Years ago a friend of mine was abandoned by her husband. She and her sons have remained in the church but now the boys are out of the house and she is alone. A couple of months ago I saw her in the hall and greeted her with a big hug. Her eyes lit up – it had been a long time since she had been touched. The Beatle’s Eleanor Rigby is not just a song, but a statement of an exploding problem throughout the world – people are lonely. Doug Saunders captured this problem in his book Arrival City in which he remarked on “the silent isolation of the middle class.” He wrote of new immigrants “no longer would they hear every word and movement around them; no longer was the air constantly vibrating with the parry and banter of the entire community.” The only regular noise many people hear at home are the sounds of the television and the computer.
Whether I see them for physical or psychological complaints, I confront loneliness frequently in my patients. Even more, whether a person feels lonely or not, being chronically alone has a negative effect on health. For example, patients with chronic knee or hip pain frequently have tight quadriceps, hamstrings, hip flexors, and heel cords as contributing factors. Improving flexibility will enhance function and decrease pain. Patients who have a spouse at home who will help them usually do better than those that do not. The same is true for other health outcomes, from shoulder pain to diabetes. Ecclesiastes 4:9-12 is right.
Doctors, counselors, and pastors frequently care for people with personal problems and mental health concerns. While we often help these patients improve, complete recovery seems elusive. Chronic pain, chronic depression, chronic insomnia, and long term poor function are maddeningly hard to beat. One reason is that we try to do it alone. In our optimism, or perhaps our vanity, we expect that our few minutes with a patient a couple of times per year, or even per month, will revolutionize their lives.
When I treat a patient, whether in the doctor’s office or the counselor’s chair, I try to get the family, friends, work, school, church, and others involved if the patient agrees. Below is a diagram entitled Context of Care and Recovery that I use to help those under my care.
How to use this paradigm
The Context of Care and Recovery paradigm actually comprises a systematic way to look at the total milieu of the patient and family, addressing each area, and thereby maximizing the likelihood of success. Lasting recovery from serious and chronic behavioral health problems requires major shifts in lifestyle; not just that of the patient, but the lifestyles of the family and close friends as well. More than just recovery for the sick, the Context of Care and Recovery paradigm can help with keeping the healthy well, and even making them healthier. I will use “her” to refer to therapist and patient and use “he” for pastors, reflecting the predominant demographics of those populations. I use the terms “patient” and “client” interchangeably.
The Inner Square – patient and family (specific factors)
The patient and family are in the inner square and are the focus of the intervention. Note that the patient is not alone in the center. The therapist will focus her efforts on the patient, but the patient must not focus on herself. Likewise, the family will not focus on the patient; they will focus on each other. The idea is to get each person in the group to focus on the others in the group.
Self-focus is as natural as it is deadly. We are by nature selfish people, but the foundation of mental health is to consistently look outside ourselves.
- We consider the person and glory of God in creation, in the Bible, and in other people (Hebrews 12:2).
- We consider the good things about others; their virtues, their skills, and their aspirations.
- We consider the needs of others.
- We consider our own needs.
There is more than just one person in the inner square. Therapy for behavioral health will not fully succeed until everyone on the team realizes this truth and adjusts their thoughts, words, and actions accordingly. Getting there is the hardest thing to do in therapy.
As patient is unique, so is every family, and one of the first tasks in regaining or improving health is to identify and accept the uniquenesses of each patient and family. Therapists should identify specific factors that have the potential to affect recovery and health.
What about the person who has no family? This is difficult, because one person is ill-equipped to stand alone. Try to involve concerned friends, distant relatives, or anyone else who is willing to help. People with behavioral health problems are less likely to have close personal ties; this is one of the effects of the disease. Nonetheless, everyone needs someone, and care professionals should mobilize helpers on behalf of their patients.
The counselor has two jobs: to guide the client and her family through the mazes that they encounter on the road to recovery, and to make sure that the client and her family are not ultimately alone. The counselor walks alongside the patient and family in the maze. For our purposes, a “maze” represents confusion about what to do and where to go to get better. People in mazes take many wrong turns and end up at dead ends, only to retrace their steps and try again.
The client is in her own mental maze, but also likely in the physical mazes of insomnia, chronic pain, overall ill health, and sometimes substance abuse. The family is in the maze of uncertainty about how to help the patient, and lack of resources, whether money, time, knowledge, or patience. Other concerned parties such as friends, co-workers, and caregivers are in mazes of their own. Navigating the health care system itself is a maze.
