Psychological Trauma: The Need for a Pastoral Response

Andrew J. Weaver, M.Th., Ph.D.
Director of Research
HealthCare Chaplaincy
New York, New York

Walter J. Smith, S.J., Ph.D.,
President and Chief Executive Officer
HealthCare Chaplaincy
New York, New York

David B. Larson, M.D., M.S.P.H.
President
National Institute for Healthcare Research
Rockville, Maryland

Traumatic events shatter the sense of connection between individual and community, creating a crisis of faith.

Judith Lewis Herman, Trauma and Recovery

It was midday when 25-year-old Patricia was brought unconscious to the emergency room. She, her husband, and their 15-month-old son had just come home from a summer vacation. Larry, her husband, was an officer at the nearby Air Force Base. When they returned to their apartment, Patricia decided to go out to get some groceries. She went alone in the family car while Larry stayed home with the baby. In order to get to the store, she had to get on the highway and travel two exits. As she left the on-ramp, her car was struck on the left side by an oil delivery truck.

From the accident site, Patricia was taken unconscious to the nearest emergency room. The hospital chaplain met Larry while he was still in the reception area. The young officer had been raised as a Southern Baptist in rural Texas, but had not been involved in religion since his youth. Nevertheless, he was receptive to the chaplain’s interest in him and his wife.

The hospital chaplain had been alerted at the time of Patricia’s admission and was in the treatment area when her condition was assessed. This was very comforting to Larry and helped to establish a relationship between him and the chaplain. "I’m sure everything’s going to be all right with Patricia because you were there to say some prayers for her. God is going to listen to you."

The neurosurgeon was not very communicative. His responses to Larry’s insistent questions were guarded, and it was clear that his judgments about Patricia’s condition were not optimistic. Should she ever regain consciousness, it would be impossible to predict the extent of her brain damage. Larry harbored hostile feelings toward the surgeon and was quick to ventilate them to his trusted confidant. The chaplain listened to the young husband as he described his frustrations with the hospital staff. "She’s going to get better, despite what the doctor keeps saying."

"We got married even though our families objected. Patricia was pregnant and we decided to marry, although we had intended to do so even before we knew about the baby. Her family did not come to the wedding, except one of her sisters. This really hurt both of us. We haven’t been very religious, though we both believe in God. Do you think God is punishing us for our lives?"

Patricia’s condition did not improve. Nonetheless, Larry kept his hopes alive, frequently entering her cubicle in the ICU, holding her hand and through his tears telling her how much he loved her, needed her, and wanted her to wake up and get better. Larry clung to the hope for a miracle.

At eleven o’clock on the sixteenth day of her hospitalization, Patricia died. Larry was not at the hospital, but was telephoned and asked to return. The chaplain was with Patricia when she died and remained at the bedside until her husband arrived. When Larry entered the unit, he bent down and embraced the body of his wife, kissing her and sobbing deeply. After a few moments of silent embrace, he looked up at the chaplain and threw his arms around his neck and wept.

For weeks after the funeral service, the grieving man could not work and spent most of his time detached and withdrawn. Larry was plagued with insomnia and disturbing nightmares about his wife’s accident. He had outbursts of rage, and could not concentrate. Prior to the accident he was active and upbeat; now he had lost interest in all activities. He constantly blamed himself for his wife’s death and took little comfort in family or friends. Larry has experienced a severe psychological trauma, which is developing into post-traumatic stress disorder (PTSD).

Chaplains and community-based clergy need the skills to recognize and assist those who come to them for counsel in the aftermath of traumatic events. Many of these persons may be suffering what mental health professionals have identified as PTSD. The word "trauma" comes from a Greek root meaning "wound." In much the same way that a physical blow may wound the body, bringing disability and pain, a psychological trauma can overwhelm the thoughts and feelings of a person and bring sustained suffering.

Graphic accounts of the effects of extreme stress on human beings have been documented in literature since Homer's Odyssey and Samuel Pepys' diary of the disastrous London fire of 1666 (Daly, 1983). In the nineteenth century, Freud recognized the effects of psychological trauma in childhood, but it was only in the wake of the devastating wars of the twentieth century, particularly the return of Vietnam war veterans to the United States, that a scientific model was developed to understand the symptoms that result from extreme stress (Van der Kolk, 1987). Recently, the PTSD model for understanding psychological trauma has been applied to understand reactions to catastrophic accidents, natural disasters, and criminal victimization (Herman, 1992).

