Chapter 11: Helping the Mentally Ill and Their Families
Madness severs the strongest bonds that hold human beings together. It separates husband from wife, mother from child. It is death without death's finality and without death's dignity.( Drugs and the Mind (New York: St. Martin's Press, 1957), pp. 167-68).
-- Robert S. de Ropp
The socially visible characteristic of the psychotic person is that he becomes a stranger among his own people.( Action for Mental Health, p. 59.)
-- Action for Mental Health
The crisis of mental illness is probably the most agonizing of all human experiences for everyone directly involved. Together with suicide, mental illness constitutes the deepest of the various forms of "deep water" through which individuals and families must sometimes go. A minister occasionally encounters persons who are on the verge or in the midst of major psychotic illnesses. More frequently he is contacted by a distraught family member who does not understand what is happening and/or does not know where to turn for help. Whether he is working with the ill person or with family members, this ministry will draw on all of a pastor's resources of empathy, interpersonal sensitivity, and compassion for those caught in the tentacles of an excruciating problem.
The clergyman has a responsibility to both the ill person and his family. In relation to the psychotic person, his role is to (a) recognize the difficulty as mental illness; (b) aid the ill person in finding psychiatric help (or guiding the family in making an involuntary commitment, if the person is unwilling to accept help); © maintain a supportive pastoral relationship during treatment, whether the person is hospitalized or treated on an out-patient basis; (d) maintain a close relationship and be available for counseling during the adjustment period following treatment.
The minister has a major opportunity in helping the patient's family. Often they are living under a dark, miasmic cloud of fear, humiliation, and guilt. Of necessity, the mental health professionals concentrate the bulk of their attention on the mentally ill person himself. Except for a minimum of help from the social work department of a mental hospital or clinic, the family is left to handle the trauma largely on its own. The pastor's opportunity to stand with the family in their lonely, confused distress is one of the privileges of being a clergyman.
The minister's role in relationship to the family is to (a) help them accept the painful fact that their loved one is mentally ill; (b) assist them in getting the person to psychiatric help; © maintain a supportive counseling relationship with them to help them understand and learn from the crisis. This involves helping them work through their painful feelings about the "stigma" of mental illness and their feelings of guilt and rejection toward the ill person. (d) The minister must help them relate constructively during visits to the hospital and help prepare them for the person's return to the family environment; (e) counsel with the family of the person requiring permanent custodial care; (f) keep in close pastoral contact with the entire family during the post-treatment adjustment, and (g) mobilize a caring ministry among members of the congregation. There are few places at which a minister can invest his pastoral time more helpfully than in a supportive ministry to the mentally ill and their families.
Recognizing Mental Illness
In the early stages of some forms of mental illness, both the individual and his family may be unaware of the nature of what is occurring. The person himself often is unaware because his illness, by its very nature, causes him to lack insight about his condition. The family members may believe that the person is merely selfish, inconsiderate, or temporarily upset. If early and intensive treatment are instituted. the severity and duration of mental illnesses can be reduced in many cases. Prompt recognition can lead to appropriate treatment before a serious disorder becomes set in a treatment-resistant stage.
A minister should not attempt to diagnose the specific nature of the difficulty. This is the psychiatrist's area of competence and responsibility. But the minister should know the general symptoms of mental illness. Here are some of the signs: (a) The person believes that others are attempting to harm him, assault him sexually, or influence him in strange ways. (b) He has delusions of grandeur about himself. © He shows abrupt changes in his typical pattern of behavior. (d) He hears voices, sees visions, or smells odors which do not exist. (e) He has rigid, bizarre ideas and fears which cannot be influenced by logic. (f) He engages in a repetitious pattern of compulsive actions or obsessive thoughts. (g) He is disoriented (unaware of time, place, or personal identity). (h) He is depressed to the point of near-stupor or is strangely elated and/or aggressive. (i) He withdraws into his inner world, losing interest in normal activities.( "A Clergyman's Guide to Recognizing Serious Mental Illness" by Thomas W. Klink is a useful resource. (National Association for Mental Health Inc., 10 Columbia Circle, New York 19, New York.)
