Category Archives: #Depression

DEFINITION OF DEPRESSION

When discussing depression as a symptom, a feeling of hopelessness is the most often described sensation. Depression is a common psychiatric disorder in the modern world and a growing cause of concern for health agencies worldwide due to the high social and economic costs involved. Symptoms of depression, like the disorder itself, vary in degree of severity, and contribute to mild to severe mood disturbances. Mood disturbances may range from a sudden transitory decrease in motivation and concentration to gloomy moods and irritation, or to severe, chronic prostration.

With treatment, more than 80% of people with depression respond favorably to medications, and the feeling of hopelessness subsides. With treatment, most people are able to resume their normal work and social activities.

Depression may occur at almost any stage of life, from childhood to middle or old age, as a result of a number of different factors that lead to chemical changes in the brain. Traumatic experiences, chronic stress, emotional loss, dysfunctional interpersonal relationships, social isolation, biological changes, aging, and inherited predisposition are common triggers for the symptoms of depression. Depression is classified according to the symptoms displayed and patterns of occurrence. Types of depression include major depressive disorder, bipolar depressive disorder, psychotic depressive disorder, postpartum depression, premenstrual dysphoric disorder, and seasonal disorder. Additional types of depression are included under the label of atypical depressive disorder. Many symptoms overlap among the types of depression, and not all people with depression experience all the symptoms associated with their particular type of the disorder.

Description

Symptoms of a depressive disorder include at least five of the following changes in the individual’s previous characteristics: loss of motivation and inability to feel pleasure; deep chronic sadness or distress; changes in sleep patterns; lack of physical energy (apathy); feelings of hopelessness and worthlessness; difficulty with concentration; overeating or loss of appetite; withdrawal from interpersonal interactions or avoidance of others; death wishes, or belief in his/her own premature death. In children, the first signs of depression may be irritation and loss of concentration, apathy and distractibility during classes, and social withdrawal. Some adults initially complain of constant fatigue, even after long hours of sleep, digestive disorders, headaches, anxiety, recurrent memory lapses, and insomnia or excessive sleeping. An episode of maression may be preceded by a period of dysthymia, a mild but persistent low mood state, usually accompanied by diminished sexual drive, decreased affective response, and loss of interest in normal social activities and hobbies.

Most individuals with depression have difficulty in dealing with the challenges of daily life, and even minor obstacles or difficulties may trigger exaggerated emotional responses. Frustrating situations are frequently met with feelings of despair, dejection, resentment, and worthlessness, with people easily desisting from their goals. People with depression may try to avoid social situations and interpersonal interactions. Some people with depression overeat, while others show a sharp loss of appetite (anorexia). In some individuals, medical treatments for some other existing illness may also cause depression as an adverse reaction. For instance, antihypertensive drugs, steroids, muscle relaxants, anticancer drugs, and opioids, as well as extensive surgery such as a coronary bypass, may lead to depression. Cancer and other degenerative diseases, chronic painful conditions, metabolic diseases or hormonal changes during adolescence, or after childbirth, menopause, or old age may be potential triggers for depression. When the first onset of depression occurs after the age of 60, there is a greater possibility that the causative factor is a cerebrovascular (blood vessels in the brain) degeneration.

Molecular genetics research has recently shown that mutations in a gene coding for a protein that transports serotonin (a neurotransmitter) to neurons may determine how an individual will cope with stressful situations. A two-decade study involving 847 people of both sexes has shown that those who inherited two copies of the long version of the gene 5-HTT have a 17% risk of suffering a major depressive episode due to exposure to four or more identified stressful situations in their lives, whereas those with one long and one short version of the gene had the risk increased to 33%. The study has also shown that individuals with two short copies of the gene have a 43% probability of a major depressive episode when exposed to four or more stressful life events. The shorter version of the gene 5-HTT does not directly causes depression, but offers less protection against the harmful effects of traumatic or stressful situations to the brain. Studies of population genetics have also shown that about 50% of the world’s Caucasian population carry one short and one long version of 5-HTT genes.

Depressive episodes may be associated with additional psychiatric disorders. Neurotic depression is often triggered by one or more adverse life events or traumatic experiences that have historically caused anxiety in the life of the person experiencing depression. For example, loss of social or economical status, chronic failure in living up to the expectations of parents, teachers, or bosses, death of a close relation, work-related competitive pressures, and other stressful situations such as accidents, urban violence, wars, and catastrophic events may lead to a depressive episode. Conversely, anxiety disorders such as panic syndrome, phobias, generalized anxiety, and post-traumatic stress disorder may trigger a major depressive crisis. Psychotic depressive disorders are likely to be associated with other psychiatric diseases or caused by them. Eating disorders such as bulimia, anorexia nervosa, and binge-eating disorder are generally accompanied by depression or may be caused by an existing depressive state. Neurodegenerative diseases such as Alzheimer’s, Huntington’s, and Parkinson’s diseases frequently have depression among their symptoms.

Dysthymia is a mild but chronic depressed state, characterized by melancholic moods, low motivation, poor affective responsiveness, and a tendency for self isolation. A dysthymic state lasting two years or longer is a risk factor for the onset of a major depressive episode. However, many dysthymic individuals experience a chronic low mood state throughout their daily lives. Dysthymia is a frequent occurrence in individuals involved in chronic dysfunctional marriages or unsatisfying work conditions. Such chronic stressful situations alter the brain’s neurochemistry, thus the opportunity arises for symptoms of depression to develop.

Psychotic depression is a particularly serious illness and possesses biological and cognitive (thought) components. Psychotic depression involves disturbances in brain neurochemistry as a consequence of either a congenital (from birth) condition or due to prolonged exposure to stress or abuse during early childhood. Prolonged exposure to severe stress or abuse in the first decade of life induces both neurochemical and structural permanent changes in the developing brain with a direct impact on emotional aspects of personality. Normal patterns of perception and reaction give way to flawed mechanisms in order for a person to cope with chronic fear, abuse, and danger. Perception becomes fear-oriented and conditioned to constantly scan the environment for danger, with the flight-or-fight impulse underlying the individual’s reactions. Delusions, misinterpretation of interpersonal signals, and a pervading feeling of worthlessness may impair the individual’s ability to deal with even minor frustrations or obstacles, precipitating deep and prolonged episodes of depression, often with a high risk of suicide. Hallucinations may also occur, such as hearing voices or experiencing visions, as part of depression with psychosis.

A major depressive disorder (MDD) or clinical depression may consist of a single episode of severe depression requiring treatment or constitute the initial sign of a more complex disorder such as bipolar disorder. MDD may last for several months or even years if untreated and is associated with a high risk of suicide. In bipolar disorder, manic (hyper-excited and busy) periods alternate with deep depressive episodes, and are characterized by abnormal euphoria (an exaggerated feeling of happiness and well-being) and reckless behavior, followed by deep distress and prostration, often requiring hospitalization.

Major episodes of depression may last for one or more years if not treated, leading to a deep physical and emotional prostration. The person with major depression often moves very slowly and reports a sensation of heaviness in the arms and legs, with simple walking requiring an overwhelming effort. Personal hygiene is neglected and the person often desires to stay secluded or in bed for days or weeks. Suicidal thoughts may frequently occupy the mind or become recurrent patterns of thinking. Painful or unsettling memories are often recalled, and contribute to feelings of helplessness.

Atypical depression causes a cyclic behavior, alternating periods of severe and mild depressive states, punctuated by mood swings, hypersensitivity, oversleeping, overeating, with or without intermittent panic attacks. This depressive disorder is more common in women, with the onset usually occurring during adolescence.

Premenstrual dysphoric disorder (PDD) is not premenstrual stress. It is a more severe mood disorder that can cause deep depression or episodes of heightened irritation and aggressiveness, starting one or two weeks before menstruation and usually persisting during the entire period. Premenstrual dysphoric disorder is associated with abnormal changes in levels of hormones that affect brain neurochemistry.

Seasonal affective disorder (SAD) is caused by disturbances in the circadian cycle, a mechanism that controls conversion of serotonin into melatonin in the evening and mid-afternoon, and the conversion of melatonin into serotonin during daytime. Serotonin is the neurotransmitter responsible for sensations of satiety and emotional stability, which is converted at nighttime into melatonin, the hormone that regulates sleep and other functions. Some people are especially susceptible to the decreased exposure to daylight during long winter months and become depressed and irritable. Overeating and oversleeping during the winter season are common signs of seasonal affective disorder, along with irritation and depressed moods. However, as the amount of light increases during the spring and summer seasons, the symptoms disappear.

Postpartum depression is a severe and long-lasting depressive state also associated with abnormal changesmone levels affecting brain neurochemistry. If untreated, postpartum depression may last for months or even years, and is highly disruptive to family and maternal-child relations.

Without treatment, the risk of suicide as a consequence of depression should not be underestimated. Suicide accounts for approximately 15% of deaths among people with significant depression, and half of all suicide attempts in the United States are associated with depression. Persistent and recurrent depressive episodes are important contributors to other diseases alike such as myocardial infarction, hypertension, and other cardiovascular disorders.