Post-traumatic stress disorder is a normal reaction to an abnormally stressful situation (Lifton, 1988). PTSD is not a sign of being "emotionally weak" or mentally ill. Those exposed to the shock effect of extreme stress will find their ordinary coping processes overwhelmed. PTSD is diagnosed when an experience occurs involving actual or threatened death or serious injury or a threat to the physical well-being of self or others if the response is one of intense fear, helplessness, or horror (APA, 1994). The traumatic event is re-experienced in specific ways, such as recurrent and intrusive distressing recollections or dreams of it. Additionally, a person often persistently avoids situations associated with the trauma and has general emotional numbness. Hypervigilance and irritability also may be experienced. PTSD becomes the diagnosis when these symptoms persist for more than a month and create significant impairment in a person's functioning.

MANY SUFFER FROM PSYCHOLOGICAL TRAUMA

PTSD represents a significant public health concern and warrants attention. Research has found that about 60.7% of men and 51.2% of women have at least one traumatic experience in their lifetime, while about 8% of Americans develop PTSD as a consequence of these experiences (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). According to the National Center for PTSD, every year as many as 17 million people in North America survive or provide rescue or relief services following a disaster such as an earthquake, flood, hurricane, tornado, wildfire, chemical explosion, toxic spill, riot, mass killing, or terrorist act. In addition, in any given year one in 100 Americans will be injured in a motor vehicle accident and about 9% of these will develop PTSD (Blanchard, & Hicking, 1997).

In the United States it is estimated that there are 450,000 trained emergency medical workers, 100,000 pre-hospital life-support personnel, 75,000 emergency nurses, and thousands of volunteers from the Red Cross and other agencies that respond to people in crisis situations (McCammon, & Murphy, 1995). These people can experience frequent, repetitive, and cumulative exposure to trauma and high levels of extreme stress. Emergency medical personnel who work with the traumatized indicate they have significant rates of religious belief and practice (Backus, Backus, & Page, 1995).

Churches and synagogues have many veterans who are suffering from psychological trauma. Among those from the Vietnam-era, a study found that 15.2% of the men and 8.5% of the women who served there suffer from PTSD fifteen or more years after military service (Schlenger et al., 1992). It is estimated that 830,000 Vietnam veterans (49%) "still experience clinically significant distress and disability from the symptoms of PTSD" (Weiss et al., 1992, p. 365). In addition, almost 25% of American men aged 65 or older served in combat in the Second World War or Korea (Spiro, Schnurr, & Aldwin, 1993) and many of these continue to suffer from the experience, especially those who were prisoners of war (Sutker, & Allain, 1996).

Unfortunately, high numbers of young Americans suffer from PTSD, since exposure to violence among teens in the U.S. is near epidemic levels. The rate of violent victimization for all those 12 to 19 years-of-age is twice that of adults over the age of 25 (Bureau of Justice Statistics, 1993). Adolescent males from large urban areas are at the highest risk of victimization and of witnessing such savagery as stabbing and shootings. In a study of adolescents and young adults (aged 14-23) in Detroit, Michigan, 42% had seen someone shot or knifed, 22% had seen a homicide, and 9% had seen more than one person killed (Shubiner, Scott, & Tzelepis, 1993). A national study of more than 11,000 eighth and tenth graders found a high exposure to violence. A full third of the students had been threatened with bodily harm, while 15% had been robbed, and 16% had been attacked in their neighborhoods. School offered little safety according to this study -- 34% of the students had been threatened and 13% had been physically attacked at school during the preceding year (American School Health Association, 1989). It is not surprising that in a random sample of adolescents, aged 16 through 19, in Detroit, Michigan, it was discovered that 4 of 10 had been exposed to a traumatic event that qualified as a PTSD stressor. The rate of PTSD in this group of urban young adults was almost one in four (Breslau, Davis, Andreski, & Peterson, 1991).

