We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place.

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We hope that this will help to inform not only those who are dealing with the issue, but will enable all of our readers to learn from the experiences and perhaps mistakes of others.

PLEASE NOTE: Due to unanticipated continuing responses to both the case and the resolution of the case, added responses can be viewed in the archives. Click HERE.

Case #17 (see responses below)

A fourteen-year-old young lady was admitted through the emergency room to the Adolescent Psychiatric unit of a hospital after attempting suicide by an overdose of drugs.

Four months before admission, her mother had died of cancer. Since that time, the adolescent's behavior had greatly deteriorated. She was skipping school more than she was attending. Her grades had fallen from a B average to failing. She became promiscuous, started on street drugs and alcohol, became belligerent in speech and abusive emotionally and physically, and began running with a wild crowd. Her attitude towards life had greatly changed from the church-going adolescent she had been six months earlier. She appears to have lost all desire to live.
She has been living with her maternal grandparents since her mother’s death. They no longer feel they are capable of caring for her and want her placed in foster care.

She shares with the chaplain that she and her mother and had attended church constantly, asking God to heal her mother, but her mother died anyway. A few weeks before her death, the mother called her daughter into her room and said that she was angry with God for not healing her. The mother said that she decided to reject God and “follow the devil instead.” The adolescent told this to their pastor. The pastor told her that it was "too bad" and that her mother was "now in hell."

What else would you want to know before making a spiritual assessment?

What is your spiritual assessment given the information already presented?

What would you advise the rest of the team in terms of how they should relate to her?

What would your plan of care be?

What outcomes would you expect?

Responses:

This is a complex case for everyone involved that could stir deep seeded emotions for everyone. It is obvious that the girl has attended a conservative church that believes in some strong values, such as heaven, hell, and sin. Exploring the religious dimensions of the whole family's life, (including the grandparents) and possibly other family members could be valuable in the spiritual assessment. Other family who might be supportive could be valuable. However the acute grief, the difficult adjustment to the new home, all need to be addressed. It would be interesting also on a first visit to see how the adolescent responds to the idea of "chaplain". Does it trigger anger because of what has happened with the pastor or some other response? I think targeting grief work would be the initial need and that may come through some relationship building at first. The treatment team may or may not even exam the "hell" question or the healing question. They will focus also on grief, as well as adjustment (and probably some medication issues for depression). It would serve the chaplain well to become part of the family meeting to further ongoing assessment. One might hope for a reframing of the pastor's response at some point; however the ethics of challenging religious beliefs would need to be carefully thought through.

Adolescent treatment often goes very fast in psychiatric hospitals and this adolescent probably will probably stay at the longest two weeks. If the treatment team does decide on foster care based on the family conference, the adolescent will be there possibly for a few more weeks. Contacting the church if the child wants this could be valuable or could be painful; however the church may be a support for the grandparents. One other goal in treatment or informally in conversations with the child may be conversations on the nature of addiction and the relationship to grief.

Assessment and treatment, at some level involve balancing religion (the church where she and her family has come from), theological beliefs (hell and healing), and spirituality (grief, family grief and adjustment, and her individual as wells as family spiritual help). Perhaps a referral at discharge to a Christian Counseling center (similar to her beliefs or a Pastoral counseling center could be in order as part of discharge planning. A lot to accomplish in a psychiatric healthcare system that will at best give her 2 weeks.

Dennis DuPont, M.Div., BCC
Director of Pastoral Care
Spring Grove Hospital
Catonsville Maryland

What else would you want to know before making a spiritual assessment?
I would want to know more about her relationship with her mother and her hopes for that relationship. Is she hell-bent to be reunited with mom? Is she acting out the way she feels that everyone around her sees her mother? Similarly, I would want to know more about her relationship with God and how she might understand the role of reconciliation in covenant.

What is your spiritual assessment given the information already presented?
The patient is emotionally and spiritually alienated from her social and moral groundings. Her spiritual world has collapsed and she is unable to access the resources necessary to rebuild it. She sees herself as painfully alone in an entirely unfriendly world.

What would you advise the rest of the team in terms of how they should relate to her?
Respond honestly to her questions and respect her opinions. Do not try to reform her so much as try to help her come to terms with who she is after this devastating loss. She needs to develop healthier ways to feel more in control of her life and may well have a great need for trust, because without trust she cannot begin to re-grow her faith.

What would your plan of care be?
Let her spend as much grief in as many forms as she chooses to share. Then explore her spiritual and religious resources uncritically, encouraging her to build an inventory of spiritual and moral stories from which she can begin to develop an independent theological framework, reflective of her family and church's stories, but not wholly dependent on them for validation.

Help her to reflect on the qualities of her mother's faith and how her faith might be like and unlike mom's faith. Encourage her to look for maternal figures in her world and in the stories of her faith tradition from which she can find solace and inspiration. Let her know that being angry with God is okay, and it doesn't mean that their relationship is over.

What outcomes would you expect?
I would expect her to make the first tentative moves toward experiencing an interior life independent of her mother, and to find some value in that discovery.

Keith Goheen
Chaplain, Beebe Medical Center
Lewes, DE USA

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