Resources

BOOKS

Klein, Donald F., MD. Understanding Depression: A Complete Guide to Its Diagnosis and Treatment. New York: Oxford Press, 1995.

Solomon, Andrew. The Noonday Demon: An Atlas of Depression. New York: Scribners, 2002.

PERIODICALS

Manji, H. K., W. C. Drevets, and D. S. Charney. “The Cellular Neurobiology of Depression.” Nature Medicine (May 2001) 7: 541–546.

Teicher, Martin H. “Wounds That Won’t Heal–The Neurobiology of Child Abuse.” Scientific American (March 2002): 68–75.

OTHER

National Institute of Mental Health: Depression. February 12, 2004 (March 31, 2004).

ORGANIZATIONS

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (800) 615-NIMH (6464); Fax: (301) 443-4279. nimhinfo@nih.gov.

Sandra Galeotti

Info Supplied by answers.com – depression

DEPRESSION

Depression has been recorded since antiquity. Everybody feels ‘blue’, ‘sad’ or ‘upset’ at times or at some stage in his or her life. Transitory feelings of sadness or discouragement are perfectly normal, especially during particularly difficult times in a person’s life. A person who cannot get over these feelings may suffer from an illness called depression. In modern medicine it is well recognized that depression is an illness caused by an imbalance of neurochemicals in the brain.

How to tell when you are depressed

You can determine whether you are depressed, and also measure the severity of the depression by completing this Questionnaire.

Depression is a serious illness (a medical condition) and should not be confused with other mood conditions such as ordinary grief, burnout or disappointment. The two major indications of a major depression are either:

  • Feeling sad, blue, down in the dumps that lasts two weeks or more;
  • Diminished interest in pleasurable activities, including sex;

If any of the above important symptoms are present, also look for:

  • Significant weight loss or gain;
  • Sleeplessness or excessive sleeping;
  • Slowed body movements or thoughts;
  • Fatigue;
  • Feelings of worthlessness or guilt;
  • Impaired concentration, indecision or forgetfulness; and / or
  • Thoughts of death or suicide.

If you have either one of the first two symptoms, coupled with any four of the last seven, it means that you probably have a major depression. When the symptoms last for at least two weeks or if they include thoughts of suicide you should consult your doctor immediately.

What Causes Depression?

With our current medical knowledge we must assume that no single cause gives rise to depression. In some cases environmental stress, personal circumstances and life events (psychosocial cause) can give rise to a depressive episode. These events may be death of a loved one, physical illness, financial hardship, retirement and retrenchment. Genetic research also supports the theory that there are family links in depression. Ultimately depression has a neurochemical cause which forms the basis of modern medical management.

Treatment for Depression

Depression is one of the most easily treated emotional disorders today. More than 80 % of depressive patients should recover within a few weeks thanks to a variety of effective treatments that have become available.

MEDICAL TREATMENT

Antidepressants are highly effective treatments. The choice of an antidepressant can be made from one of several classes of antidepressants. The most commonly used first line treatment for depression is the Selective Serotonin Reuptake Inhibitors (SSRI’s). Older classes of antidepressants are the Tricyclic Antidepressants and Monoamine Oxidase Inhibitors. Several new classes of antidepressants have been launched in recent years. Electroconvulsive or ‘shock’ therapy (ECT) is considered by many to be a very effective treatment for severe depression. It is used as a last line of treatment when all the other options were not successful.

What can you expect when treated with an antidepressant?

This is a graphic representation of the phases during treatment.

depression_treatment

  • The onset of action of all antidepressants is slow and you can expect at least two weeks of taking the antidepressant medication before you would start feeling better.
  • A full response would only be felt after 6 to 8 weeks.
  • It might be necessary for your doctor to adjust the dose of the medication upwards, or even change the medication to another class should you not have an adequate response.
  • The duration of treatment should be at least 6 months to a year. Some patients might even have to stay on a maintenance dose of medication for a longer time, in some cases even for life.
  • Never stop or change the dose of your medication without consulting your doctor. The patient must be committed to treatment and follow-up with his or her doctor at regular intervals.
  • Antidepressants do not have any addictive properties.
  • Maintenance is probably the most important facet in successful long-term treatment of depression – This can only be done by monitoring the outcome (Results) of treatment of depression on a regular basis.

PSYCHOLOGICAL TREATMENT

Even if medication is working, the value of psychotherapy is important. Therapy is useful during or after medication to repair other problems associated with depression. Psychotherapy involves the verbal interaction between a trained professional (usually a psychologist) and a patient with emotional or behavioural problems. The therapist applies techniques based on established psychological principles to help the patient gain insights about him or herself and thus change his or her maladaptive thoughts, feelings and behaviour. Several forms of this ‘talk treatment’ have proven useful in helping the depressed person. Today it is well recognized that Cognitive-Behavioural Therapy is most effective in dealing with patients with depression.

It is also important that depressed patients take responsibility for their own well being and develop a lifestyle that enhances this well being. The way you live your life, take care of yourself, and feel about yourself affects mood instability and depression. A concerted effort to alleviate stress in your life will go a long way to stabilize your mood. Making positive changes in your lifestyle and changing negative thought patterns to positive ones will also enhance overall well being. Take stock of your life, look at your lifestyle, build positive self-esteem and self-confidence, develop new ways of thinking, use relaxation techniques, change your diet, get regular exercise and join support groups.

How can family and friends help?

The willingness to listen to the negative thoughts and emotions of the depressed person is very important. Family and friends should be able to talk about and recognize feelings of such a person. (The following articles can be used as guidelines in understanding and developing these skills. Emosionele Inteligensie en Aktief Luister ). Family and friends should also be willing to find out more about depression, to learn the symptoms, and to help with treatment. Depression affects functioning, personality, attitude and perspective. People should know what to expect during the early stages of depression and over the long term. Relationships and lives will most probably be disrupted. An afrikaans article is available called ” Hoe om depressielyers te verstaan en te ondersteun “.

Depression usually means a loss of self-esteem or self-confidence. By maintaining as normal a relationship as possible, talking through unwarranted negative thinking, encouraging efforts to improve, and acknowledging that the person is suffering from an illness will improve the depressed person’s self-worth. Telling him “pull your-self together” will only worsen the situation, so do not use this, thinking it is a form of encouragement.

Understanding, care and respect will go a long way in giving the depressed person hope that his condition will eventually improve and his life return to normal.

Never ignore remarks about suicide or death. Report them to the treating doctor.

Self-help books can also be a valuable source of information. Consult your local bookstore or ask for “The Depression Workbook” by Mary Copeland (New Harbinger Publications).

If you have any more questions regarding Depression consult your Doctor.

Support Groups

The Depression and Anxiety Support Group, Johannesburg branch can be reached at Depression and Anxiety Group. Trained counsellors will be able to provide you with counselling and further information and booklets on Depression and Anxiety. They can also put you in touch with a branch in your area.

ANXIETY DISORDERS

Anxiety is a feeling of uneasiness, uncertainty or fear, in response to a real or imagined danger. The body responds to anxiety by releasing a number of “stress” hormones, like adrenaline and cortisol, which have an effect on almost every organ in the body.

What are Anxiety Disorders?

Mild forms of anxiety caused by emotional conflict or life stress are common and unproblematic. Anxiety disorders are a group of conditions in which the feelings of anxiety are not associated with a real or appropriate threat, or are much more intense and long lasting than they should be. People feel frightened and distressed for no apparent reason. This condition can paralyze the individual into inactivity or withdrawal, and can dramatically reduce productivity and significantly diminish a person’s quality of life.

Anxiety disorders are common – nearly 25% of people will experience anxiety disorders at some time in their lives.

Symptoms of Anxiety Disorders

Physical symptoms of anxiety disorders are due to released stress hormones. These may increase blood pressure, cause heart palpitations, chest pain, rapid breathing or breathlessness, sweating, increased muscle tension or irritability. Intestinal blood flow decreases, resulting in nausea or diarrhoea. There is often a decreased sex drive. Children may also have a fear of being away from the family, a refusal to go to school, a fear of strangers, a fear of falling asleep or have recurrent nightmares.

Anxiety disorders

Specific anxiety disorders each have their own particular pattern of symptoms and additional behavioural characteristics.

Depression and Anxiety

The simultaneous occurrence of depression and anxiety is very common. Figures show that between 60% and 90% of people with depression also have symptoms of anxiety. The combination is well recognized and can significantly increase the disability and disruption of normal function suffered by the patient. The anxiety associated with depression can take many forms including panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder or a generalized anxiety disorder. Fortunately medication is available which can effectively relieve both depression and anxiety. If symptoms of depression and anxiety are a problem to you, you should discuss them with your doctor. Appropriate treatment can then be prescribed.

Types of Anxiety Disorders

A number of anxiety disorders have been classified. It is common for one anxiety disorder to accompany another anxiety disorder, depression, eating disorders orsubstance abuse.

