The human race was created by God in His own image. While theologians differ on precisely what that image involves, all agree that we are complex in our ability to think, to feel, to desire, to dream of a future. Humanity has a range of responses to external events that encompass the physical, intellectual, emotional and spiritual spheres. To minister effectively to people in crisis, we must understand the normal range of reactions that frequently surround the human immersed in a crisis situation. Grief, depression, and anxiety are perhaps the most common coping mechanisms when facing severe stress.
Now we do not want you to be uninformed, brothers and sisters, about those who are asleep, so that you will not grieve like the rest who have no hope. (1 Thess. 4:13)
Grief is a natural emotional response to loss. Though perhaps associated most commonly with death, a person can experience grief in response to many other losses. To a teenager who has experienced a "relationship failure," to a person whose beloved pet has died, or to someone fired from the "job of his dreams," grief is real and profound. For an understanding of the intensity of grief, we will focus on the death of a loved one in this section.
Scripture about Grief
We see many examples of grief in the Bible. One of the most significant figures is Job. After losing his livestock, servants, children, and health, he refused to curse God, as his wife had advised. He worshiped God in the midst of his devastation; and yet without shortchanging the emotional expression of his pain, he tore his robe, shaved his head, sat in ashes, and was so visibly distressed that his friends were speechless. Scripture testifies that "in all this Job did not sin" (Job 1:22; 2:10). In fact, from a crisis-counseling perspective, Job's friends ministered best when they spoke least. The days of silence after these men showed up to be with Job in his pain picture the central importance of the ministry of presence. When these friends chose to speak, being "more sure than right," they presumed on the origin of Job's suffering. That is, they attributed Job's calamity to some sin. They believed God was judging Job for secret disobedience. It is often hard to resist this conclusion when ministering to a grieving individual, but God keeps His counsels hidden most times, and the wise course is to provide the comfort and strength of a loving presence. At times words are unnecessary and may even cause additional pain.
Begin your ministry to the grieving by merely communicating how sorry you are for their loss. And even if you have experienced a similar tragedy, do not presume that you know how that person feels. You simply do not. Each of us grieves individually, in unique and specific ways. So recognize that the pain is profound, and, through prayer, carry it to the throne of grace.
Though Scripture testifies to Job's innocence in his expression of grief, not all grief is, in fact, sin-free. Sin taints all aspects of life, and grief is no exception. Not only do we grieve in a fallen world, but we also grieve as fallen creatures. Having said this, our primary concern when ministering to someone in grief is to offer compassion, comfort, and support. Correction for the grieving should be done with only the utmost caution, lest suffering be compounded.
Having taken on human form in the Incarnation, Jesus knew grief well during His time on earth. He was despised and rejected by people; He experienced pain and was acquainted with grief (Isa. 53:3). He also pronounced blessing on those who mourn (Matt. 5:4) and wept at the tomb of Lazarus, even though He knew that He would raise his friend from the dead (John 11:4, 32–36). He wept over Jerusalem (Luke 19:41) because of the sin and disobedience of God's people, and He entreated God in anguish in the garden of Gethsemane as He anticipated the cross (Matt. 26:37–44; Mark 14:33–36; Luke 22:41–44). Our Savior expressed the full range of human emotions during his sojourn here.
The examples of Christ and Job demonstrate that profound expressions of grief do not run counter to righteousness. While we are not to grieve as those who have no hope (1 Thess. 4:13), an important commonality we share with the unbelieving is that we do grieve.
Sources of Grief
A variety of losses can lead to profound grief—death, fractured relationships, destroyed dreams, the grief of a friend, failure, loss of skills or mobility, and relational losses from relocation. The list could go on. Grief can be as recognizable as the emotion evoked upon the death of an aged parent or something as silent and invisible as the onset of menopause for a single female. Often grief accompanies those in long-term counseling as they come to terms with losses—perhaps mourning the father they never had or mourning the far-reaching consequences of choices they made. Grief can result from watching a loved one make self-destructive choices and being unable to stop him or her, or from persevering in a difficult marriage with a spouse who shows no incentive to change. The upheaval of one's parents' divorce can bring grief, as can a broken engagement. Grief can come from any great number of things that are "not the way they're supposed to be."