Between 1975 and 1987 alone, an estimated 700,000 refugees from Southeast Asia settled in the United States (Mollica, Wyshak, & Lavelle, 1987). Many refugees that immigrate to North America and Europe have suffered maltreatment and torture (Mollica, 2000). Researchers have documented that approximately one-half of the refugees coming to the United States from war-torn areas of Central America, Central Europe, Africa and Southeast Asia, groups with which many religious communities have become actively involved (Hopkins, 1990), are suffering PTSD (Cervantes, de Synder, & Padella, 1989; Fox, & Tang, 2000).

Children also suffer from psychological trauma and can have the full constellation of PTSD symptoms. Youngsters, and as a result their family members, often experience psychological trauma when a child is seriously injured (Boyer, Knolls, Kafkalas, Tollen, & Swartz, 2000). PTSD is also common among children who are abused or neglected (Duber, & Motta, 1999) or who are put in grave danger (Garbarino, Kostelny, & Dubrow, 1991; La Greca, Silverman, Vernberg, & Prinstein, 1996). They can have much the same set of PTSD symptoms as adults, although expressed in somewhat different ways (Terr, 1992).

USING FAITH TO COPE

Religious belief and practice are traditional ways through which many develop personal values and their beliefs about meaning and purpose. With psychological trauma, an individual's sense of order and continuity of life is shattered. Questions of meaning and purpose emerge as a person experiences a loss of control over his or her destiny. Religious faith is a primary coping strategy for many suffering from psychological trauma (Weaver, Koenig, & Ochberg, 1996).

A recent study (Astin, Lawrence, & Foy, 1993) found evidence suggesting that religiously committed women who are battered suffer less severe PTSD symptoms than those without such commitment and that religious involvement of a couple reduces the risk of domestic violence (Ellison, Bartkowski, & Anderson, 1999). This finding is consistent with research related to combat veterans which discovered that those experiencing psychiatric problems or PTSD attend religious services less frequently than those not experiencing them (Watson, Kucala, Manifold, Juba, & Vassar, 1988).

Weinrich and colleagues (1990) studied the effects of stress in the wake of the terror and destruction caused by a class IV hurricane (Hugo) in South Carolina on 61 nursing students and 10 faculty involved in disaster relief. After three weeks of work, three-quarters of those examined reported that religion was a primary positive coping strategy. In a separate study, researchers investigated religious coping methods used by 225 individuals who experienced the devastating impact of a major midwestern flood. Frequent prayer and worship attendance were associated with better mental health (Smith, Pargament, Brant, & Oliver, 2000).

In addition to offering the social support of community, nurturing religion provides a healing means of addressing a traumatic experience. Faith can facilitate faster and more effective recovery (Pargament, 1997). In a long-term study of 124 parents who lost a child to sudden infant death syndrome, McIntosh, Silver and Wortman (1993) found that greater religious participation was related to increased emotional support by others and increased meaning found in the loss. This is no small finding, given the high level of trauma that follows the sudden death of a child. Religion appeared to provide for these parents an effective means to make sense of the loss that enhanced well-being, lowered distress, and facilitated recovery.

In a well-designed study of persons grieving the death of a family member or very close friend, it was discovered that there is a strong link between the ability to make sense of the loss through religious belief and practice and positive psychological adjustment (Davis, Nolen-Hocksema, & Larson, 1998). In a third investigation, fathers of children being treated for cancer in a hospital clinic were asked about various methods of coping. Among 29 different strategies used, prayer was both the most common and most helpful for the fathers (Cayse, 1994).

SEEKING CLERGY COUNSEL

Clergy, vowed religious, and healthcare chaplains and are in an ideal position to recognize and assist those suffering from psychological trauma (Weaver, 1995). There are 353,000 Christian and Jewish clergy serving congregations in the United States (4,000 rabbis; 49,000 Catholic priests; and 300,000 Protestant ministers, according to the U.S. Department of Labor, 1998). In addition there are 92,107 sisters and 6,578 brothers in religious orders nationwide (Stark, & Finke, 2000). These are among the most trusted professionals in society (Gallup, & Lindsay, 1999). They are often in long-term relationships with individuals and their families, providing ongoing contacts in which they can observe changes in behavior that can assist in the assessment and treating of PTSD. Surveys by the National Institute of Mental Health found that clergy are more likely than psychologists and psychiatrists combined to have a person with a mental health diagnosis see them for assistance (Hohmann, & Larson, 1993). It should be noted that more than 10,000 of these clergy serve as professional healthcare chaplains working closely with medical professionals (VandeCreek, & Burton, 2001).