Panic Disorder

People with panic disorder experience recurrent, unexpected attacks of intense anxiety or terror usually lasting 15 to 30 minutes. These attacks reach peak intensity within seconds and then subside over 5 to 20 minutes. Episodes of terror are accompanied by shortness of breath, rapid heart beat (palpitations), chest pain, hot flushes or chills, nausea, dizziness, abdominal cramps, sweating, shakiness, a choking feeling, feelings of unreality, and fears of dying or going insane. Frequency of attacks can vary widely, and may occur spontaneously or in response to a particular situation.

Phobias

Phobias are persistent, irrational fears of certain objects or situations. These people are so overwhelmed by anxiety that they avoid the feared objects or situations.

Social Phobia/Social Anxiety Disorder is an extreme fear of embarrassment or humiliation in social situations. Social phobias disrupt normal life, interfering with work, social relationships and career choices, especially when they develop during adolescence which they commonly do. People give up many pleasurable and meaningful activities due to these fears.

Agoraphobia is a paralyzing fear of being in places or situations from which a person feels there is no escape or help in case of an attack. These people confine themselves to places in which they feel safe, usually at home, which may have very damaging effects on work and social interaction. It occurs typically together with panic disorder.

Post-Traumatic Stress Disorder (PTSD)

PTSD is an extremely debilitating condition that occurs after exposure to intensely frightening events or experiences in which severe physical harm was threatened or occurred. These events include violent personal assaults such as rape, mugging, disasters, car accidents or military combat. These people repeatedly re-live the ordeal in the form of mental flash backs, nightmares or disturbing thoughts or memories, especially when reminded of the trauma. Symptoms can occur weeks, months or even years after the traumatic event. Symptoms of PTSD include emotional numbness or withdrawal, hopelessness, mood swings, sleep disturbances, depression, irritability, outbursts of anger, feelings of intense guilt, inability to concentrate and an excessive startle response to noise.

Obsessive-Compulsive Disorder (OCD)

People with OCD suffer from repeated, unwanted thoughts or mental images (obsessions) which may result in compulsive behaviour – repetitive, uncontrollable routines performed in the hope of preventing the obsessive thoughts or making them go away. Rituals such as hand washing, counting or checking are common. These rituals, however, provide only temporary relief, and not performing them markedly increases anxiety. OCD is time-consuming, distressing, and can disrupt normal functioning. Read more on OCD…

Generalised Anxiety Disorder (GAD)

People with GAD suffer from an almost constant state of tension and anxiety lasting more than 6 months, without an obvious cause for the anxiety. They usually expect the worst, worrying uncontrollably about money, health, family or work. They are constantly on edge, have difficulty concentrating and typically have physical symptoms such as fatigue, sleep disturbances, trembling, muscle tension, headaches, irritability or hot flushes. They may interpret other people’s intentions or events in a negative way, and therefore feel unsafe in the world. These symptoms cause much distress and impair normal functioning.

What Causes Anxiety Disorders?

Genetic factors, environmental influences, family and childhood experiences and biochemical disorders make certain people more susceptible to stress stimuli than the normal population. Alcohol or substance abuse, other psychological problems like depression and medical conditions like thyroid disease may also play a role.

How are Anxiety Disorders Treated?

Most anxiety disorders respond well to treatment even if two or more anxiety disorders exist simultaneously. An effective approach is a combination of cognitive-behaviour therapy (CBT) and medication.

Drug Therapy will most likely be required for prolonged periods. Anti-anxiety drugs, antidepressants like the selective serotonin-reuptake inhibitors (SSRI’s), tricyclic antidepressants (TCA’s) or Monoamine Oxidase Inhibitors (MAOI’s) may be used. Drug interactions and side effects must always be monitored.

Cognitive-Behavioural Therapy teaches a patient to control their reactions to stress and stimuli, thus reducing the feeling of anxiety. Some therapies teach patients to understand their thinking patterns so they can react differently to the situations that cause them anxiety.

Other

Therapies may use techniques which either gradually or rapidly expose the patient to the anxiety- producing stimulus. Breathing exercises to prevent hyperventilation may also help.

Healthy Lifestyle. Regular exercise, adequate rest, and good nutrition can help reduce the impact of anxiety attacks. Rhythmic aerobic programs may also help to reduce the effects of anxiety.

It is important to remember that these conditions are treatable. Your length of therapy will be based on your personal needs. It is important to continue taking your medication for as long as your doctor advises, even if you are feeling better.

Helping someone with Anxiety Disorder
  • Don’t make assumptions about what the affected person needs – ask him or her.
  • Be predictable – don’t surprise them.
  • Let the person with the disorder set the pace for recovery. Be patient, but don’t allow self-pity to develop.
  • Never criticise or trivialise the condition.
  • Find something positive in every experience. Don’t allow the patient to avoid the anxiety.
  • Encourage the patient to take even a small step forward.

Courtesy of Medical Essentials, Health Information

STRESS MANAGEMENT

What is Stress?

As a condition, which affects you, stress is the reaction of the mind and body to a stressor. A stressor is any event or force, which is powerful enough to affect the way you normally function, from a dead- line at work to a dose of flu to the death of a friend. Stressors like these can shake you, both mentally and physically, and the result is the condition known as stress.

What effect does stress have on you?

It’s known as the “fight or flight” syndrome. Back in pre-history, when humans lived much simpler lives, a stressor would probably be something like an encounter with a lion. The body would immediately react by preparing you to either fight the animal or run away as fast as possible. Hormones like adrenaline flood the body, giving the muscles higher tone so they are ready to react quickly. The heart beats faster, filling the muscles with blood from which they can draw energy, you breathe faster to get more oxygen and think faster to help you think your way out of trouble. There are a whole lot of other, similar effects, all of them intended to make as many resources as possible available in a crisis. When the stress response is prolonged, it can have serious consequences, on both your body and your mind.

Stress disorders may be classified as follows:
  • Acute stress disorders occur when a person is exposed to a severe stressor causing intense fear, helplessness or horror and experiences recurrent thoughts or flashback episodes, associated with symptoms of anxiety lasting for up to 1 month after the traumatic event.
  • Post traumatic stress disorder is diagnosed when such exposure to a severe stressor is associated with distressing recollections of the event and severe anxiety, lasting for more than 1 month.
  • Intermittent stress is when a person regularly experiences stressors, leading to episodes of anxiety, and begins to feel that their life is “spinning out of control”.
  • Chronic stress develops when ongoing exposure to anxiety causing stressors over a sustained period of time leads to feelings of hopelessness or worthlessness, and even thoughts of suicide.
How does stress affect the body?
  • Heart and circulation: while your pulse rate gets faster, your blood pressure rises. The blood gets stickier, so that if you are injured, it will clot more easily.
  • Mouth, throat and digestive system: the mouth and throat become dry as fluids are diverted away from places where they’re not essential. The digestive system shuts down – you don’t need to spend energy on digesting food when faced with a lion!
  • The skin: as the blood flow is diverted away from the skin, it becomes cool, clammy and sweaty. Your hair often feels as though it’s standing on end, because the skin tightens.
  • The immune system: the white blood cells are the immune system’s soldiers which fight off infection, so they are sent to parts where you might be injured, like the skin and bone marrow.
  • All of these reactions would not be dangerous if they were only taking place briefly and occasionally. But long-lasting stress can have serious implications:
  • Raised blood pressure over the long-term can lead to heart disease, strokes or kidney failure if it is left untreated. Stickier blood increases the likelihood of a blood clot, which may block arteries and cause a heart attack.
  • Prolonged disruptions of the digestive system can cause unpleasant symptoms like diarrhoea or constipation. Stress is linked to irritable bowel syndrome or spastic colon, which causes bouts of severe pain, and can also lead to episodes of extreme diarrhoea, followed by constipation.
  • Skin conditions like psoriasis, exzcema and acne may be made worse by stress.
  • Chronic stress affects the immune system, making you more vulnerable to developing infections like colds and flu, and even certain cancers.
  • Stress can also disturb your hormonal system. Women may produce smaller amounts of oestrogen – which makes them more vulnerable to heart disease, they can even stop menstruating. Stress is linked to a reduced desire for sex, and men may experience erectile dysfunction (impotence).
  • Since stress tightens up the muscles in preparation for action, it’s obvious that prolonged stress could cause stiffness and spasms.
  • All these physical disturbances may cause a disruption in sleeping patterns.
How does stress affect the mind?

One of the most common problems that stressed people experience is an inability to concentrate and to remember. You may suffer from feelings of panic or fear, you may be more irritable and get angry more often and more easily, you may even suffer from depression, feeling that you are worthless and that life is not worth living.

Good stress and bad stress

Not all stress is bad stress. A certain amount of stress is normal and keeps body and mind functioning. Your feelings about the source of the stress contribute to how well you handle it, so good stress is less likely to have bad consequences. None of us would be very healthy if our lives contained no surprise, delight, shock or demands of any kind!

How do you cope with stress?

For most of us, the most common answer is, very badly. We tend to do all the wrong things under stress: we eat badly, reaching for fast foods loaded with sugar and fat, and forget to take our multi vitamins or chronic medications. We drink too much alcohol in an effort to relax, we smoke and we feel we don’t have the time to exercise. To avoid the dangers of stress, we really need to adopt a strategy that addresses the whole of our lives.