When a minister sees any of these signs, he should help get the person to psychiatric treatment without delay. Although the vast majority of mentally ill persons are not dangerous to others, the deeply depressed person is always a suicide risk. Occasionally the individual with hallucinations or feelings of persecution may strike out destructively at others. Whatever the symptom, the earlier psychiatric treatment is begun, the better the chances for full recovery. If the minister encounters signs of psychosis in counseling with an individual, he usually should inform the family or other responsible persons. Unless there is obvious danger of precipitating a suicidal or homicidal attempt, the minister should explain to the individual why he must bring the family into the picture -- whether or not he understands or agrees with this action. Unless it is unavoidable the minister should not act behind the person's back in ways that the person may interpret as betraying him or plotting against him.
Family members sometimes deny that their loved one is really mentally ill, holding on desperately to the hope that the person will "snap out of it" or that "all he needs is a good rest." Their own feelings of distress, social stigma, fear, and guilt may be too strong for them to take appropriate steps without firm support and guidance by a trusted clergyman. The minister's logical ally in this situation is the family physician. The individual and the family should be steered in his direction for an evaluation of the problem and for assistance in arranging for psychiatric treatment. A family will often accept a physician's counsel on such matters. Also he can give sedation or other emergency medical help and arrange for hospitalization.
Finding Treatment Resources
Although the family physician usually should be the key person in arranging treatment of the mentally ill person, the minister occasionally has an important role in counseling with the family concerning their decision about whether or not to hospitalize the individual against his will. Many families arc reluctant to utilize state mental hospitals because of the "snake pit" stereotype which is in their minds. Often they believe (in some cases rightly) that the social stigma in state mental hospitals is greater than in private psychiatric hospitals. This is unfortunate since private facilities are usually very expensive and the ill person will not necessarily receive better care there. The treatment may be inferior to up-to-date state hospitals and is likely to be less adequate than in Veterans Administration mental hospitals, which generally have higher standards than state hospitals.
In the light of the minister's and doctor's evaluation of the available treatment resources, the family should be able to make the painful decision concerning which course to follow. If any one of the following has a possibility of sufficing, it should be tried before commitment to a mental hospital; short-term treatment in a psychiatric unit of a general hospital, outpatient treatment in a mental health clinic, or a day care or night treatment center. There is increased awareness among mental health professionals that if possible, it is better to treat a person in his community on an outpatient basis.
Two guiding questions to ask in selecting treatment facilities are: (a) Where will the person get intensive and appropriate treatment immediately? (b) Which approach will tend to separate the person least from his geographical and familial setting and most briefly from his work? Unless the state hospital treatment is obviously inadequate, families should be discouraged from acquiring a major debt to finance private hospitalization.
The most distressing situation for the family occurs when they must take responsibility for committing a relative involuntarily. "Commitment" is a legal procedure by which a court consigns a person to a mental hospital. His status becomes that of a child. He loses his adult rights to vote, marry, and enter into contracts. The hospital authorities, functioning as though they were his parents, grant him those liberties which they regard as constructive. He is restored to adult legal rights only when they release him, declaring that he is again competent to function as an adult. It is important for the family of a person who must be committed to recognize that mental illness has already deprived their loved one of the ability to make adult judgments. Commitment merely recognizes what has already happened and protects the person while he recovers adult competence through treatment. (A helpful discussion of the problems of hospitalizing a person with mental illness is found in Counseling Your Friends by Louis J. and Lucile Cantoni (New York: The William-Frederick Press, 1961), Chapter 7).
A minister should be familiar with commitment procedures in his state so that he can help interpret them to the family. The liberalization of some state laws permits increasing numbers of voluntary admissions to state hospitals. Application for such admissions may be by the person himself or by parents (or guardians), in the case of minors. If, after a psychiatric examination, the person is found to need hospitalization, he will be admitted. In most states he can leave at any time he chooses. In the case of involuntary commitments, in some states any adult relative or friend can file a request (with the court which handles such matters) that the allegedly mentally ill person be committed. The court appoints psychiatrists who examine the individual and report to the judge, who then makes the decision. If the individual wishes to contest the action, he can have a sanity hearing before a judge or jury, with his lawyer and with testimony from his own psychiatrist. After commitment, in some states the person (or anyone on his behalf) may file a petition for his release, which initiates another court hearing.