Some people chose pastoral counseling, some chose secular (non-Christian) counseling, and some choose both. Either way, the counselor must address all aspects of the person:
- Physical fitness – strength, endurance, flexibility, mobility
- Environmental fitness – heat/cold, altitude, noise, air quality
- Medical fitness – access to care, immunizations, screening, prophylaxis, and dental
- Social fitness – social support, task cohesion, social cohesion
- Behavioral fitness – substance abuse, hygiene, risk mitigation
- Psychological fitness – coping, awareness, beliefs/appraisals, decision making, engagement
- Nutritional fitness – food quality, nutrient requirements, supplement use, food choices
- Spiritual fitness – virtuous living, positive beliefs, making meaning, ethical leadership, accommodating diversity
This paradigm comes from the Total Force Fitness program in the US military, and is a comprehensive way to look at the health of each individual and group.
Personal spiritual direction
In our context, being “spiritual” means that a person acknowledges some level of existence beyond the material world of atoms and molecules. Almost everyone is “spiritual” by this definition, and even those who say they are not usually are. Most people will say that they are spiritual. Those who deny it, typically believe that love exists, such as that between a man and a woman, and that it is more than the fluctuations of atoms in the body.
Being spiritual, most people seek some type of spiritual direction. This may or may not involve “god” and certainly will not come completely from the counselor; religious leaders, family and friends, and even the media play a role. For the Christian, some aspects of spiritual development are universal. God intends certain things for all of His people:
- That they be genuine Christians.
- That they forgive as they have been forgiven (Matthew 18:21-35).
- That they exhibit the fruits of the Spirit (Galatians 5:22-23).
- That they engage in the spiritual disciplines (see Fasting in the Bible for the whole list)
- That they be active in ministry.
Pastors, doctors, and other caregivers must understand the spiritual direction of the patient and her family and incorporate that into therapy. For example, if a patient says that God wants her to serve in a food ministry, the pastor should inquire further. Unless there is some major concern, he should try to help her find such a ministry.
Assuming that the patient is involved in religious practices, leaders in that setting (pastors, deacons, elders, priests, rabbis, imams, etc.) will provide pastoral care. This may include home or hospital visitation, marriage, burial, or other services. The person providing pastoral care may not be the same person providing counseling, but these people must work together.
For example, if a younger woman is seeing a counselor for marital problems, that counselor could arrange for the patient to meet with an older woman who is trusted and respected in the church. By providing this “pastoral” care, the older woman could become part of the younger woman’s care team.
People whose bodies are unhealthy cannot have minds which are healthy. Therapist and physician must work hand in hand to treat the whole patient and the whole family. Counseling for depression will be limited in value if the patient eats poorly and cannot sleep. Similarly, medication for depression won’t work as well in a patient who is trapped by anxious thought patterns.
Families provide more medical care than doctors and nurses. Doctors prescribe the medications, but families help the patient take the medications daily. Nurses dress wounds once in the outpatient clinic, but families dress them every day at home. Nutritionists and cooks ensure healthy and tasty meals while in the hospital, but families provide them for breakfast, lunch, and dinner.
Communities have their own effects on health and well-being, and have different resources to assist their members. Companies have employee assistance programs, schools have educational programs, and other organizations have resources to benefit their participants. By working with leaders in these areas, caregivers can help their clients and patients recover from mental and other illness, and better their health.
The purpose of the Context of Care and Recovery paradigm is to help caregivers and clients systematically identify contexts in which patients with mental health problems live. It is also useful to identify contexts of people without diagnosed disease who wish to improve their well-being. Having identified such contexts, caregivers use them to promote recovery and better health. Pastors preach, teachers teach, and administrators lead in the church, and all of these activities contribute to the healing milieu for patients. Preachers should make mental health, and health in general, a periodic topic from the pulpit. Teachers should offer classes on health, mental health, recovery, and similar topics in Sunday School, Bible Fellowships, and other teaching venues. Administrators likewise should arrange church or organization-wide opportunities for health, from blood drives to immunization campaigns.
Health is not the raison d’etre of the church, but the church (and other religious organizations) can make a huge difference in the health of its people. For example, a young woman in our church group struggling with anxiety improved markedly when she went on a mission trip with the youth choir.
Churches can improve the health of their congregations with the arts. Music has been shown to improve health outcomes, and even nature art in the halls can improve overall well-being. Gardens, lighting, and water features can be therapeutic.