Stress management techniques

Exercise makes the body better able to cope with the physiological effects of stress. It improves circulation, loosens up muscles stiffened by tension and has a profound impact on your mental health – there’s strong evidence that exercise helps to fight off one of the most unpleasant mental effects of stress – depression.

Good nutrition: Your body and mind can’t cope with stress if you aren’t getting the nutrients they need to operate. Try to eat five portions a day of fruit and vegetables. You need a mix of vegetables to get the best nutrition – dark green leafy vegetables, orange-coloured vegetables, which contain lots of anti-oxidants, cruciform vegetables like cauliflower and broccoli, which contain cancer-fighters. It’s actually quite hard to get the nutrition you need from your food these days.

Nutritional supplements

Food loses nutrients as it is harvested, handled and processed. So nutritional supplements will help to keep you well nourished. Choose a good multi-vitamin, and if you are under special stress, top up with extra B-complex vitamins, and a mix of calcium and magnesium. Calcium and magnesium also have a good effect on mental functioning.

Support from others. Devote some of your precious time to nurturing your personal relationships. Spend time with family and friends, and don’t hesitate to get help from a counsellor if you feel the need. Very often, all we need to release a build-up of pressure is a listening ear.

Reduce stress at work. Take a long, hard look at how you operate at work, and change it if necessary. Effective time management is essential. Organise and prioritise! Learn to delegate. Resolve to say ‘No’ if you feel that you are being overburdened. Communication is vital.

Relaxation techniques: As mentioned, stress management embraces a wide range of strategies and actions which address every aspect of our lives and it can be very helpful to incorporate one or more of the following relaxation techniques into your regular activities:

  • Deep breathing
  • Muscle relaxation
  • Massage therapy
Conquer stress – a lifetime commitment

Sometimes it feels as though it’s just too much effort to put into place any of the stress-beating tactics outlined here. But that’s the stress talking! It will be hard to discipline yourself to exercise, to eat properly, to meditate every day or practise one of the other relaxation techniques mentioned, but once you get into a routine, you will find that the effort is more than repaid by the results!

Recommended Reading: “Proverbial Stress Management Busters” by Prof. L. Schlebusch. (Publisher: Human & Rosseau).

Courtesy of Medical Essentials, Health Information

Bipolar Depression (An Interview with Robert Hirschfeld, MD)

Editor’s Note:

Surveys indicate that up to 70% of patients with bipolar disorder are incorrectly diagnosed with unipolar or major depression. Because traditional antidepressant therapy can destabilize this population, misdiagnosis thus has significant consequences. To reduce the incidence of misdiagnosis, Robert Hirschfeld, MD, and his colleagues developed the Mood Disorder Questionnaire (MDQ), a brief survey to detect past episodes of mania in patients with depression.

On behalf of Medscape, Jessica Gould interviewed Dr. Hirschfeld about this instrument. Dr. Hirschfeld is the Titus Harris Chair of the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical Branch in Galveston.

Medscape: What prompted you to develop the questionnaire for bipolar disorder?

Dr. Hirschfeld: A bipolar screening tool was actually prompted by a man named Sean Nolan, who worked for Avis Pharmaceuticals; he suggested that we needed a screening instrument for bipolar disorder. At the time, I thought it was foolish and that it was obvious that we didn’t need it. How wrong I was!

Medscape: Why did you think it was foolish, and what led you to change your mind?

Dr. Hirschfeld: At the time we were conceptualizing the Mood Disorder Questionnaire (MDQ), I believed that mental health professionals rarely missed the diagnosis of bipolar disorder. Research findings, including those from my own studies, proved that opinion wrong.

Medscape: How did you formulate the questionnaire?

Dr. Hirschfeld: I put together a small work group. We came up with a set of questions drawn from the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), from our clinical experience, and from research interviews that were created to diagnose bipolar disorder.

Then we compiled them and tested them in our clinics in a group of patients who had bipolar and other psychiatric disorders. We used various psychometric techniques to devise the 13 yes/no questions that are now widely in use. Since that time, we’ve carried out a number of validations in other populations.

We conducted the original validation in several psychiatric clinics that tended to specialize in mood disorders. We subsequently tested it in a large nationwide community survey. This was a group, not of patients, but of citizens who were part of an ongoing epidemiologic survey.

We’ve also tested the MDQ in several primary care clinics, and it has been translated into a number of languages throughout the world. So it’s very widely used.

Medscape: When and how should providers use the questionnaire?

Dr. Hirschfeld: My recommendation is to give it to anyone who is going to be prescribed an antidepressant, especially to treat depression. Approximately 1 in 4 or 5 people who present with depression are going to have bipolar disorder in some form. You’re going to find quite a few people with bipolar simply by administering the questionnaire. Then, if you get a positive screen, you’ll want to evaluate the individual more carefully for bipolar disorder. Because simply getting a positive screen does not mean that you’ve got bipolar disorder.

Medscape: I can conceive of situations in which people without bipolar disorder might answer “yes” to several of your questions — sleeping patterns disrupted while cramming for an exam, the stress of a new job, or perhaps the elation of falling in love. How do you distinguish these cases from someone presenting with the symptoms of bipolar disorder?

Dr. Hirschfeld: It is true that many of the symptoms of mania are emotions people can experience for a variety of reasons other than having a psychiatric disorder. That’s why it’s important to conduct the clinical interview. In the clinical interview, we’re going to try to see whether these things co-occurred, whether they lasted for a significant period of time, and perhaps of greatest importance, whether they caused a problem.

Medscape: What constitutes a problem?

Dr. Hirschfeld: It could be a problem in a relationship, a problem in a job, a legal problem. Did they create some kind of a mess or cause dysfunction in any way? These are fundamental to the diagnosis of all psychiatric disorders, but it’s particularly an issue with bipolar disorder, because people who do have the disease make very bad decisions. Their judgment is impaired, and when they are at the far end of the spectrum, they can actually be delusional.

Medscape: I know that bipolar disorder is often accompanied by a high degree of denial. I would imagine it could be difficult to get such patients to fill out the questionnaire.

Dr. Hirschfeld: It’s not necessarily difficult to get them to fill out the questionnaire, but they may not regard things that happen to them to be a problem, especially if they are high at the time. An unfortunate lack of insight is really fundamental to the illness and just compounds the problems.

Medscape: How do you get around the problem of lack of insight?

Dr. Hirschfeld: The lack of insight presents a sometimes insurmountable barrier to initiating treatments and certainly to ongoing adherence to treatment. Often it is only after several episodes with devastating consequences that individuals begin to confront, in a realistic way, the fact of their illness and what they need to do to help improve their lives.

The MDQ has certainly been used by many family members to help demonstrate to individuals that they might have bipolar disorder. People may be able to see themselves in some of the answers to some of the questions raised.

Medscape: Can you envision similar questionnaires for other disorders?

Dr. Hirschfeld: Certainly the use of questionnaires, especially if they are brief and simple, can help identify problems that are frequent and that are frequently being missed.

Medscape: What kind of feedback have you received about the questionnaire within the psychiatric community of providers?

Dr. Hirschfeld: Most respond positively. There were some questions about sensitivity and specificity and so on. It is not a perfect instrument, to be sure. One of the problems with bipolar disorder is that people can answer one way today and then another way at another time.

Medscape: What are you working on now?

Dr. Hirschfeld: Well, we just completed a study that involved giving the MDQ to everyone who was arrested in Galveston County. It’s part of a screen that the police do. Everyone who gets arrested gets a medical screen. One of the things that police are interested in is identifying people who might be at risk for suicide and who have very significant medical problems.

The rates of bipolar disorder were somewhat lower than we expected. I expected it to be in the range of 10% to 20%, and I think that a possible reason it was below that range is, not because there is a low incidence of bipolar disorder among people being arrested, but rather because you get a huge amount of naysaying.

We are also looking at what happens to responses over time, at the stability of the instrument. We’re giving it to people at several time frames and then comparing their answers.

We just completed a version to compare the prevalence of bipolar disorder in Britain vs the United States. We came up with a slightly lower prevalence in Britain — under 3%. Our 2 nationwide community studies using the MDQ also suggest that the prevalence of bipolar disorder in Britain may be lower than that in the United States. This may not, in fact, be true, but may reflect differences in how people in England respond to questionnaires about manic behaviors compared with how people in the United States respond. We are hoping to replicate these studies in many other countries to help elucidate this. We are working specifically on programs in France, Spain, and Canada. Furthermore, we’re looking at the prevalence of bipolar disorder in adolescents. To
my knowledge, this is the first look at the prevalence of bipolar in adolescents in a community study.

This interview is published in collaboration with NARSAD, The Mental Health Research
Association, and is supported by an educational grant from GlaxoSmithKline.