If a person is violent and/or adamantly refuses to accept help, it may be necessary for the family to call the police who will transport him to a public psychiatric ward (in a county hospital) or to a mental hospital for observation, This is the least desirable method of getting the person to treatment, but it sometimes becomes necessary as a last resort. Unless there is no alternative, the clergyman should not be involved directly in involuntary commitment procedures since this tends to distort his future relationships with the sick person.
Help During Hospitalization
The minister has important roles in helping both the hospitalized person and his family. With both, his ministry is primarily supportive and pastoral. Even though a mental hospital has an effective chaplaincy service the patient's minister should visit him as regularly as distance permits. This is assuming, of course, that such a call is desired by the person and there is no psychiatric reason why it would be disturbing. It is good procedure for the minister to phone the hospital in advance of a call to ascertain whether the medical staff feels that the person should have visitors at a certain stage in his recovery. Pastoral visits are usually encouraged by the medical staff. The minister is often allowed to visit during the first week or ten days within which visits by the family are not permitted in many mental hospitals.
An experienced mental hospital chaplain, Ernest E. Bruder, describes the importance of pastoral visits:
Much can be said about the deep psychological significance of a friendly visit from one's pastor. It can be one of the most constructive contributions to the patient's recovery. The very nature of the patient's illness has led him to believe himself to be ostracized. Thus, when a representative of the community calls -- and that representative is a clergyman -- it often encourages the patient to feel that he may not be as evil or wicked and hopeless as he felt himself to be. This is one of the most helpful contributions possible to the increase of the patient's self-esteem and as such -- his ability to get well.( The Church and Mental Health, p. 189.) Chaplain Bruder recommends that calls be brief; that the patient not be argued with, admonished, or criticized; and that the minister avoid making any promises which cannot be met helpfully. Prayer and scriptures should be used only when they are welcome and when the pastor has some insight concerning what they mean to the patient. When used they should be brief, affirmative, and supportive in nature.
A talk with the patient's doctor, preferably before the first visit, can be helpful in ministering both to the patient and to his family. The minister's understanding of the nature and prognosis of the problem puts him in a stronger position to help guide the family and interpret the patient's behavior and the therapy to them. This can assist them in facing the realities of the situation while avoiding unnecessary anxieties.
In order to minister effectively to the family, the minister needs to strive for '`heart-understanding" of their inner world. When the evidence becomes inescapable that a member of one's family is mentally ill, each family responds in its own unique way to this painful realization, depending on previous relationships within the family circle. Some families fragment while others unite under the crisis. Each individual responds with his own inner attitudes and feelings about mental illness. From his culture he has probably soaked up automatic responses of shame and stigma. Such feelings often are present even in persons with "enlightened" ideas about mental illness. People respond psychologically, not logically, to mental illness, particularly when it intrudes cruelly into their own family. Robert S. de Ropp's words, quoted at the beginning of this chapter, put the matter accurately and forcefully: "Madness severs the strongest bonds that hold human beings together . . . It is death without death's finality and without death's dignity."
The family's response is more than a reaction to the social stigma which still clings, leech-like, to mental illness. It is a response to the bizarre changes in the ill person himself which makes him a "stranger among his own people." It is a response to the disruption of essential family interaction, the disturbance of usual family patterns, the financial insecurity which arises from both the heavy costs of treatment and, in the case of the breadwinner, the loss of family income. During the development of mental illness, family life may be a nightmarish chaos. The natural self-protective tendency of the family is to retreat from social contacts to escape the social stigma they fear. But drawing into a shell only compounds the sense of isolation and the spiraling fear and hostility within their closed windowless walls.
The pastor who has some understanding of the family's inner world can be of inestimable help to them. Just knowing that he understands, cares, and stands beside them in their darkness probably helps them more than anything he does. He can assist the family in avoiding the automatic response of hopelessness which the majority of us have when mental illness strikes. Such a response is no longer valid in the light of the dramatic progress that has been made during the last decade in treating mental illness (see Chap. 5). It is important to acquaint the family with the new hope and help that is available without reassuring them in ways that will leave them unprepared to handle the grim possibility that treatment of their loved one may not be effective.