Ethnic minority persons are more likely to receive pastoral assistance in times of crisis and psychological trauma than European-Americans. In 1986, Mollica and colleagues found that African-American pastors were much more likely to go into the community and seek out people in crisis than their non-African-American colleagues. Researchers at Yale Unversity discovered that 94 of 99 urban churches in Connecticut offered community outreach programs for those in need (Williams, Griffins, Young, Collins, & Dobson, 1999). Most offered services to persons who suffer from conditions that place them at risk for PTSD, including homelessness, hunger, substance abuse, child abuse, domestic violence, AIDS, and imprisonment. Similarly, Mexican-Americans are more than twice as likely to seek help with personal problems from clergy than from psychologists and psychiatrists combined (Chalfant et al., 1990). In fact, that study found that the degree of identification with Mexican ethnicity was strongly related to seeking pastoral help as a primary resource.

Clergy are most often called upon in crisis situations associated with grief, depression or trauma reactions, such as personal illness or injury, death of a spouse or close family member, divorce or marital separation, serious change in the health of a family member, death of a close friend (Fairchild, 1980; Smith, 1985; Weaver, Preston, & Jerome, 1999). People in "crisis" involving the "death of someone close" reported almost five times more likelihood of seeking the aid of a clergyperson (54%) than all other mental health sources combined (11%) (Veroff, Kulka, & Douvan, 1981). Further highlighting the prominent role that clergy play in community mental health, the U.S. Surgeon General’s 2000 Report on Mental Health found that each year one in six adults and one in five children obtain mental health services either from a health care provider, the clergy, a social services agency, or a school (Satcher, 2000).

Both pastoral care and mental health publications have found that clergy respond with pastoral care and counsel to persons exposed to a wide range of extreme stressors (Dykstra, 1990). They document responses to natural disasters such as floods (Smith et al., 2000) and tornadoes (Chinnici, 1985), catastrophic accidents (Black, 1987), child abuse (Weaver, 1992), elder abuse (Weaver, & Koenig, 1997), and human-created disasters including death camps (Cohen, 1989), war (Zimmerman, & Weber, 2000) and torture (Lernoux, 1980; Daries, 1990).

Researchers have found that 1 in 5 adults (700,000 survivors) who are victimized in a violent crime (e.g., rape, robbery, assault) seek the counsel of a clergyperson (Norris, Kaniasty, & Scheer, 1990). This is the same number who seek help from all categories of mental health professionals combined or a medical doctor (Norris et al., 1990). It is also estimated that 1.8 million women are physically abused each year by husbands or intimate partners (Branner, Bradshaw, Hamlin, Fogarty, & Colligan, 1999). A national survey of one thousand battered wives found that one in three received help from clergy, and one in ten of their husbands were counseled by clergy (Bowker, 1988).

Often a person suffering from PTSD will have additional symptoms, particularly major depression or substance abuse. These problems may be the first means by which clergy and other religious professionals will recognize that someone has suffered a psychological trauma. Major depressions, which occur in about half the people who develop PTSD (Kessler et al., 1995), are usually associated with a predominantly sad mood, hopeless feelings, very pessimistic thinking, loss of the ability to experience pleasure, pronounced and continual sleep disturbance, significant agitation or restlessness, suicidal thoughts and attempts, and the loss of self-worth (Weaver, 1993). Self-medication with alcohol and illicit drugs at first may allay PTSD symptoms, such as sleep disturbance and anxiety, but with time they exacerbate the distress. A comprehensive study of Vietnam veterans found that 75% of those with PTSD developed alcohol abuse or dependence (Kulka et al., 1990).

Clergy are accessible helpers within communities that offer a sense of continuity with centuries of human history and an experience of being a part of something greater than oneself. They are visible and available leaders in communities that have a language of faith and hope. Rabbis, priests, ministers and vowed religious are also in a unique position of trust in which they can assist persons in connecting to support systems available through their faith communities and beyond (Weaver, Revilla, & Koenig, 2001). Undoubtedly, persons in distress go to clergy in large numbers because accompanying the stressful state for many individuals are questions of meaning and purpose uniquely addressed by religion.