The Experience of Grief
Though typically thought of as an emotional experience, grief also can have physiological effects. A person may experience respiratory distress—finding breathing difficult, gasping, or expressing deep sighs. He or she may feel tightness in the throat or abdomen, feel nauseated, or notice significant changes in appetite. Additionally, the grieving person may feel weak, lacking energy or muscular strength. Many complain of pain—diffuse, difficult-to-localize aching that simply will not go away. In the case of a lost loved one, the grieving person may occasionally imagine seeing or hearing the deceased, or dream vividly about him or her.
At an emotional level, grief is experienced as mental anguish, including shock (not the medical shock of low blood pressure but rather a surreal sense that nothing makes sense, that this cannot really be happening), numbness, sorrow, and anxiety. Such mental anguish can compromise one's ability to think rationally. A grieving person also may display selective and incomplete memory. Shock is a common component of grief, even in the event of the slow and expected death of a loved one who was terminally ill. Anxiety may stem from the stress and sorrow of separation or express the struggle against accepting our human finitude in the face of suffering. In the case of intense grief, a person may have suicidal thoughts. A loss suffered by a family will put stress on family relationships, as people tend to experience and deal with grief differently. Children may express grief by irritable moods, regression to immature behaviors, or general opposition to authority. Recognize that children do grieve and do so deeply; it just manifests itself in different ways.
Abnormal Grief: Cause for Concern
There is a wide spectrum of normal grief expression, but some ways of handling grief are abnormal. Normal grief includes disrupted life rhythms, anger, guilt, and a variety of physical and emotional symptoms. These may last six months to a year following a significant loss. One should begin to see some improvement, however, as the months unfold.
Abnormal grief, which will not naturally resolve, includes symptoms such as psychosis (seeing and hearing things that are not there), complete denial of the pain, or obsession with the loss. Some people make "shrines" out of the room or belongings of the deceased. While there is no rush to remove reminders of the deceased, making such objects "sacred" can signal a dangerous grieving process.
Grief is indeed a process that is often slow and agonizing. It can be helpful to think of it in terms of common grief "stages," such as initial shock/denial, followed by anger/depression. Some bargain instead of getting angry, trying to "strike a deal" with God to make things the way they were. Ultimately a new reality emerges in that the deceased takes a new place in the memory of the grieving survivor. A new rhythm develops that some refer to as "acceptance," or "healing," which includes a return to regular activities. In her classic work based upon extensive interviews with the terminally ill as death was approaching, Kubler-Ross identified five stages in facing one's own death: (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance.
The length and intensity of the grief process will vary from person to person and is influenced by multiple factors, including the degree to which the loss was anticipated, the magnitude of the loss, and the grieving person's personality makeup and faith system. The stages are not "mandatory," of predictable length, or logically ordered. But knowledge of this general progression can assure the counselor that progress is being made through the grief.
Ministry to the Grieving
As members of the body of Christ, we minister God's presence to each other. Pastoral care has a particular capacity to symbolize the presence of God to a grieving person. This ministry of presence is a central part of caring for the grieving. In a very real sense, half the job (or more!) is simply showing up and being with people in their pain.
Early contact with the grieving individual(s) communicates care for and recognition of the significance of their loss and will aid future healing. As a minister on behalf of the church, you are naturally expected to initiate contact. In the ministry of presence, connection is made through compassion, authentic empathy, and genuine respect. Ask open-ended questions and listen. It is important for those who are grieving to have the opportunity to verbalize their negative emotions, and a genuine listening ear can do much to encourage this expression.
Repression of such emotional expression early in the process may lead to greater disturbance in the future. Be aware of all members of the family, and be careful not to overlook children. They may not understand as much of what is going on, but they are picking up on much more than their behavior may indicate. Don't be afraid to get down on their level and talk to them.