Suggested Readings

  • Ettinger AB, Reed ML, Goldberg JF, Hirschfeld RM. Prevalence of bipolar symptoms in epilepsy vs other chronic health disorders. Neurology. 2005;65:535-540.
  • Hirschfeld RM, Bowden CL, Gitlin MJ, et al. Practice guideline for the treatment of patients with bipolar disorder (revised). Am J Psychiatry. 2002;159(Suppl):1-50.
  • Hirschfeld RM, Cass AR, Holt DC, Carlson CA. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Pract. 2005;18:233-39.
  • Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875.

Robert M.A. Hirschfeld, MD, Titus Harris Chair; Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, Texas.

Disclosure: Jessica E. Gould, BA, has disclosed no relevant financial relationships.
Disclosure: Robert M.A. Hirschfeld, MD, has disclosed that he serves as an advisor or consultant to Abbott Laboratories, AstraZeneca, Bristol-Myers Squibb, Forest Laboratories, GlaxoSmithKline, Janssen, Eli Lilly & Company, Novartis, Organon, Inc., Pfizer, Shire, UCB Pharma, and Wyeth-Ayerst.

Medscape Psychiatry & Mental Health. 2006;11(1) ©2006 Medscape

ARE YOUR NIGHTS PLAGUED BY A SLEEP DISORDER?

We all know the importance of a good night’s sleep. Experts agree that eight hours should do it for most of us. But while many people simply ignore this advice because they’d rather watch their favourite late night host or catch up on missed chores, other people lose sleep from something that may be out of their power ‘a sleep disorder’.

Sleep experts estimate that over 100 types of sleep disorders affect 70 million Americans each year. A sleep disorder is loosely defined as having some sort of difficulty sleeping, be it the inability to fall or stay asleep, too much sleep or falling asleep at an inappropriate time, or exhibiting abnormal behaviours during sleep. Here are the most common types of sleep disorders.

Insomnia

Insomnia can wreak havoc on the lives of those who are unfortunate enough to have to deal with it, especially if it’s not just temporarily. Insomnia can be caused by persistent stress, lack of exercise, excessive noise or light, using stimulants like drugs and alcohol, psychiatric problems or physical illnesses. Chances are you’ll know if you have insomnia because you can’t fall asleep or stay asleep, or have a generally poor quality of sleep, even if you create good sleeping habits for yourself. To treat insomnia, sleeping pills and behavioural therapy may be effective, but check with your doctor for a proper diagnosis and treatment plan.

Sleep Apnea

People with sleep apnea may snore loudly and wake up frequently during the night because of disrupted breathing, gasping, gagging or choking, or actually ceasing to breathe while they sleep. Sounds dangerous, doesn’t it? Sleep apnea is a serious sleep-related breathing disorder that can affect anyone, but most commonly affects obese, middle-aged men. It has to do with the size of the neck; the heavier you are, the more fat there is in the throat. That fat narrows the airway, blocking the ability to properly breathe. Fortunately, sleep apnea can be treated with positive airway pressure, where air is blown into the throat, position therapy, oral appliances, and most importantly, weight loss.

Narcolepsy

It may be comical to see someone all of a sudden fall asleep, but it’s no laughing matter when someone does this in situations like driving or while on the job. Narcoleptics may experience cataplexy, a weakness in the leg, arm or face that can be caused by the oncoming of strong emotions. They may also experience sleep paralysis, an inability to move or speak while conscious, as well as hypnagogic hallucinations, strange dreamlike episodes where they may see things that aren’t there. No cure exists for narcolepsy but with proper treatment, often in the form of stimulants during the day, narcolepsy can be better managed.

Sleepwalking

It might also look funny to find someone sleepwalking, but again it can be a serious matter. Sleepwalking, or somnambulism, occurs when you complete actions while asleep, like sitting up in bed or getting up to walk around. The eyes are open and appear glassy, and often the actions involve something strange,inappropriate or dangerous. Sleepwalking is common in children but usually goes away in the teens, and sleepwalking often runs in the family.

Restless Legs Syndrome

Remember experiencing what your mom called ‘growing pains?’ Many people mistake restless leg syndrome for growing pains, when in fact they’re not. Symptoms of restless leg syndrome include little involuntary movements in the toes, feet or legs or other uncomfortable or painful sensations that make someone want to walk around or move them (which provides immediate relief). Similar to RLS is periodic limb movement, where someone experiences rhythmic jerking in the feet or legs, which causes restless sleep too. Medication is available for treatment, and doctors also encourage lifestyle changes.

Shift Work

Doctors and nurses and those who work the graveyard shift can attest to this sleep disorder that has to do with the circadian rhythm, the body’s internal clock that controls the times you feel the need to sleep. The effects of shift work usually go away once a schedule goes back to normal, but tweaking hours forward rather than backward, limiting number of shift changes and allowing for small periods of rests can help.

Some of the more minor sleep disorders can be prevented by developing a healthy sleep routine, while others are simply out of your control. Sleep disorders don’t have to be something to lose sleep over. Get help immediately if any of these signs and symptoms relate to you, and be on your way to a better night’s rest.

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From Life Script home page…

VIOLENCE TAKES TOLL ON KIDS’ OVERALL WELLNESS

Children’s health advocates have long stressed the toll that post-traumatic stress disorder, or PTSD, can take on a child’s psychological development. After witnessing or experiencing some form of violence, children often exhibit common PTSD symptoms including insomnia, bed-wetting, and flashbacks. New research is now indicating that the symptoms of PTSD can bleed over into the physical realm, as well. A University of Michigan study finds that children exposed to some form of violence ‘in school, at home or in their communities’ are much more likely than their peers to suffer from a host of gastrointestinal problems, complain of frequent headaches, and exhibit a weaker immune response to common childhood afflictions. The implications of the study are particularly troubling for children from low-income families, a startling three-quarters of whom report witnessing or experiencing some form of violence. Researchers drew a link between the new study and previous research showing that anxiety can lead to worsened physical health.

From Life Script home page…

WHAT DO WE DO WITH SUFFERING?

“The church consists of people who sit in a pool of their own tears.”So believe a growing number of pastors, counsellors, and lay people. There are no formal polls or rigorous statistics to prove this assumption, but many Christians would agree. More importantly, God’s Word agrees and goes one step further and states that “the whole creation has been groaning as in the pains of childbirth” (Romans 8:22). Human life entails misery and woe. Broken relationships, agonizing illness, the prospect of one’s own death, depression, injustice and atrocity, quiet yet paralysing fear, memories of sexual victimization, the death of a child, and many other painful problems leave none unscathed. It would be impossible to minimize the breadth and depth of suffering both in the church and the world.

But this proposition sits at a juncture where Christians are pulled in one of two directions. Some exalt pain, others deny pain. Some are bleeding hearts, others are stoics. Some are “pain counsellors,”others are “sin counsellors.”Pain counsellors are expert at having people feel understood; sin counsellors are expert at understanding the call to obedience even when there is pain. Pain counsellors run the risk of over-emphasizing pain to where the alleviation of suffering becomes the thing of first importance. Sin counsellors run the risk of rendering personal pain of little or no importance. Pain counsellors can be slow to lead sufferers in responding to the gospel of Christ in faith and obedience. Sin counsellors can run the danger of breeding stoics whose response of obedience is unaware of God’s great compassion. Pain counsellors might provide a context that enhances blame-shifting and a counselee’s sense of innocent victimization. Sin counsellors may be so concerned about blame-shifting that they have a poorly developed theology of suffering. There are pitfalls to each.

Exalting pain

Those who lean toward exalting pain have said or heard, “The Bible doesn’t speak meaningfully to my suffering.”The Bible’s theology of suffering doesn’t seem to “work.”They tried the Bible, but it didn’t have deep answers. They have heard counsellors and friends encourage them to have faith. They may have heard excellent preaching and biblical teaching about suffering. But nothing has really spoken to the depths of their pain.

This accusation seems strange considering that the Bible is filled with penetrating teaching about suffering. Why does God’s Word seem shallow for some Christian sufferers? Why do Christians seek out counsellors who will understand them and enter into their pain, but who will not lead them to the gospel of Christ and God’s purposes in suffering? Undoubtedly, one reason is that many sufferers have been stung like Job by his comforters. We have all encountered people in the body of Christ who deal with suffering in a way that is academic, aloof, and whose counsel can be summarized as “shape up.”These counsellors and friends have not really known what God says to those in pain, so they are poor ambassadors to others. But this is not the only reason.

We are becoming a psychologised church, where healing from pain has become our deepest need! Consider this preface to a popular Christian book: “We have behaved compulsively [translation: sin] because it’s a way to stop pain.”The writer then describes three different men: one obsessed with sex and pornography, one with work, and one with alcohol. “In each of these men the behaviour was not the real problem. The behaviour was only a symptom of the problem. All of them were hiding from pain. The things they did were medicating the hurt that came from some deep wound some-where in their lives. ¹

Here is a consequence of exalting pain beyond biblical boundaries: our pain problem becomes deeper than our sin problem. We revise our theology to say that pain is actually the cause of sin. But is this what God says? Is it true that pain precedes sin? It certainly often feels that way. Most people who are angry in marital disagreements would say that hurt and disappointment stand behind their sin. But there are significant problems with granting primary status to suffering. Biblically, sin can never be reduced to or explained by pain. Sin is just sin. We cannot find the culprit anywhere else but in our own law-breaking. The cause of sin does not reside in the actions of another person or our desire to protect ourselves from more pain. Other people do, indeed, inflict pain on us; but this pain can never lead us into sin or keep us from loving others.