SUMMARY

Accounts of the effects of traumatic events have been documented over the history of humankind. Post-traumatic stress is an expected reaction to an abnormally stressful situation and represents a significant public health concern that warrants attention. Churches and synagogues have many persons in their congregations who are suffering from psychological trauma and need help. Religious faith is a primary way that people successfully cope with the negative effects of traumatic experiences. Faith communities can offer both social support and a healing means of addressing a traumatic event. Rabbis, priests, and ministers are in a unique position of trust in which they can assist persons in the aftermath of psychological trauma. They need effective skills to recognize the signs of PTSD and information about how best to respond.

EPILOGUE

The young man in the opening vignette has the classic signs of PTSD. He is suffering from disturbing nightmares (intrusively re-experiencing the trauma), along with detachment, and loss of all interest in activities. He also has outbursts of anger and lack of concentration that are often seen in trauma survivors. It appears that he is suffering survivor's guilt for remaining alive after the death of his wife. It would be important in psychological treatment to assist him in releasing himself from blame. Initially it may be easier for the survivor to fault himself for the accident than to allow himself to feel his massive grief. Healing will require that he process his loss and find an end to excessive self-blame. At a later point it may helpful to seek to "normalize" his experience by explaining the pattern of PTSD symptoms and that their occurrence is common in the aftermath of psychological trauma. The overall treatment goal will be to help him integrate the traumatic event into the ongoing context of his life, so that he no longer continues to re-experience it. Because coming to grips with the pain of what has happened is extremely difficult, he will need encouragement both to enter and continue treatment.

The interventions made by the hospital chaplain with Larry during the hours immediately following the accident in which Patricia sustained her fatal injuries, contributed significantly to the way he managed the stress and its psychological consequences. The sustained relationship with the chaplain during the extended crisis helped Larry to gradually absorb the reality that his wife would not recover and that he would need to prepare himself and his son for life without her. The pastoral counsel and support helped the young officer regain emotional equilibrium in the face of a catastrophic loss. Without destroying his psychological defenses, the chaplain was able to work with his denial of the seriousness of Patricia’s injuries and begin to address his anger and guilt. Larry’s hostile reactions to other hospital professionals were linked to his sense of powerlessness in the face of this catastrophe. The chaplain provided a safe haven, as Larry began the difficult process of regrouping and reorganizing his life. Competent pastoral interventions, especially those at the onset of the crisis, can weaken the effects of PTSD and increase the likelihood of a positive prognosis.

RESOURCES

--Anxiety Disorders Association of America (ADAA); 11900 Park Lawn Drive, Suite 100, Rockville, MD 20852; (301) 231-9350; www.adaa.org; provides educational materials on PTSD.

--Gift From Within; (207) 236-8858; 16 Cobb Hill Road, Camden, ME 04843; www.sourcemaine.com/gift; is a non-profit organization dedicated to helping those who suffer from PTSD. It maintains a roster of trauma survivors who participate in a national network for peer support.

--National Center for Post-Traumatic Stress Disorder; VA Medical Center, 215 N. Main Street, White River Junction, VT 05009; (802) 296-5132; www.ncptsd.org.

--International Society for Traumatic Stress Studies; 60 Revere Drive, Suite 500, Northbrook, IL 60062; (847) 480-9028; www.istss.com.

--National Center for Victims of Crime; 2111 Wilson Boulevard, Suite 300, Arlington, VA 22201; (800) 394-2255; www.nvc.org; founded in 1985, provides self-help groups and makes referrals to existing organizations. It has a quarterly newsletter and conducts conferences.

HELPFUL BOOKS

"Post-traumatic Stress Disorder" in the Clinical Handbook of Pastoral Counseling, Volume 2, edited by R.J. Wicks and R.D. Parsons (New York, NY: Paulist Press, 1993) offers a helpful chapter on PTSD from a pastoral care perspective.

