgiven us by the priest, His unworthy instrument. He honors His warranties to us!
There is no doubt that at times, God has been portrayed as an angry God. I remember in my school days a poem by Jonathan Edwards "Sinners in the Hands of an Angry God." Many church fathers have pointed out that our God revealed Himself to mankind in specific ways at different times. In the Old Testament, His wrath could be devastating, but even Lot could negotiate with God to find a single righteous man to assuage His anger. It can be said that in the early history of mankind when punishment was the main controller of behavior, God's anger could be mitigated by love and mercy.
Interwoven in the psychospiritual treatment were conventional Cognitive-Behavioral interventions, including thought stopping, picking a specific time to review thoughts and asking and reviewing other ways of "perceiving or looking" at them.
As a reminder of the work we did together, I asked this patient to consider the following in a letter I wrote:
Glory to Jesus Christ! I want to follow up on three more items you're your consideration. Yesterday, we talked about how to overcome your anxiety. Now, I would like you to consider how to be in Our Lord's bosom:
- We must be spiritual children with complete trust in God, just as a child has complete confidence in their parent. We have to give ourselves over to Our Lord in complete trust. "Truly, I say to you, unless you turn and become like children, you will never enter the kingdom of heaven. "Whoever humbles himself like this child, he is the greatest in the kingdom of heaven. (Mat 18)
- Our Father feed us. St. Luke in Chapter 12 (24-32) tells is what Our Lord said: "Consider the ravens: they neither sow nor reap, they have neither storehouse nor barn, and yet God feeds them. Of how much more valuable are you than the birds! And which of you, by being anxious, can add a cubit to his span of life? If then you are not able to do as small a thing as that, why are you anxious about the rest?
- Consider the lilies, how they grow; they neither toil nor spin; yet I tell you, even Solomon in all his glory was not arrayed like one of these. But if God so clothes the grass which is alive in the field today and tomorrow is thrown into the oven, how much more will he clothe you, O men of little faith!
- And do not seek what you are to eat and what you are to drink, nor be of anxious mind. For all the nations of the world seek these things; and your Father knows that you need them. Instead, seek his kingdom, and these things shall be yours as well. "Fear not, little flock, for it is your Father's good pleasure to give you the kingdom.
- How much is it the "Father's good pleasure to give us the kingdom of heaven?" Consider, the statement made by the "good thief" next to Jesus on the cross: just a simple acknowledgment of his unworthiness. He is the only person canonized a saint by Jesus Himself. Consider how little he said and Jesus' response to him: "Do you not fear God, since you are under the same sentence of condemnation? And we indeed justly; for we are receiving the due reward of our deeds; but this man has done nothing wrong." And the "good thief" said to Jesus: "Jesus, remember me when you come into your kingdom." And Jesus said to him, "Truly, I say to you, today you will be with me in Paradise." (Luke 23: 40-43).
So child-like spiritual trust and complete abandonment to God's will vanquishes anxiety, go in peace, faith, trust, hope and love.
In Christ, his unworthy priest,
In summary we can note that the believing Christian clinician need not be limited merely to scientifically supported treatment models. Our own surety in the vivifying power of God's grace coupled with the sincere faith, prayer and sacramental incorporation into the Body of Christ and His Church can be of great aid in healing of the patient suffering from dysfunctional emotions and family problems. (Morelli, 1987, 1988, 1997; Muse, 1997) It should be noted that the scientific community has recently become more receptive to the healing potential of faith systems (e.g. Benson, 1975). In DSM IV this is listed under "Ethnic and Cultural Considerations". Clinicians are instructed to consider "belief, or experience that are particular to the individual's culture" in diagnosis and treatment. This allows non-Christian clinicians to use their patient's conviction system both for understanding and treatment. More importantly, it allows the Christian clinician to actively incorporate the patient's spirituality in the healing process. The patient's knowledge that his or her clinician shares his or her spiritual orientation as well as a willingness to use prayer can be a powerful therapeutic tool.
In one clinical situation, right before ending a therapy session with one patient, I said: "G, please pray for me." He said to me "Father, I have never had a priest ask me to pray for him before. Why do you need prayer?" I replied: "G, all of us are in need of God's help. We are all struggling with our own problems and need salvation." He frequently made reference to this exchange in subsequent sessions. Apparently, it helped him focus even more on the spiritual dimension of treatment.
Beginning in 1994, DSM IV, (APA, 1994) has adopted a code for the treatment of spiritual and religious problems. As clinicians, learn about the laws of neuropsychological and emotional functioning through continuing scientific research, the Christian clinician can view this as fulfilling the charge God gave when He created us in His image. He gave us the responsibility to use our intellect to have dominion over the world, (Gen 1:28). In this way, body, mind and spirit as a unit are used to become closer toward God. (St. Maximus the Confessor).
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V. Rev. Fr. George Morelli Ph.D. is a licensed Clinical Psychologist and Marriage and Family Therapist.
Fr. Morelli is the Coordinator of the Chaplaincy and Pastoral Counseling Ministry of the Antiochian Orthodox Christian Archdiocese and Religion Coordinator (and Antiochian Archdiocesan Liaison) of the Orthodox Christian Association of Medicine, Psychology and Religion.
Fr. Morelli is a Senior Fellow at the Sophia Institute, an independent Orthodox Advanced Research Association and Philanthropic Foundation housed at Columbia University and Union Theological Seminary in New York City that serves as a gathering force for contemporary Orthodox scholars, theologians, spiritual teachers, and ethicists.
Fr. Morelli serves on the Executive Board of the San Diego Cognitive Behavior Therapy Consortium (SDCBTC)
Fr. Morelli serves as Assistant Pastor of St. George's Antiochian Orthodox Church, San Diego, California.
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