There are other things a minister can do to help the family. He can help them ventilate and clarify their swirling chaotic feelings about what is happening. In many cases, these feelings have been accumulating during the long weeks, months, or even years of growing stress preceding hospitalization. Guilt, hostility, and fear usually form a vicious alliance in the deeper feelings of the family members. Mental illness has hit one whose life is merged with theirs at many points. Thus, the illness has struck a blow at a part of their own psychological fields. If they are particularly fortunate they will have access to a mental hospital which holds regular family orientation or, better, family counseling sessions. If not, their contacts with the hospital staff will probably be frustratingly brief and totally inadequate to give them the amount of help needed in handling their own crisis and in relating constructively with their patient. The sensitive clergyman's ministry of listening and interpretation can help fill this need.
As the minister functions in this way he may become gradually aware of the ways in which the problems of the ill person and those of the family intertwine. He should, of course, not suggest to the family that this is true. To do so would be to push a threatening truth on them at the very time they need most to deny it. Eventually, if they have the capacity to learn and grow from the experience, they will be able to examine and rectify their interaction with the ill person.
There is a variety of practical ways in which a minister and his key laymen can help the family. To illustrate, if it is the mother who is ill, someone can be found to care for the children while the father is at work or visiting the mother. If it is the father, guidance in finding financial help during the crisis is often needed. The congregation should be encouraged to rally around the family quietly, in order to help them resist the temptation to withdraw from the sustaining, perspective-giving relationships with the extended family (including the church), which they need desperately. Maintaining a web of meaningful relationships is crucially important to the family at this point.
A simple but effective way for a congregation to express its concern for a family reeling under a heavy blow is for a number of persons to take them gifts of food. Not only does this have practical value at a time when family members may not have the time or energy to fix meals but it also has a profound symbolic meaning on the level of feeding and nurturing. A casserole may have more meaning than a prayer under certain circumstances.
There are several books and pamphlets which are useful in ministering to the family of the mentally ill. The classic in the field is by Edith M. Stern, Mental Illness: A Guide for the Family.( (4th ed.: New York: Harper & Row, 1962). It is a detailed manual which may help the family understand the various stages of hospitalization and posthospital care. The Family and Mental Illness by Samuel Southard ((Philadelphia: Westminster Press, 1957). This book contains an insightful description of the family crisis resulting from mental illness.)
has a pastoral emphasis but lacks some of the detailed answers to the family's questions about hospitalization, which is the strength of the Stern book. A mental hospital chaplain and a psychiatrist collaborated in producing a valuable pamphlet, "Ministering to the Families of the Mentally Ill." (By A. F. Ward and G. L Jones. This pamphlet can be obtained from the National Association for Mental Health, 10 Columbus Circle, New York, New York.) The Public Affairs pamphlet series includes "When Mental Illness Strikes Your Family" (K C. Doyle, Public Affairs pamphlet #172.) which is helpful to the family in coping with this crisis.
The Patient Who Does Not Return
The most difficult adjustment a family can be required to make occurs when a mental patient does not respond to treatment and becomes chronically ill. To the family, the person is in a sense dead and yet he is not dead. The normal bereavement process -- "grief work" -- cannot proceed since the person is not gone and the grief wound is infected. Such a wound cannot heal. Even though pitifully crippled psychologically and unable to show his need, the patient continues to need attention from the family. Unfortunately, his negative responses may help alienate them. I recall one mental hospital in which some six hundred patients received not a single Christmas card. Many of these had been abandoned by their relatives.
Edith Stern's book contains a brief but helpful chapter on the chronic patient. She writes to the family:
No matter how remote you regard the possibility of recovery, never abandon a patient.... It is pitiful to see mental hospital inhabitants who have not had a caller for perhaps twenty years groom themselves and wait hopefully on visiting day. Often the fact that someone related by blood or marriage still cares is the only thing in life to which a patient clings -- and this holds good even if he displays apparent indifference or antagonism to anyone and everyone. If the regular letter writer and visitor in your family dies, be sure that someone else takes over. (Mental Illness: A Guide for the Family)
This advice also applies to the ongoing ministry of pastoral care (by both laymen and clergymen). The chronically ill sheep are still members of the flock. Often, their need for shepherding is great. Fortunately, with newer methods of treatment (remotivation, for example), some persons who had been regarded as "hopeless" or "untreatable" for years are now responding.
A related problem is the pastoral care of the family in which there is a harmless, ambulatory psychotic who has been given all that psychiatry has to offer but has not been helped. A supportive ministry to such a person and his family can be a godsend. Here, for instance, is the husband of a mildly and chronically paranoid woman. The help he receives from the worship services and an occasional talk with his minister is a major factor in helping him carry a staggering load.