Coping with Trauma: A Guide to Self-Understanding (Jon G. Allen, Washington, DC: American Psychiatric Press, 1995) explains the effects of traumatic experience on a survivor's personality and social relationships. He describes treatment approaches and self-help strategies.

Helping Traumatized Families (Charles R. Figley, San Francisco, CA: Jossey-Bass, 1989).

Post-traumatic Therapy and the Victims of Violence (Frank Ochberg, New York, NY: Brunner/Mazel, 1988).

Trauma and Recovery: The Aftermath of Violence -- from domestic abuse to political terror (Judith Lewis Herman, New York, NY: Basic Books, 1997).

REFERENCES

American School Health Association. (1989). The national adolescent student health survey: A report on the health of America's youth. Oakland, CA: Third Party Publishing Co.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: APA.

Astin, M.C., Lawrence, K.J., & Foy, D.W. (1993). Posttraumatic stress disorder among battered women: Risk and resiliency factors. Violence and Victims, 8, 17-28.

Backus, C.J., Backus, W., & Page, D.I. (1995). Spirituality of EMTs: A study of the spiritual nature of EMS workers and its effects on perceived happiness and prayers for patients. Prehospital and Disaster Medicine, 10(3), 168-173.

Black, J.W. (1987). The libidinal cocoon: A nurturing retreat for the families of plane crash victims. Hospital and Community Psychiatry, 38(12), 1322-1326.

Blanchard, E.B., & Hicking, E.J. (1997). After the Crash. Washington, DC: American Psychological Association.

Bowker, L.H. (1988). Religious victims and their religious leaders: Services delivered to one thousand battered women by the clergy. In A.L. Horton & J.A. Williamson (eds.), Abuse and Religion: When Prayer Isn't Enough, (pp. 229-234). Lexington, MA: D.C. Heath.

Boyer, B.A., Knolls, M.L., Kafkalas, C.M., Tollen, L.G., & Swartz, M. (2000). Prevalence and relationship of posttraumatic stress in families experiencing pediatric spinal cord injury. Rehabilitation Psychology, 45(4), 339-355.

Branner, S.J., Bradshaw, R.D., Hamlin, E.R., Fogarty, J.P., & Colligan, T.W. (1999). Spouse abuse: Physician guidelines to identification, diagnosis and management in the uniformed services. Military Medicine, 164(1), 30-36.

Breslau, N., Davis, G.C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216-222.

Bureau of Justice Statistics. (1993). Criminal Victimization in the United States, 1992. Washington, DC: U.S. Department of Justice. Publication NCJ-144776.

Cayse, L.N. (1994). Fathers of children with cancer: A descriptive study of the stressors and coping strategies. Journal of Pediatric Oncology Nursing, 11(3), 102-108.

Cervantes, R.C., de Synder, U.N.S., & Padella, A.M. (1989). Posttraumatic stress in immigrants from Central American and Mexico. Hospital and Community Psychiatry, 40, 615-619.

Chalfant, H.P., Heller, P.L., Roberts, A., Briones, D., Aguirre-Hochbaum, S., & Farr, W. (1990). The clergy as a resource for those encountering psychological distress. Review of Religious Research, 31, 305-313.

Chinnici, R. (1985). Pastoral care following a natural disaster. Pastoral Psychology, 33(4), 245-254.

Cohen, M.S. (1989). The rabbi and the holocaust survivor. In P. Marcus & A. Rosenberg (eds.), Healing Their Wounds: Psychotherapy with Holocaust Survivors and Their Families (pp. 167-176). New York, NY: Praeger.

Daly, R.J. (1983). Samuel Pepys and post-traumatic stress disorder. British Journal of Psychiatry, 143, 64-68.

Daries, J.M. (1990). Baptists and human liberation: South Africa. American Baptist Quarterly, 9(4), 307-309.

Davis, C.G., Nolen-Hocksema, S., & Larson, J. (1998). Making sense of loss and benefiting from the experience: Two construals of meaning. Journal of Personality and Social Psychology, 75(2), 561-574.

Duber, A.E., & Motta, R.W. (1999). Sexually and physically abused foster children and posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67(3), 367-373.

Dykstra, R.C. (1990). Intimate strangers: The role of the hospital chaplain in situations of sudden traumatic loss. Journal of Pastoral Care, 44,(2), 139-152.