Information and experiences from outside sources
The world is full of information and disinformation, and helping the patient separate truth from falsehood is one of the key duties of the counselor. Medicine advances in ways that can help patients, with new medications and other effective therapies arising constantly. Other areas in science and technology also progress. For example, self-driving cars will help epileptics and the elderly drive safely, providing flexibility and freedom that many today lack. Doctors, therapists, and families must be constantly on the lookout for new products, procedures, and paradigms that will help the patient and family.
Other interventions from animals to arts can help with mental and physical health. Theater, drama, dance, and music at all levels, from the high school to the Kennedy Center, can make people healthier. Both watching and participating are helpful. Outdoor activities such as riding, hiking, and photography make a difference.
At the same time, disinformation abounds. The internet carries 10 lies for every truth, and even facts on the internet are often misinterpreted. How many people look up medical symptoms on a trusted site, get sound information, and then convince themselves that they have that disease? In the 21st century, expectations are equally skewed. Photographs of beautiful women in magazines and on television/video put tremendous pressure on young women to be equally beautiful, even though the images are lighted and retouched as to be unreal.
Pastors, doctors, therapists, families, and patients should identify what information they consume, evaluate that information against the standard of truth and falsehood (including the Bible and the creation), use what is true and useful, and discard the rest. They should then modify their lives to exclude misleading and damaging information. Permanently turning off (or at least curtailing) the television and limiting the internet can be a good start.
Friends and acquaintances
The media and other factors are influential, but nothing shapes people as much as other people. Friends and acquaintances outside the home and the church can help or hinder a patient’s recovery. All those concerned about the patient, including the patient, can try to align their efforts to promote health.
Community and societal well-being and public health
Beyond the confines of the patient’s environment lies the wider world, and this wider world has an enormous effect on the health, and the mental health, of patients and their families. Poverty is associated with a litany of poor health outcomes. Pollution, whether air, water, food, noise, or any other, can kill. Cholera in London killed 616 people (1854) and smog in London caused about 4,000 premature deaths (1952). Even factors that do not kill can cause disease, harm function, and decrease quality of life. Lead poisoning was once widespread due to lead in paint and lead in gasoline but is now declining. It rarely kills but often harms, causing abdominal pain, anemia, confusion, headache, irritability, seizures, and long term brain damage. Large organizations such as government and major corporations typically act on this level.
The sovereign work of God
Bible-believing Christians are compelled to acknowledge the sovereign hand of God over all of the affairs of man. They are also commanded to understand the power of prayer to influence the work of God. Pastors, doctors, counselors, and other care givers must acknowledge these truths and use them in their patient’s/client’s life. The Lord will bless the efforts of all those who belong to Him, although He does not usually do so in the time or way that we expect (Romans 8:28, 2 Timothy 1:12). He will ensure that His perfect will is done in the lives of Christians, but we need to persist in faith, hope, and love. The Bible contains thousands of beautiful promises for those who know and love God, and counselors cannot fully succeed in their mission without believing and using them.
Life is hard, and medicine is hard. I could not do it without the strength of God. I pray for my staff and patients every day because I want, and need, to enlist the power of the Almighty on their behalf. The health and well-being of our patients and clients is so important, I do not know how caregivers could do otherwise. I strongly encourage all care givers to pray with and for their patients regularly.
People who deny Christ are still under the sovereignty of God. Muslims believe in a sovereign lord of the universe, as do Orthodox Jews. Patients of other religions and secularists, agonists, and atheists will react in accordance with their own beliefs. Therapists will do likewise.
Conclusion – Putting it all together
The Context of Care and Recovery paradigm focuses attention on the entire milieu surrounding a patient and family. Consider an obese, elderly woman suffering from arthritis, depression and diabetes. Many people will be involved in her care:
- She will comply with instructions and actively participate in all aspects of her care.
- Her family will help her with medications, appointments, diet, exercise, sleep, and coordinating with professional caregivers and other stakeholders. Her close friends will assist the family in these efforts.
- Her pastor will preach and teach on health issues occasionally, provide pastoral care, and lead the church to support her and others like her.
- Her church administrator will help organize elder transportation and an immunization fair to help keep her from getting the flu.
- Her employer will arrange her schedule to accommodate appointments and provide an employee assistance program to optimize her support at work.
- Her community pool offers a water aerobics and workout class that will help her move better, lose weight, and have better blood sugar control.
- Companies will support health in their employees, workplaces, and communities.
- Local, state, and federal government will help ensure a safe and healthful environment.
By helping coordinate the environment and all of its players, the patient, the family, the church, and all involved will benefit.
 Doug Saunders, Arrival City – How the Largest Migration in History is Reshaping Our World, Pantheon Books, New York, 2010, 282.