You will be ministering not only to emotional needs but to spiritual needs as well. Offer to pray with people. Sharing Scripture is also appropriate, but be careful here. Scripture can be offered prematurely in a way that shuts down emotional expression. Be sure that when you share Scripture it is genuinely for the other person's good and not a means of shielding yourself from the intense emotions of the grieving one. It is also important to be aware that although the experience of grief raises many difficult questions—which may often be verbalized to you—grieving people are not looking for instant answers. They may ask for an answer, but their heart cry is for the return of the loved one. What you can offer is empathic understanding, comfort, reassurance, personal presence, and hope, framed in a biblical view of time and eternity.
Grief is a journey, and people need company on that journey. Some have described the process as "work" needing to be done, like rehab after surgery. It is a fitting image—that of helping a brother or sister in Christ accomplish the necessary "grief work" to accomplish healing of the soul. Practical strategies to suggest for processing grief include thinking reflectively, journaling, talking through the memories, weeping, and remaining involved in relationships and life and the spiritual disciplines (prayer, meditation, and directed Bible study may have appropriate times). The Psalms can be especially helpful in this journey, providing people with words to voice their pain and confusion to God. Encourage them to "pour out [their] heart like water before the face of the Lord" (Lam. 2:19).
A very common question of individuals ministering to those in grief is, How long is it OK to grieve? It depends. Duration is not as important as not getting stuck. The question is not so much, Is this taking too long? but, Are we still moving ahead?
As people journey through their grief, they will grow stronger and gradually need you less. Your flexibility and ability to recognize their progress and decreased need for you is an important part of their being able to move on. At the same time recognize that loneliness is still a major problem for most people at one year. A card or note at anniversary dates of the loss is a wonderful way to evidence continued caring as people move on.
If you have not personally experienced much grief, consider asking someone who has to talk with you about his or her experience. Let this person be your teacher. This will be an invaluable experience, not only in learning about grief, but also in increasing your comfort level in talking with individuals about such an emotion-laden topic.
I am exhausted as I groan; all night long I drench my bed in tears; my tears saturate the cushion beneath me. (Ps. 6:6)
Depression affects the whole person. Many think in terms of the "ABCs of Depression"—that is, the affect (feeling), behavior (doing), and cognition (thinking). Depression impacts all areas—the physical, intellectual, emotional, and spiritual—to a significant degree.
Regarding affect, a depressed person's emotions evidence a deep sadness, helplessness, despair, and/or irritability. Feelings of worthlessness and hopelessness dominate. The struggle of depression can lead to an overwhelming sense of guilt and shame. Clearly, all relationships suffer. Both the spiritual life and human relationships are damaged. Spiritual disciplines such as reading the Bible and prayer often seem dry and pointless. This may lead to feelings of distrust, anger, and even hatred toward God. In such dark moments, the individual may sense only disapproval and condemnation from the Lord.
Regarding behavior, depression can cause a significant loss of energy and lack of desire to do anything. Depressed persons often have difficulty eating properly, sleeping, or even getting out of bed. Simple tasks such as routine hygiene may seem an overwhelming undertaking. The depressed individual may try to withdraw from all human contact for extended periods. Appetites are affected. Depressed people generally consume too little or too much. Libido often disappears. In fact, most activities that the depressed person previously enjoyed doing no longer hold interest or pleasure.
Regarding cognition, depression often deeply disturbs thought processes. Memories are difficult to recall; focus and attention span suffer. Decision-making ability is gone. Thoughts are often slowed, though in certain individuals the mind may race with a "pressure of ideas" and forced speech such that it may exhaust the one who tries to listen and follow the line of thinking.
Causes of Depression
As of this writing, "depression" describes a collection of symptoms, not an objective diagnosis based on a particular lab value or scan. The pain of depression can be intense, lasting from short periods to months or even years. Many theories surround depression, ranging from genetic causes, familial circumstances, neurochemical imbalances, and even sinful behavior. Volumes of research point to a many-factored cause of this symptom complex we call depression. There are neurochemical changes; serotonin, norepinephrine, and dopamine do play a role. Whether the changes cause the depression or result from the depression remains to be precisely determined, but considerable current medical effort seeks to discover the origins of debilitating depression so that the treatments might be more effective and specific.