Ellison, C.G., Bartkowski, J.P., & Anderson, K.L. (1999). Are there religious variations in domestic violence? Journal of Family Issues, 20(1), 87-113.

Fairchild, R.W. (1980). Finding Hope Again: A Pastor's Guide to Counseling Depressed Persons. New York, NY: Harper and Row.

Fox, S.H., & Tang, S.S. (2000). The Sierra Leonean refugee experience: Traumatic events and psychiatric sequelae. Journal of Nervous and Mental Disease, 188(8), 490-495.

Gallup, G.H., & Lindsay, D.M. (1999). Surveying the Religious Landscape: Trends in U.S. Beliefs. Harrisburg, PA: Morehouse Publishing.

Garbarino, J., Kostelny, K., & Dubrow, N. (1991). What children can tell us about living in danger. American Psychologist, 46(4), 376-383.

Hohmann, A.A., & Larson, D.B. (1993). Psychiatric factors predicting use of clergy. In E.L. Worthington, Jr. (ed.), Psychotherapy and Religious Values (pp. 71-84). Grand Rapids, MI: Baker Book House.

Hopkins, N.M. (1990). The politics of U.S. refugee policy. The Christian Century, 107(9), 279-281.

Herman, J.L. (1992). Trauma and Recovery. New York, NY: Basic Books.

Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.

Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., Weiss, D.S., & Grady, D.A. (1990). Trauma and the Vietnam War Generation. New York, NY: Brunner/Mazel.

La Greca, A.M., Silverman, W.K., Vernberg, E.M., & Prinstein, M.J. (1996). Symptoms of posttraumatic stress in children after Hurricane Andrew: A prospective study. Journal of Consulting and Clinical Psychology, 64(4), 712-723.

Lernoux, P. (1980). Cry of the People. Garden City, NJ: Doubleday.

Lifton, R.J. (1988). Understanding the traumatized self: Imagery, symbolization, and transformation. In J.P. Wilson, Z. Harel & B. Kahana (eds.), Human Adaptation to Extreme Stress: From the Holocaust to Vietnam (pp. 7-31). New York, NY: Plenum.

McCammon, S.L., & Murphy, E.J. (1995). Debriefing and treating emergency workers. In C.R. Figley (ed.), Compassion Fatigue (pp. 115-130). Levittown, PA: Brunner/Mazel.

McIntosh, D.N., Silver, R.C., & Wortman, C.B. (1993). Religious role in adjustment to a negative life event: Coping with the loss of a child. Journal of Personality and Social Psychology, 65(4), 812-821.

Mollica, R.F. (2000). Waging a new kind of war: Invisible wounds. Scientific American, 282(60), 54-57.

Mollica, R.F., Streets, F.J., Boscarino, J., & Redlich, F.C. (1986). A community study of formal pastoral counseling activities of the clergy. American Journal of Psychiatry, 143, 323-328.

Mollica, R.F., Wyshak, G., & Lavelle, J. (1987). The psychosocial impact of war trauma and torture on Southeast Asian refugees. American Journal of Psychiatry, 144, 1567-1572.

Norris, F.H., Kaniasty, K.Z., & Scheer, D.A. (1990). Use of mental health services among victims of crime: Frequency, correlates and subsequent recovery. Journal of Consulting and Clinical Psychology, 58(5), 538-547.

Pargament, K.I. (1997). The Psychology of Religion and Coping: Theory, Research, Practice. New York, NY: Guilford Press.

Preston, J., O’Neal, J.H., & Talaga, M.C. (1994). Handbook of Clinical Psychopharmacology for Therapists. Oakland, CA: New Harbinger.

Satcher, D. (2000). Mental health: A report of the Surgeon General executive summary. Professional Psychology: Research and Practice, 31(1), 15-13.

Schlenger, W.E., Kulka, R.A., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., & Weiss, D.S. (1992). The prevalence of posttraumatic stress disorder in the Vietnam generation: A multimethod, multisource assessment of psychiatric disorder. The Journal of Traumatic Stress, 5(3), 333-364.

Shubiner, H., Scott, R., & Tzelepis, A. (1993). Exposure to violence among inner-city youth. Journal of Adolescent Health, 14(3), 214-219.