It may help the families of persons with chronic mental illness to become involved in volunteer service in a community mental health project or a mental hospital. This can reduce the feelings of blind frustration and channel some of their blocked concern into socially constructive efforts.
When the Patient Returns from the Hospital
It is reliably estimated that readmission rates to mental hospitals could be reduced from almost thirty-five percent to around ten percent were adequate medical, social, and vocational aftercare facilities available. Unfortunately, few states provide more than minimal aftercare services to help patients bridge the yawning chasm between the moment of discharge and satisfying functioning in the community. The Joint Commission on Mental Health and Illness reported in 1961 that aftercare services were in a "primitive stage of development almost everywhere." (Action for Mental Health, p. xvii.) Halfway houses (where small groups of patients who are not ready to return to their homes live together and receive help in social rehabilitation), day hospitals, foster home services, rehabilitation centers, and ex-patient clubs are still in short supply in all parts of our country. Thousands of relapses could be prevented if there were an abundance of such facilities. This is one of the major mental health challenges of the 1960's(For a graphic description of the problem of aftercare and examples of what is being done in scattered places, sec "Mental Aftercare: Assignment for the Sixties" by Emma Harrison, Public Affairs Pamphlet #318. C. A. Chambers' dissertation "A Determination of the Extent to Which Certain Protestant Churches Can Meet the Needs of Former Mental Patients" (Temple University, 1960) describes the church's role.)
The acute shortage of community aftercare resources increases the responsibility of the local church in meeting this vital need. As shown by C. A. Chamber's research, churches can respond effectively to this need. A refreshing example of direct congregational action in providing aftercare facilities is Baker Street House in San Francisco. This is a halfway house sponsored by a Methodist church in that area. It serves as a residence for young adults who have been released from mental hospitals and for those who are receiving treatment at outpatient psychiatric services. These persons live there with other young adults who have no major psychological problems. Residents participate in resident government, cook for themselves cooperatively, take part in both spontaneous and planned recreation and educational activities, and receive guidance they may desire in such matters as seeking employment and utilizing health and educational agencies in the community. Residents stay at least a month and no longer than 18 months. The setting is designed to serve as a springboard to more permanent living situations. The house is co-educational. House parents are responsible for program and administration. They fill the role which Erik Erikson calls the "adult guarantors." The sponsoring committee from the church takes responsibility for guiding the financial operation of the house. Committee members spend considerable time at the house interacting informally with the residents. The sponsoring committee and the houseparents receive regular training and counseling. (Twenty-three people from the church completed a sixteen-week training course in preparation for opening this facility.) The Glide Foundation launched the project and provides leadership-training. This halfway house provides a supportive interpersonal environment with a combination of peer group discipline and freedom. Here the recovering young adults may learn new social skills and test them out in actual relationships of the house. They can do reality-testing in an accepting group. This is a form of "social therapy" complementing the psychiatric treatment which is available in other facilities. Leaders of this project report that the church people involved have become excited with its obvious value. They believe that the churches can do a more effective job than any other agency in this area of great need and that such involvement can bring churches alive with a new sense of mission.
The minister can work with the family and with key laymen in his congregation to help prepare them to receive the discharged mental patient in a way that will contribute to his full recovery. Mental patients about to be discharged usually face the outside world with considerable anxiety about how their families, friends, and potential employers will react to them as "ex-mental patients." Families and friends are also anxious. How the ex-patient is received by the important people in his life (including, in many cases, his fellow church members), and whether he is able to find a job are important factors in determining whether or not he suffers a relapse. Finding employment is often difficult because of prejudice against those who have had major psychiatric problems. In some cases a minister can help the mentally restored person by contacting potential employers in the congregation.
Edith Stern's Mental Illness: A Guide for the Family has an excellent chapter on what to do when the patient comes home. And Lauren H. Smith, former Chairman of the Council on Mental Health of the A.M.A. gives this list of "Do's and Don'ts" to help an expatient:
Do . . . Give support, encouragement, respect and affection . . . Expect in general the same kind of conduct you would from anyone else . . . Be optimistic about the ability to change . . . Recognize the right to disagree . . . Keep up prescribed medicine.