To believe that pain causes our sins and that the alleviation of pain is really our deepest need has dramatic implications. First, sin is reduced to self-protection. That is, our greatest sin is protecting our self from further pain. This misses the distinctly against-God, law-breaking nature of all sin. Second, when we realize that we are not shielded from suffering, and as we find that “healing”never really loosens the grip of suffering, we believe that God has reneged on His promises; and we feel justified in our anger toward Him. We also believe God’s Word has no meaningful answers to the deepest problem in living. God, however, never promises temporal freedom from suffering. In fact, He speaks to us on almost every page of Scripture in order to prepare us for suffering. As difficult as it may sound, the gospel doesn’t take away all present pain. Instead, the gospel goes deeper. It heals our moral problem.

It points us to realities that are more beautiful than our suffering is hard, thus offering joy even in suffering. It gives power for a new obedience that can endure under suffering. The Bible doesn’t provide a technology that removes suffering but teaches us how to live in the midst of it. To teach anything different would be to compromise the gospel itself.

Ignoring Pain

Those who lean in the direction of minimizing pain, or calling for a stoic acceptance of it are often more precise in their theological formulation. But they may be guilty of ignoring important biblical themes and thus do not offer the full counsel of God to those who suffer. For example, if suffering is a result of being sinned against by another, those who minimize suffering might immediately think about the call to forgive the perpetrator. This theme is critical, so it certainly is no mistake to make forgiveness part of the counselling agenda. Yet it is a problem when forgiveness is made a theory-counselling agenda. Too often, the first and last advice given to a severely victimized woman is to forgive the perpetrator.

To compound this problem some counsellors might attach a rider to forgiveness. That is, forgiveness must be accompanied by forgetting. This is sound counsel if forgetting is understood as not allowing your view of the perpetrator to be controlled by the sin. However, counselees typically hear this counsel to mean that they are sinful if they even think about the victimization. The result: the victim now becomes the perpetrator, and victims feel guilty if they ever again mention that being sinned against still hurts.

Those who minimize personal suffering can also err by attempting to rapidly fix the sufferer. Men, in particular, seem to drift in this direction. The intent might be praise-worthy. Most of us want people in pain to feel better. But the way it is carried out can be hurtful. Counsellors might barely hear the outline of the suffering before they race in with answers. Counselees often respond by feeling like the counsellor does not want to hear of the pain, and counselees then feel that the pain is in some way wrong.

At other times, the “fix it”intent might not be so laudable. Some people simply don’t want to hear about another’s suffering. Tears are too messy to their otherwise comfortable lives. “Just get on with it”is their counsel. A brief study of the compassion of Jesus is a profound rebuke to this selfishness. The incarnation itself was the dramatic example of God entering into the lives of His people. Jesus was characteristically moved with compassion for those who were leaderless, oppressed, destitute, or bereaved. As Jesus counsels us to mourn with those who mourn. He points us to His own life as the example. The stoic avoids or ignores these clear themes in Scripture.

Ask people who have gone through difficult suffering what most helped them. Many will say something like, “She was there with me.”A friend or counsellor was able to be physically present during times of suffering. This friend might not have offered lots of counsel or advice. Rather, he or she was available so the grieving person did not feel so alone and swallowed up by the suffering. Perhaps it meant having an open house or a standing invitation to dinner, so the suffering person had a place to be with other people who cared and understood. Perhaps it meant sitting with the person in church. If our chief goal is to fix suffering, to make pain go away, we will probably make it worse.

Another common pitfall of stoics occurs when a counsellor has an internal alarm clock that goes off, announcing that it is time for the suffering to be over. There are different reasons for this. Perhaps the counsellor is compassionate and wants the pain to be alleviated. Perhaps the suffering is an inconvenience to the counsellor. Or perhaps the counsellor thinks there is a biblically imposed one-month or one-year limit on grief, and then it is time to get on with life. Biblically, however, there is no timetable; there are no predetermined stages of grief and suffering. There are sorrows that will not be erased until the last day (Revelation 21:4). Counsellors are to be patient with everyone, to mourn with those who mourn, and to maintain the goal of assisting people to love others and love God in the midst of suffering.

So two potential hazards cap lead us away from a biblical approach to suffering. If you exalt suffering, then pain becomes the cause of sin; self-protection becomes the problem; and the alleviation of suffering is the chief problem to be addressed you ignore suffering, then pain becomes a minor, fixable problem; and compassion becomes a temporary step that is intended to pave the way for more important things. Even with the large number of good books about suffering, there are problems that a current theology of suffering must address. The practical theological task is to speak with compassion to those in pain and point them to realities deeper than their pain.

In what follows, this task will be approached through two basic questions. Where does suffering come from? How can I help those who suffer?

Where does suffering come from?

When pain comes at me, from what direction is it coming? Is it my fault? Is it Satan’s initiative? Or is God the author of it? These questions are different than the inevitable question, “Why didn’t (or doesn’t) God stop it?”or, “Why me?”And, frankly, the “where does it come from”questions are less burning for most people. But the “where”.questions do have important biblical answers, and these answers are dense with potential applications.

Others. One answer to “Where did it come from?”is other people. A king rules harshly, a husband leaves his wife for his secretary, a wife skewers her husband verbally, a drunk driver kills a child, and a person she trusted rapes a woman. Other people sin against us, and it hurts deeply.

So when a victimized woman asks “Why?“, you might shade it as a “where”question and answer “because of your father’s wickedness.”Perhaps the question she poses is, “Why did God allow this?“, but the answer continues to be “It was your father who did it; it was because of his sin.“

Admittedly, this obvious answer doesn’t address all the mysteries that surround the problem of pain, but it is an important answer. Many sufferers rail at God or themselves and ignore the obvious. It offers encouragement because it clearly says to victims that the cause of their particular suffering was someone else, not them selves. Although this seems self-evident, those who have been victimized seem to have an instinct that says, ”I am responsible.“ God responds by reminding us that we do not cause the sin of other people. They are responsible for their own sin.

This answer can also encourage us because it points us to the heart of love: forgiveness of sins. As Christians, we are not stuck when someone else has inflicted the pain. Instead, we have the opportunity to grow in an attitude of forgiveness that will hopefully lead to a fully transacted forgiveness, to reconciliation and restoration of the relationship.

Of course, there are cautions that fence suffering inflicted on us by others. God warns us against being self-righteous in our judgments. He tells us that the sin of other people can’t be an excuse for our own disobedience or lack of love. And he reiterates that He, alone, is judge; and we are to trust his judgments. Therefore, we do not repay evil for evil.

Another caution is that “others”are not the only cause of suffering. Occasionally, young children reduce their pain to this cause. If they fall and a parent is close by, they might instinctively say, “Daddy!”as if their father was responsible. Adults do this, too. Blame shifting can assign all fault to others. There are other places we must look as well.

Me. Another obvious answer is Me, I suffer because I have sinned. I am pregnant outside of marriage because I left the safety of God’s commands. My children have left me because I have constantly provoked them and dealt with them harshly. I am physically sick from my constant jealousy. My fiancé broke the engagement because of my angry outbursts. I have emphysema because I smoked two packs a day for 40 years. I lost my job because I was caught stealing from my employer. I am destitute because I have been a sluggard.

The encouragement in this type of suffering is that there is hope for change. Not only does God offer us complete pardon for sin in Christ, but He also gives power to put off sin. We can change! We do not have to be plagued by sinful anger, sexual lust, lies, the rule of addictions, or laziness. We have been given the Spirit of power who gives grace for continual growth in grace.

The cautions about suffering caused by “me”are well known. In the same way that others are not the only cause of suffering, neither am I the only cause of my suffering. If there is not an obvious link between a person’s sin and suffering, then we must be careful not to assume a relationship. We should remember that some people – especially those who have been severely hurt by their own families embrace this cause rather than avoid it. They are so uncomfortable with the idea that people who are supposed to love them were, instead, very hurtful and sometimes wicked toward them that they prefer to blame themselves. In thinking this, the victim is still able to retain the illusion that the perpetrator really loved him or her. Again, the Scripture counters that we don’t cause others to sin; instead, each person is responsible for his or her own sin.

Adam. A third cause for suffering is Adam and the curse. Even though we participate in Adam’s sin (Romans 5), it was Adam himself who sinned and brought misery and death to all his offspring. Because of his sin we experience the curse on all of creation. As a result, we experience accidents that injure, sickness and physical weakness, the loss of loved ones, and painful toil.

This may be the most frustrating cause of suffering. It’s as if no one is at fault. There is no one to reconcile with, no one to forgive, and no assurance of change. Indeed, medicines may temporarily roll back some of the effects of Adam’s sin, but the benefits seem superficial and temporary. And herein lies its main exhortation to us. The curse from Adam’s sin keeps us from loving the world too much. It induces us to anticipate something better. The encouragement to people who feel the weight of the curse is to anticipate the consummation when Jesus returns and the curse will be rolled away.