Some depressions are closely tied to precipitating events. Postpartum depression, for example, can be remarkably severe, causing separation from the infant, husband, family, and friends. Many women suffer depressive symptoms after childbirth but relatively few progress to full-blown postpartum depression (symptoms lasting more than two weeks). Such patients need medical consultation as research has identified clear ties between dramatic hormonal changes and the severe symptoms, particularly in families where other members have struggled with depression. The rare cases of postpartum psychosis—with delusions, hallucinations, and suicidal and/or homicidal thoughts—remind us of the fragility of the human form.
Another type of depression with an identifiable cause is seasonal affective disorder (SAD), with symptoms generally limited to the winter months. Apparently, in some cases mood changes can be related to environmental change.
Depression certainly can be the result of sin, caused by the guilt and shame that follow poor choices. Thus the minister must listen well to fully understand what is happening within the person in crisis. Recognizing a strong family history of depression may give important clues as to who may be at greatest risk and who may need to be referred for consultation with a physician.
Current understanding of mood disorders focuses on extremes: the low, hopeless, helpless feelings of depression and the high, hyper-energetic, overproductive, creative "manic." Some "in-betweens" exist, but these two states are the two ends or "poles" of the spectrum. Thus, a "bipolar" person has both depressive and manic phases. Treatments differ for those with pure depression versus individuals suffering from bipolar disorder. There are strong family tendencies often seen in bipolar persons. Pay very close attention to the family's history of any sort of mental disorder, treatment and/or hospitalization for this type of diagnosis.
Depression also can have a physiological connection with certain hormonal abnormalities, particularly low thyroid production. Most individuals who are stressed beyond their capacity and/or those who suffer from sleep deprivation, exhaustion, or serious life events will experience some of the symptoms of depression. Thus, the symptoms of depression are a very common part of the human experience. The spectrum of severity in depressive symptoms remains vast and will likely constitute a major part of crisis ministry.
A depressed person needs the help that the community of faith brings: genuine care, concern, support, and at times direction to physicians or counselors. Notice the parallel approaches to the person suffering from grief.
• Be available.
• Be empathetic, not just sympathetic. Through empathy enter into the pain with the depressed person so that he or she will not feel isolated from you.
• Listen to the depressed person, and get to know his or her story. Crucial events or episodes reveal themselves only over time.
• Love and support the depressed person with appropriate encouraging words.
• Be patient. A depressed person may not see things clearly or correctly for a long time. Resolution likewise may take many months.
• Never encourage anyone to quit taking antidepressant medication. Abrupt cessation of certain medications can be life threatening. However, it may be appropriate to encourage depressed individuals to discuss with their physicians the reasons for their particular medicine, how long their doctors expect them to use it, and any possible side effects or interactions it may have with other medications.
Ministers take a variety of approaches to help depressed persons. Each method uniquely affects aspects in a person's life that lead to depression.
Biblical Counseling Model
"Biblical counseling" as a formal approach brings the truth of Scripture to bear on the life circumstances, thoughts, attitudes, and actions of the individual. The counselor has the sacred privilege of speaking the truth of God's words in a timely fashion to encourage or confront as necessary. This approach parallels the cognitive/behavioral therapy in the secular world but differs in that biblical counseling has the authority of God's inerrant Word, rather than only the logic of human capabilities. It is appropriate to view all depressed persons first from the perspective of biblical revelation, as sinners saved by grace or as lost souls suffering the effects of sin. This approach may be effective by itself or at times benefit from the addition of physician-prescribed and -monitored medications.
Relational models of counseling focus on the interactions a depressed person has with others. This approach seeks to address any sinful or unhealthy ways a person interacts with others. Some counselors specialize in family-centered relational therapy, which tries to understand the individual in the context of all family relationships. Others examine all the depressed individual's interpersonal relationships in order to distinguish healthy, holy relationships from those that might be harmful or destructive. This is not contrary to biblical teaching or the "biblical counseling" method, and may hold the key to understanding the factors causing or deepening the depression.