Smith, W. J. (1985). Dying in the Human Life Cycle: Psychological, Biomedical and Social Perspectives New York: Harcourt Brace.

Smith, B.W., Pargament, K.I., Brant, C., & Oliver, J.M. (2000). Noah revisited: Religious coping by church members and the impact of the 1993 Midwest Flood. The Journal of Community Psychology, 28(2), 169-186.

Spiro, A., Schnurr, P.P., & Aldwin, C.M. (1993). Combat-related posttraumatic stress disorder symptoms in older men. Psychology and Aging, 9(1), 17-26.

Stark, R., & Finke, R. (2000). Acts of Faith: Explaining the Human Side of Religion.Berkeley, CA: University of California Press.

Sutker, P.B., & Allain, A.N. (1996). Assessment of PTSD and other mental disorders in World War II and Korean Conflict POW survivors and combat veterans. Psychological Asssessment, 8(1), 18-25.

Terr, L. (1992). Too Scared to Cry. New York, NY: Basic Books.

United States Department of Labor. (1998). Occupational outlook handbook: United States Department of Labor. Washington, DC: Bureau of Labor Statistics.

Van der Kolk, B.A. (1987). Psychological Trauma. Washington, DC: American Psychiatric Press.

VandeCreek, L., & Burton, L. (2001). Professional chaplaincy: Its role and importance in healthcare. Journal of Pastoral Care, 55(1), 81-97.

Veroff, J., Kulka, R.A., & Douvan, E. (1981). Mental Health in America: Patterns of Help-Seeking from 1957 to 1976. New York, NY: Basic Books.

Watson, C.G., Kucala, T., Manifold, V., Juba, M., & Vassar, P. (1988). The relationships of post-traumatic stress disorder to adolescent illegal activities, drinking, and employment. Journal of Clinical Psychology, 44, 592-598.

Weaver, A.J. (1992). The distressed family and wounded children. Journal of Religion and Health, 31, 207-220.

Weaver, A.J. (1993). Depression: What clergy need to know. Currents in Theology and Mission, 20(1), 5-16.

Weaver, A.J. (1995). Has there been a failure to prepare and support parish-based clergy in their role as front-line community mental health workers? A Review. The Journal of Pastoral Care, 49, 129-149.

Weaver, A.J., Koenig, H.G., & Ochberg, F.M. (1996). Posttraumatic stress, mental health professionals and the clergy: A need for collaboration, training and research. Journal of Traumatic Stress, 9(4), 861-870.

Weaver, A.J., & Koenig, H.G. (1997). Uncovering elder abuse: How to stop the hidden violence. The Christian Ministry, 28(4), 18-19.

Weaver, A.J., Preston, J.D., & Jerome, L.W. (1999). Counseling Troubled Teens and Their Families: A Handbook for Pastors and Youth Workers. Nashville, TN: Abingdon Press.

Weaver, A.J., Revilla, L.A., & Koenig, H.G. (2001). Counseling Families Across the Lifespan: A Handbook for Pastors, Chaplains, and Other Religious Professionals. Nashville, TN: Abingdon Press.

Weinrich, S., Hardin, S.B., & Johnson, M. (1990). Nurses response to hurricane Hugo: Victims' disaster stress. Archives of Psychiatric Nursing, 4(3), 195-205.

Weiss, D.S., Marmar, C.R., Schlenger, W.E., Fairbank, J.A., Jordan, B.K., Hough, R.L., & Kulka, R.A. (1992). The prevalence of lifetime and partial posttraumatic stress disorder in the Vietnam theater veterans. The Journal of Traumatic Stress, 5(3), 365-376.

Zimmerman, G., & Weber, W. (2000). Care for the caregivers: A program for Canadian military chaplains after serving NATO and the United Nations peacekeeping missions in the 1990s. Military Medicine, 165(9), 687-690.

Acknowledgements:

This article is dedicated to the co founder of the Catholic Worker, Dorothy Day, who gave her life to the ministry of the poor. We wish to express our gratitude to The Rev. Carolyn L. Stapleton, Eileen Gorey, R.N., and Lisa Matsumoto , M.LIS., for their generous help in the development of this project.