These three causes represent the most obvious reasons for our suffering; but, as the book of Job reveals, there are two other causes as well.

Satan. Suffering is also from Satan. He is “like a roaring lion looking for someone to devour”(I Peter 5:8). He delights in sending pain to God’s people. The book of Job exposes him as an enemy who uses suffering to advance his own kingdom agenda. He is a murderer (John 8:44) who inflicts suffering by way of physical pain and loss. The Apostle Paul’s torment from “a messenger of Satan”(II Corinthians 12:7) illustrates how Satan is just barely out of view in suffering. But Satan can inflict pain that goes even deeper than physical torment. Through lies, accusations, and promoting gut-wrenching division in the body of Christ, Satan strives to lead us into hopelessness, questioning God’s goodness.

Do you get mad when you see suffering? Satan is the appropriate, although elusive, target. He is deceptive. His hand in suffering is often overlooked. Those who suffer should be warned about his purposes so they can be alert to his lies and quickly engage him in battle then violence can be done to this foe. The most severe violence can be done by trusting God and following Christ in obedience even when we suffer.

Yet there are cautions here too. Satan is not the sole cause of suffering. For example, even if Satan is active in all suffering, his presence does not minimize the responsibility of either others or ourselves. Satan can never be used as a way to share responsibility for the wickedness of sin. No one can say, “The Devil made me do it.”We cannot use Satan as an excuse for personal sin, and we can’t use Satan as a way to minimize other’s sin. The raiders that inflicted such suffering on Job were fully responsible for their heinous, barbarous sin. Judas, not Satan in Judas’ body, was the person who betrayed Jesus. Satan can cause great suffering, but he can’t make us sin.

God Curiously, Satan is rarely the target of a sufferer’s frustration or eyen anger. Instead, God is. It seems that agnostics and even theists become theists when going trough suffering. They ask, “Why, God, are you doing this to me?”“What have I done to you?” Is it true that God causes suffering? Naomi certainly believed so. Upon returning to her homeland, after losing her husband and sons, she said, “The Almighty has made my life very bitter”(Ruth 1:20). And she was right. She was myopic and didn’t see the fullness of God’s plan, but she was right. Job’s wife also believed that God did it when she counselled her husband to “curse God and die.”Her counsel was wicked, but there was truth in her understanding that God was over Job’s suffering. Lamentations and Habakkuk are treatises on how faith embraces and wrestles with God’s hand in suffering.

Some Bible teachers try to distinguish between what God ordains and what He allows. But the distinction is sometimes an overly tidy attempt to justify God. A less technical statement might be this: by the time suffering gets to us, it is God’s will. “So then, those who suffer according to God’s will should commit themselves to their faithful Creator and continue to do good”(I Peter 4:19) Is it possible to say that some suffering is not God’s will? God forbid that we should suggest that something is over Him. The world is not a cosmic push-pull between Satan and God. God is king over all. God is not the author of sin and suffering, but He is over all things, even our suffering. He “works out everything in conformity with the purpose of His will”(Ephesians 1:11).

God from all eternity did, by the most wise and holy counsel of His own free will, freely and unchangeably ordain whatsoever comes to pass: yet so as thereby neither is God the author of sin, nor is violence offered to the will of the creatures, nor is liberty or contingency of second causes taken away, but rather established. (Westminster Confession of Faith, from “Of Eternal Decrees“)

The encouragement from this is clear. Our faithful God reigns. The world is not in chaos. Neither Satan nor wicked criminals have won. But counsellors must know where the theological boundaries lie. As noted by the Westminster Confession, God’s sovereignty does not rob creatures of their will. Granted, this is a conundrum. It is a mystery to maintain that God rules over all, meaning that He ordained, not simply foreknew, while also maintaining “a man’s own folly ruins his life” (Proverbs 19:3). But God’s greatness is such that He has established a world that is ordained but not robotic.

Here is another caution. We can never think that since God has ordained all things He is then somewhat indifferent to our sufferings. The gospel makes it clear that God is moved with great compassion at the suffering of His people. Jesus Christ entered our suffering (Hebrews 2:14-18). Perhaps we can say that God’s emotional responses to His creation are complex and varied, but we can never say that He is without compassion for our suffering.

Figure 1. The causes of suffering 

These five categories (Figure 1) answer the question, “Where does suffering come from?”They are important for their mind-clearing effect on sufferers, as well as the cautions they provide. When these relevant causes appear in bold relief, it can be immensely helpful for those in pain. It brings a biblical clarity that fosters biblical responses. When people who have been blaming themselves realize that their suffering was the consequence of another person’s sin, the sufferers are relieved of a burden that wasn’t theirs. Also, they can respond by learning how to forgive; and they may consider confronting the perpetrator in love. When a family has lost their crops to drought or flood, they don’t have to look for blame in themselves or others. Rather, they can realize that suffering is an intruder that will eventually be banished. Then they can proceed by being suffering servants who work diligently and make wise decisions about their next planting. A careful review of the five causes of suffering helps us to hear God’s word more meaningfully and helps lead us to the appropriate biblical response.

But these answers are not always tidy. Suffering rarely falls neatly into any one of these categories. Instead, suffering often falls into all of them. Many psalms move back and forth from one cause to another. In any one incident there may be more emphasis on one part of the observable triad of “me,”“others,”and “Adam,”but the issue will be one of relative emphasis. For example, in cases of sexual victimization the emphasis is certainly on being sinned against by others. But this does not exclude the fact that the victimization wouldn’t have taken place if it were not for Adam’s sin, and it also does not exclude that we are sinners who will profit from God’s discipline in our lives. Apart from Jesus there is no such thing as an innocent person suffering.

Or consider the case of physical sickness. The most obvious emphasis within the triad of “others,” “me,”and “Adam”would be the curse associated with Adam’s sin. However, physical sickness can also be related to personal sin, and it can be a result of the sin of other people (e.g., Aids from a blood transfusion).

Effect people to avoid reducing the causes of suffering to one cause. If suffering is reduced to “others,”we become blame-shifters. If suffering is reduced to “me, as it was by Job’s counsellors, then guilt and condemnation are ever-present. If it is solely from Adamic sin and the curse, we become fatalists. If it is only from Satan we become one-sided spiritual warriors who ignore the purposes of God and the interpersonal aspects of suffering. The only sure “diagnosis”is that suffering by the time it gets to us, is God’s ordained will for our lives. Yet we cannot reduce the cause of suffering even to God. God is over sin and suffering, but He is not their author It is the blasphemers and angry ones who make God the sole cause of suffering. What the Bible emphasizes is that suffering, no matter what the cause, is a time for tears and wrestling, for repentance, for putting faith in God amid anguish, for following Him in obedience. With this basic theological background, we’re ready to help fellow sufferers.

How do I help those who suffer?

The biblical strategy for helping those in pain is to outweigh it. In other words, at first all the weight seems, on the side of suffering. It is as if sufferers are unable to see anything outside of their own pain. Gradually, as they practice fixing their eyes on Jesus, they encounter, glory-weights heavier than the weight of their pain. These glory-weights include the sufferings of Christ the joy of forgiveness of sins, the contentment of obeying Christ in small ways amid large hardships, the presence of God in our lives, and the hope of eternity. To this end, those in pain must be surprised by both the intimate love and the transcendent glory of God; and they must be led to know God in a way that obeying, trusting, and worshiping God become irresistible.

Biblical sufferers can guide us. When we encounter these people in Scripture, it is as if they come alongside us, take our hand, and lead us to truths that are deeper than suffering. First, consider Job, a companion for many sufferers. In Job 1:21 he says, “The Lord gave and the Lord has taken away; may the name of the Lord be praised.”After the most horrifying of losses, this is Job’s first response. He worshiped God. The weight of God’s glory was more than that of his own suffering. Likewise, Shadrach, Meshach and Abednego had amazing spiritual instincts when, facing a fiery death, they said, “If we are thrown into the blazing furnace, the God we serve is able to save us from it, and He will rescue us from your hand, O King. But even if He does not, we want you to know, O King, that we will not serve your gods or worship the image of gold you have set up”(Daniel 3:17-18). Suffering, or the threat of suffering and death, was a time when they knew they were called to depend on God alone.

The Apostle Paul rehearses the same theme in II Corinthians 4:17. Only Jesus himself surpassed his sufferings. After recounting his sufferings in chapter one, and before he reminds his audience of even more suffering in chapters eleven and twelve, Paul says, “Our light and momentary troubles are achieving for us an eternal glory that far outweighs them all.”How do you think a person in pain might respond to the Apostle Paul’s comments? If they didn’t read the context, they might say something like this: “Light and momentary? Get real, Paul, you don’t know about my suffering.”But when we recognize the extent of Paul’s suffering, he begins to engage our attention. Paul is a credible sufferer to whom we must listen. He is not offering pie-in-the-sky encouragement. He is speaking truths that are weightier than suffering. Getting to the point where we echo these words may seem a long and impossible trek; but Paul sets before us a goal that can guide our prayer and meditation. He reminds us to look for biblical glory-weights that counterbalance, thus lighten, the sufferings.