Many secular therapists and psychiatrists use the psychodynamic model, which focuses on basic internal conflicts within a person. Most forms look for poor relationships early in life that have initiated such an internal conflict and strive to help the person resolve them. Pastoral caregivers need to be alert to the spectrum of input that depressed individuals receive from various counseling services, even those that claim to be Christian. There may well be useful information gleaned from exploring unhealthy childhood experiences and relationships, not to excuse behavior but to understand patterns so that "strongholds" may be broken. Some "biblical counseling" counselors look for basic allegiances a person has that are in conflict with the person's allegiance to God.
The physiologic model focuses on treating suspected neurochemical imbalances with various medications. Many depressed individuals respond quickly to prescribed antidepressants or normalizing hormonal levels. However, such treatment requires the evaluation of a physician trained in this area. Much current research on depressive disorders has suggested that deficits in certain brain chemicals (neurotransmitters) may be responsible or at least involved in mood disorders. While there is currently no specific test for levels of these hormones, functional studies of the brain (CT scans, PET Scans, Spect Scans, and functional MRIs) show strong evidence for a connection between depression and problems in the area of neurotransmitter efficiency. Recent research suggests a biochemical marker for depression that may well help predict those that will need and respond to antidepressant medications.
As mentioned, whether these neurochemicals cause depression or result from depression remains to be fully elucidated, but many depressed individuals simply cannot think properly to process and understand biblical direction without normalizing these chemicals. Some types of depression are clearly linked to body physiology and hormonal changes (postpartum depression, perimenopausal depression, depression in premenstrual syndrome, hypothyroid).
There are a number of classes of medications that are designed to treat depression and/or anxiety. Physicians generally "start low and go slow," so it may take some weeks before the medication's full benefit will be noticed. A patient's failure to respond right away to any of these medications or to a change in dosage may not represent medication failure. Encourage the individual to further consult with their physician if they express concerns about their medication.
Most people suffering from depression can be helped. The hopeless, helpless, isolated feelings do not have to be permanent. Whether medications are necessary and/or appropriate must be determined by a trained clinician with the experience and ability both to prescribe and to follow the course of the illness over time. Scriptural encouragement always plays a role as we each grow into conformity with Christ.
A person can relapse into depression, sometimes when circumstances become overwhelming again, but sometimes also without any apparent precipitating cause. Relapses may be far more difficult to treat than initial difficulties, so a person acclimating well on medications should seek good medical counsel before deciding to stop treatment.
Many competent pastoral leaders are uncomfortable counseling the person who shows signs of serious depression for fear they will miss a potentially suicidal individual. See chapter 14, which will detail the continuum of risk and encourage you to get involved, ask the right questions, and refer when appropriate.
Anxiety and Panic Disorder
Do not be anxious about anything. Instead, in every situation, through prayer and petition with thanksgiving, tell your requests to God. And the peace of God that surpasses all understanding will guard your hearts and minds in Christ Jesus. (Phil. 4:6–7)
In addition to grief and depression, anxiety is another common human response to crisis. Estimates suggest that forty million American adults ages 18 and older suffer from anxiety disorders. While almost anyone can experience anxiety from time to time as a result of life stress, a genuine "disorder" is diagnosed based on the severity and frequency of symptoms. Often alcohol and substance abuse are associated with true anxiety disorders, along with a predisposition to depression. In the past, anxiety disorders have constituted the most commonly diagnosed childhood psychiatric condition, so ministers should be familiar with its constellation of symptoms.
Persons suffering from excessive, acute anxiety may feel threatened at all times by their surroundings, may be socially isolated and disconnected, and often find no solid spiritual grounding. The disorder is commonly seen after traumatic episodes (break-ins, muggings, natural disasters) and is characterized by a sense of loss of control. Statistically, there seems to be a genetic tendency toward anxiety problems, but no particular gene has been isolated as yet. A genetic tendency, however, does not free the individual from responding biblically to this disorder.
Children with anxiety disorders are noticeably "clingy" toward trusted adults and such children express a variety of physical complaints. Various aches and pains or stomach distresses that prevent school attendance are often the first clues. Sleep disorders are common, along with nightmares, which can result in an overriding fear that affects or inhibits friendships and social interactions.