Don't . . . Be over solicitous or encourage dependency . . . Be de- manding, disrespectful or rejecting . . . Threaten a return to the hospital . . . Agree with "extreme" talk or attitudes . . . Talk behind his back ("When a Mental Patient Comes Home," This Week (January 6, 1963).
There is almost always a period of readjustment to living outside the hospital and often the person has some residual symptoms. These take patience and understanding on the part of the family. Many families are "jumpy" with the ex-patient, fearing that every ripple of his emotional sea foretells a relapse. When they are beset by such worries, they should be encouraged to contact the psychiatrist who treated the person. The period of readjustment is especially difficult for many families because the mental illness is intimately related to family relationships. It behooves the minister to stay close to the families in his congregation who are in the throes of such an adjustment. The steadying influence of a concerned person from outside the family may be precisely what is needed.
The minister with training in counseling can perform a valuable service by being available to counsel with parishioners who are completing their recovery following discharge from a mental hospital. Before attempting anything beyond supportive counseling, it is wise to check with the psychiatrist, if possible. Ernest E. Bruder's volume, Ministering to Deeply Troubled People (Ernest E. Bruder [Englewood Cliffs, N. J.: Prentice-Hall, 1963.]) should be regarded as prerequisite reading for counseling with the mentally ill. Bruder's depth understanding of the "wilderness of the lost" makes this book a moving experience. He points out that persons with mental illness can be our teachers if we dare get close to them. Any minister who is tempted to assume that counseling with persons who are in the process of recovering from mental illness should be entirely the province of the psychiatrist, ``rill find himself confronted by this paragraph:
Mental illness . . . is involved with faith -- faith in the Ultimate, faith in each other, faith in ourselves. Distortion and conflict in any one area affect all areas. Whether it is expressed in religious terms or not, the meaning of life, values, destiny -- ultimates -- are matters of faith and therefore are religious concerns. This is the area of the clergyman. Faith proceeds from trust and trust arises from the good relationships that we have with others.(Ibid., p. 70)
Anton Boisen's view that mental illness is often a religious crisis -- a last-ditch effort of the psyche to find a new orientation of meaning, correlates with Bruder's view of mental illness.
Bruder recommends this approach to persons recovering from mental illness:
Fundamentally . . . the minister seeks to understand what the patient has experienced in his living which has made it necessary for him to become mentally ill. He does his best when he offers the patient the greatest gift he has -- the gift of himself, rooted and grounded in the Being of God. His own friendly interest, his own reaching out with concern, his own desire to be helpful through a trained and understanding use of his unique religious resources -- these are the things the patient needs. Being exposed to this attitude in the minister, the troubled person comes to feel encouraged to reach out of the loneliness of his isolation for the help which is available.(Ibid., p. 70)
Ministering to the Suicidal Person
In the United States every sixty seconds, someone attempts to end his own life.( Karl Menninger in the Foreword to Clues to Suicide by E. S. Shneidman and N. L. Farberow (New York: McGraw-Hill Book Co., 1957). Some fifty times a day persons succeed in doing so. Suicide ranks ninth among the causes of death in our country. Each year some 18,000 persons destroy their lives. Probably five times this number attempt to do so. Reflecting on their experiences at the "Suicide Prevention Center" in Los Angeles, E. S. Schneidman and N. L. Farberow point out that all suicides, whether attempted or committed, "involves tremendous disruption of life, emotional turmoil, social discord." (Norman L Farberow and Edwin S. Schncidman (eds.), The Cry for Help (New York: McGraw-Hill Book Co., 1961), p. 4.) Any minister who has dealt with the impact of suicide on a family can vouch for the accuracy of this statement.
Concerning the minister's role in preventing suicides, psychiatrist Herbert M. Hendin declares:
For some time now it has been evident that concerted effort and awareness on the part of those in close contact with the potential suicidal person could greatly reduce the number of actual suicides. Since members of the family are often too much involved themselves to see the oncoming development of suicide in one of their number, it is here that the minister may well save a life.( "What the Pastor Ought to Know About Suicide," Pastoral Psychology (December, 1953), p. 41.)
How does one recognize a potential suicide? Suicides occur most often among the following: (a) Those who threaten suicide. The old belief that "those who talk about suicide don't commit suicide" is a deadly fallacy. Of every ten persons who kill themselves, eight have given definite warning of their intentions.( "Some Facts About Suicide," Public Health Service Publication #852, 1961, p. 3.) The only safe rule to follow is this -- all suicidal threats must be taken seriously. Even the person who has no intention of killing himself, but who uses the threat to force others to take care of him, pay attention to him, or do what he demands, is emotionally disturbed and in serious need of psychiatric help. All suicide threats are serious, but they are especially dangerous if the person is an older male. Men kill themselves twice as frequently as women, although women attempt suicide twice as often as men. In general suicide attempts are more apt to be successful among older persons. (b) Persons who express feelings about their lives being empty, meaningless, worthless or "no longer needed" by anyone may be making suicide threats in disguise. (c) Any seriously depressed person, whatever the cause. One or more of these signs may accompany psychological depression -- feeling of a "heavy weight" on one's mind, loss of interest in normal activities, severe insomnia, undiminishing fatigue, feelings of "What's the use?", loss of appetites for food and sex, tension and agitation, social withdrawal, general motor retardation. (d) Persons who have experienced major losses which deprive them of a dependency person or of a source of self-esteem such as a highly valued job. (e) Those with protracted illnesses. Feelings of hopelessness and helplessness, particularly if the person is in intense pain, are danger signs. (f) Persons who suddenly make plans for death (making a will or getting their affairs in order) This is a warning sign if they are also generally unhappy or depressed. (g) Those suffering from pathological grief reactions. (h) Those suffering from mental illness. Suicides are frequent among schizophrenics, psychopathic personalities, alcoholics, and those with psychotic depressions. A suicide attempt may signal the onset of a psychotic episode.
If a minister knows or suspects that an individual is suicidal, he should inform the family or other responsible person and strongly recommend that psychiatric help be obtained at once. If no psychiatrist is available, any medical doctor will do. In an emergency, the person can be taken to a county hospital or the emergency service of any general hospital.
In talking with a person suspected or recognized as suicidal, the minister should encourage him to talk openly about it. This will tend to rob suicide of some of its distorted appeal to the person and give the minister an opportunity to help. The fear of suggesting suicide to a person who has no suicidal thoughts by raising the question, is largely unfounded. The minister should offer the person help and hope. If he does not respond to this offer, he has probably given up. If so, the minister should not let him out of his sight until some other responsible person has taken charge. If the person is intent on killing himself, the minister (and others) should use whatever persuasion or coercion is necessary to block this. For example, if the suicidal person believes that he is doing what is best for his children, it should be pointed out forcefully that leaving them with the psychological burden of his suicide is the worst thing he could do for them. If a person is determined to destroy himself, and this feeling continues over a long period of time, it is often next to impossible to prevent his death. Hospitalization of such a person is essential. Fortunately, most suicidal persons have ambivalent feelings about dying and self-destructive impulses ordinarily diminish, given time. Sixty-five per cent of those who make one unsuccessful suicide attempt do not try suicide again. The majority of second attempts occur in the ninety days after the first. This is the most critical period.
The clergyman who has a community resource such as the Los Angeles Suicide Prevention Center (For more information write Suicide Prevention Center, P. O. Box 31398, Los Angeles 51, California.) is very fortunate. The People's Church of Chicago sponsors a telephone answering service labeled simply "Emergency Call." The phone book carries this ad: "Emergency Call; Don't let worry end in tragedy. Call Longbeach 1-9595 day or night. A sympathetic minister will be happy to talk with you." When calls come from those in serious trouble, a minister in the caller's district is notified. If the case is urgent, the women who answer the phone try to hold the caller on the phone until a physician or the police can be alerted.( V. A. Kraft, "Suicide Call," Christian Advocate (March 17, 1960), pp. 9- 10.)
One's Own Attitude Toward the Seriously Disturbed
In the final analysis, one's own deep feelings about mental illness and suicide will determine one's effectiveness in this type of pastoral care. Because each of us is in our culture as a fish is in water, the stigma of mental illness is in our deeper feelings to some degree. If these feelings are strong, they will block our effectiveness in ministering to the mentally ill person and his family.