Severe anxiety manifests itself as constant, often nonspecific fear, with the accompanying physical responses—hyperventilation, elevated heart rate with palpitations (pounding in the chest), gastric distress with nausea, and, at times, a fear of dying. This, collectively and condensed, may be called a "panic attack" and when recurrent is labeled as part of a "panic disorder."
When encountering a person who struggles with severe anxiety, it is always wise to consider a medical consultation. Elevated thyroid hormone, as well as other hormonal problems, can cause such physical symptoms and the fear that can accompany them. Failure to consider underlying medical issues—including nicotine, caffeine, and even substance abuse—may condemn the sufferer to far longer periods of distress than necessary. Most people, however, can be approached with biblical encouragement. Depressive symptoms may accompany the anxiety, so thorough questioning and careful listening as described previously will likely prove beneficial.
Anxiety that progresses to panic attacks should be appreciated as a definite life crisis. People genuinely believe that they are going to die from the episode they are experiencing. The fear can overwhelm them, and the accompanying physical symptoms are profoundly frightening. Estimates suggest that between four and eight million Americans are affected by panic attacks. Roughly 7 percent of our general population has experienced an isolated or occasional episode that fits the criteria of panic attack. Unfortunately, many of these people are misdiagnosed or dismissed as having an "overemotional" response to a stress or event. Untreated, these people can develop phobias that cause considerable distress.
Common symptoms of a panic attack center on an intense fright. The heart rate elevates with feelings of "pounding." Coupled with shortness of breath and dizziness, such symptoms can make the episode look like a heart attack. In fact, that's what most people initially believe is happening, and they are often taken to the emergency room believing that death is imminent. The adrenaline pumped into the bloodstream in response to the fear causes all these symptoms, along with elevated blood pressure and abdominal pain or distress.
Hyperventilation can lead to numbness and tingling in the extremities that add to the sense of doom. The sufferer's thoughts race, making it very difficult to concentrate as he or she feels totally trapped and out of control.
Panic disorder often begins in early adulthood and is more commonly seen in women than men. The episodes are generally short and resolve before any treatment is actually begun, but the ten or fifteen minutes they ordinarily last seem like an eternity to the one who fears for their life.
Some medical conditions mimic this disorder, for example, a tumor that secretes adrenaline, or, as already mentioned, an elevated thyroid hormone level. If you have ever been in a "close call" car accident, your body released a surge of adrenaline, and you have had many or all of the symptoms outlined above. The "fight or flight" response when a wave of fear hits is very similar to what those suffering from panic attacks experience on a regular basis.
Ministry approaches to panic attacks and anxiety disorder include, first, an understanding of how frightening these episodes are. Truly, a Christian does not live in fear but in faith, but a measure of understanding will begin the process of connecting with the person in crisis. After ruling out genuine medical emergencies, effective therapies include right thinking and right speaking. For example, Philippians 4:6 directs the believer to not be anxious about anything, and 1 Peter 5:7 says to cast all your cares on him because he cares for you. These can be foundational in beginning the process of right thinking about whatever the trigger might prove to be.
Once medical causes are eliminated, breathing techniques and relaxation exercises while meditating upon Scripture can be beneficial in avoiding or quickly ending the attacks. Acutely, while the person is in such distress and afraid another attack is "around the corner," some medications have been effectively prescribed to get ahead of the disorder. Particularly if the person has suffered for many months or years with panic attacks, occasionally getting some measure of success by stabilizing the neurochemical environment may be appropriate.
Certain lifestyle measures have been beneficial, including proper diet, exercise, and rest. God has designed us to need rest and nourishment in appropriate measure. Restful sleep can be one of God's greatest graces. Avoidance of stimulants (caffeine, nicotine, alcohol, and nonprescribed medications) can make an enormous difference. Developing spiritual friendships, which may include you as a minister, likewise form the support that aids recovery.
Taken from The Church Leader's Handbook: A Guide to Counseling Families and Individuals in Crisis © 2009 by William R. Cutrer. Published by Kregel Publications, Grand Rapids, MI. Used by permission of the publisher. All rights reserved.
Scripture taken from the NET Bible® copyright ©1996–2005 by Biblical Studies Press, L.L.C. http://www.bible.org/. Scripture quoted by permission. All rights reserved.