One of several values of clinical pastoral training in a mental hospital is that it provides an opportunity to work through feelings about oneself in relation to deeply disturbed persons. However it occurs a ministering person needs to achieve something of a fellow feeling for the mentally ill person -- to get beyond the labels he has been given and become aware of a suffering fellow human being. As psychiatrist Frieda Fromm-Reichmann once put it, "Unless one believes and feels that the most regressed catatonic, on the back ward of the mental hospital, is more alike than different from oneself, one will be of little help to the mentally ill person." (Lecturer at the William A. White Institute of Psychiatry, 1948).
There are a number of factors which converge to produce the attitudes of rejection which many ex-mental patients experience (See Chap. 5). These include the fear that the person's irrational side will break through again; fear. of our own irrational impulses of which this illness reminds us; resentment of his irritating behavior; resentment of the threat to family pride which his former condition continues to pose; and the painful confrontation with the dark unknown in human life. (1 am indebted to Camilla M. Anderson for pointing me to the two final factors.)
In discussing the minister's work with the mentally ill, Ernest Bruder writes pointedly that "what a minister is in himself matters far more than what he does." He continues in this searching vein:
Only when he has dared to allow himself to experience something of the suffering and joys of his own living, when he has come to terms with his own experiences, is he in a position to appreciate similar feelings in others.... If the pastor has a keen awareness of what we have come to regard as the interpersonal hurt of his patient; knows the desperate and yet fatal need of the patient to evade further pain, no matter by what means, and often by striking out and hurting loved ones; feels something of the almost overwhelming and intolerable anxiety the patient experiences; is not too shaken by the terror evoked through what Kierkegaard expressed as "shut-up-ness unfreely revealed"; and can accept the consequent intense feelings of guilt and shame which isolate the patient from himself, from others and from God, then his ministry has within it the necessary element for a supportive and creative experience for the patient.( Ministering to Deeply Troubled People, p. 70.)
A therapeutic attitude is essential for working redemptively with any troubled person -- an alcoholic, a prisoner, a suicidal person, a mental patient, or the families of any of these. That the helping person possesses something of this attitude is vastly more important than the particular counseling techniques he uses in such a relationship. The late Otis Rice who did some of the pioneering work in pastoral counseling with alcoholics once commented that to help an alcoholic, one must love him, and this isn't easy, since a drinking alcoholic can be very unlovable. One thing that had helped him, Rice reported, was "to remember that God loves the alcoholic, that he also loves Otis Rice, and then to remember how much God has to put up with in loving Otis Rice." (Talk before the New York Academy of Medicine, 1952.)
A retired minister, Harold W. Ruopp of Minneapolis, while reflecting on his life, provided a striking illustration of what I mean by a therapeutic attitude. In retrospect, he identified three stages in his ministry. In the first stage, he tried to stand outside the life process as a spectator rather than a participant. He used an analogy to describe this stage -- that of sitting on a riverbank preaching '`helpful" sermons to the swimmers struggling in the current. In the second stage of his ministry a few years later he became a kind of lifeguard -- a great helper "humbly proud" of his role, from time to time jumping into the river to put his arm around someone going down for the third time. As soon as he got him steadied to swim again, he would return to his place on the bank to wait for the next person who needed saving.
The third stage of his ministry came, he recalls, because of circumstances beyond his control in his own life. From then on, he was in the river all the time! Instead of always trying to hold someone else up, he gladly permitted another person to hold him up. Instead of being the savior, he realized that he too needed saving. Again and again, he found that the humblest person had his arm around him, even as he tried to support that person. He concludes: "In the admission of great weakness, I found great strength. In the willingness to be helped, I became a better helper." (The original form of this illustration appeared in Harold W. Ruopp's recently published book of sermons, One Life Isn't Enough (St. Paul, Minn.: Macalester Park Publishing Co., 1965), in the section "Postscript."
This is the therapeutic attitude! A minister or layman who has it will be of genuine help to individuals and families who are "going through deep waters."
Bruder, Ernest E. Ministering to Deeply Troubled People. Englewood Cliffs, N.J.: Prentice-Hall, 1963.
Farberow, Norman L., and Schneidman, Edwin S., eds. The Cry for Help. New York: McGraw-Hill Book Company, 1961.
Southard, Samuel. The Family and Mental Illness. Philadelphia: Westminster Press, 1957.
Stern, Edith. Mental Illness: A Guide for the Family. 4th ed., New York: Harper & Row, 1962.