The counselling strategy that follows consists of five statements that can guide your support and counsel to those who suffer. They are all prefaced with “God says”as a way to emphasize that God speaks clearly to the sufferer through His Word. Each is another glory-weight that counterbalances personal pain. The five headings are:

  • God says, “Put your suffering in to speech.“
  • In cases of overt victimization, God says, “You have been sinned against.“
  • God says, “I am with you and love you.“
  • God says, “Know that I am God.“
  • God says, “There is a purpose in suffering

There is a logic to this order, but these five statements are not intended to reveal a step-by-step process. Instead each is overlaid on the one before it. “You have been sinned against”is overlaid on “put your suffering into speech.”Sufferers do not “finish”one step and move to the next. So while you may be emphasizing one particular theme, the other themes remain present.

1. God says, “Put your suffering into words.“

An initial surprise to many people, and a glory- weight in itself, is that God actually encourages those who suffer to speak honestly to Him. Why is this a surprise to many sufferers? Sufferers tend to feel alone and isolated. They often think that God is very far from them. But God penetrates this isolation and prods us to put our painful experiences into speech. Not just any speech, of course. Not faithless bitterness. Not pagan laments in a world that is meaningless. God encourages us to direct our speech to Himself.

This is the pattern of the Psalms, and it is a pattern .woven through Scripture in books such as Job and Lamentations. God encourages us to put the laments of our heart into speech, and all “speech must be addressed to God, who is the final reference point for all life.“2 Even though it defies understanding. God desires to hear the depths of our hearts. In fact, when we are unable to express ourselves before God, God gives us words to express these silences. God actually “names the silences” in our hearts. The inarticulate groanings become speech.

Perhaps the church is poorer for not systematically singing through the Psalms. If we did, we would know that God puts our suffering into speech.

My bones are in agony. My soul is in anguish. How long, O Lord, how long? (Psalm 6:2,3).

Why, O Lord, do you stand far off? Why do you hide yourself in times of trouble? (Psalm 10:1).

How long, 0 Lord? Will you forget me forever? How long will you hide your face from me? How long must I wrestle with my thoughts and every day have sorrow in my heart? (Psalm 13:1).

Why are you so far from saving me, so far from the words of my groaning? (Psalm 22:1).

My soul is full of trouble….You have put me in the lowest pit, in the darkest depths (Psalm 88:3,6).

So counselling begins by being present with sufferers and encouraging them to talk about their suffering, both to you and God.

But what if counselees are complaining or angry? Should we encourage them to name the silences then? If you read through the Psalms, you will probably find that God gives much more latitude than most people think. He gives us words to say things that some would consider almost blasphemous. But there is bad complaining and good complaining. Bad complaining is the cry of one who does not acknowledge who God is. It is the cry of the selfish heart that says, “You must meet my needs.” The utmost concern is alleviation of suffering rather than the glory of God. Bad complaining doesn’t believe God’s promises; it grumbles and rages against God. Good complaining calls out “Why have you forsaken me?”because of the knowledge of God. This complaint comes from a heart that knows God and His promises, and is mystified that God seems so far away. “How could this be, when my God is the faithful God of Abraham, Isaac, Jacob, Israel and Moses?”cries the person in pain. Good complaints are cries of faith that are connected to a desire to know God. They are complaints and appeals to God, not against God.

What do you do when the complaints of sufferers are more the bad complaints of the atheist than the good complaints that arise from faith? You allow the Psalms to set your goal. You shape the complaints so that they will conform more and more to the way God teaches us to name the silences of our hearts.

Given this encouragement to speak, what might you overhear as someone names the anguished silences? Chances are you will hear a complex stew of emotions. It will not be some linear progression of emotions that travel through denial, anger, bargaining, depression and on to acceptance. It will be more like fragments of a shattered pane of glass. There may be dozens of experiences, some of them contradictory, held simultaneously.

For example, consider a woman who has been sinned against sexually. She may be afraid, filled with shame, feel unclean, and feel numb. And this is only the beginning. Guilt is almost always present. She may feel responsible for what happened: as the ageless myth says, “Bad things happen to bad people.”Job should have changed our minds on this; but many people still think that if something bad happens to them, it must mean that their own behaviour brought it on.

This guilt is particularly troublesome because, in a certain sense, it is beyond forgiveness. In other words these victims have a keen sense that they are responsible and guilty, but they have no idea what to confess (at least regarding the sexual assault). If they find things to confess, the guilt remains. Left to fester some women report self-hatred and contempt. They feel like guilty people who are objects of scorn.

What else might you expect to find in the silences? Pain, a sense of betrayal, helplessness like that of a child, rage toward the perpetrator, but also sometimes love and a desire to protect the perpetrator. Sometimes there is a determination to put hope to death. Hope is perceived as an enemy that, if aroused, will only lead to more pain. More hidden are feelings and thoughts that have to do with one’s relationship to God. Questions of God’s sovereignty almost inevitably arise. “Why didn’t He stop it?”“Why did He abandon me?”Close by might be anger against God that terrifies the person. Both you and the victim will probably be overwhelmed with the sheer number of emotional fragments.

Expressing your empathy is often the best initial response. Sufferers feel isolated. They feel like no one really understands their pain. Therefore, counsellors are anything but passive during this time. They actively move into the world of the sufferer, seeking to understand through the eyes of the sufferer. “What is it like for this person?”is an ongoing question. Furthermore, it is critical that counsellors express their responses to the sufferer. Are you overwhelmed by the complexity of the suffering? Tell the counselee. Are you grieved by what you hear? Say so. Are you angry at the wickedness of the person who caused the suffering? Express it. Are you moved to tears? Mourn with the person in pain.

Do you do this for an hour? A month? Years? How long do you have compassion on the person in pain? How long do you encourage sufferers to name the silences in their souls? The answers are obvious. You have compassion as long as there is pain. You encourage people to speak as they have parts of their lives that are unexpressed before God. This doesn’t mean that they never listen. The expression of their heart is the beginning of a dialogue that consists of speaking to God and listening to God.

With the fragmenting of experience you might think that it would be an endless process to address each fragment biblically. But if you maintain that the cross of Jesus is central, you will find that you can speak to all these experiences simultaneously. For example, the cross proclaims power to the weak, a lifting up for the humbled, a covering for the naked, love for those who have been hated, redemption for those who are slaves, grace for those who are trying to pay for their sins, forgiveness for sinners, and judgment on the enemies of God. God surprises us with the sheer breadth of His work of redemption as well as His love to the oppressed and victimized. Many sufferers, however, believe that God has abandoned them. Therefore, the cross may seem very far away, so far that the benefits of redemption do not extend to them. The counselling task is to surprise sufferers with who God is and what He says. Initially, this means to remind sufferers that God not only permits but also He encourages them to speak honestly to him. God’s truth teaches us to be honest, even as it reshapes the content of honesty.

Homework Ideas

  • Read the Psalms through this lens: God is encouraging the sufferer to speak honestly to Him.
  • Put your pain into words, either verbally to a friend or a counsellor, or by a journal. Some may prefer to draw a map that captures the complexity of their experience.
  • Go through the Psalms selecting words, phrases, or entire Psalms that express your own heart.
  • Say or write your experiences before God, remembering that God is present and hears.
  • Suffering comes from the sin of other people, the sin of Adam and the ensuing curse on all creation, or your own sin. Also, Satan is the enemy behind all suffering, and God is over suffering and uses it for a good purpose. Where is your suffering from?

2. In cases of overt victimization. God says, “You have been sinned against.“

When it is obvious that the cause of suffering was the sin of other people. God speaks to victims. While continuing to encourage them to speak honestly. He helps victims sort out responsibility for the “defilement.”Although a victim is certainly a sinner – like all of us – God’s initial emphasis is to show that He is for the victim and for justice. Love “visits orphans and widows in their afflictions”(James 1:29). Could victims have yelled louder, told a friend earlier, resisted more, and so on? Perhaps, but this does not make them responsible for other people’s sin. For example, in cases of childhood incest a woman was victimized by a person who had authority over her; and God holds those authorities responsible, whether they were leaders of Israel (Jeremiah 23, Ezekiel 34), pastors, parents, or other adults. Further-more, God says that He is against the oppressor (Exodus 22:21-24).

Some counsellors are timid to use the biblical category of victimization because it sounds too much like blame-shifting. People who have been oppressed often do blame-shift about their responses, justifying sinful self-pity, bitterness, vindictiveness, substance abuse, and so forth. Victims are also notorious for blaming perpetrators’ evil for evil returned: “My suicidal and homicidal rage is that person’s fault.”Many popular psychologies reinforce such self-righteousness. So counsellors are rightly concerned that they will leave people helpless, irresponsible, and angry. But the categories of perpetrator and victim are biblical categories, and using them well is part of thinking biblically. If we avoid these categories, we ignore God’s word to people in pain. Blame-shifting is a sin with which we are all familiar. But the Bible is balanced. “Do not return evil for evil”both identifies people as sufferers of evil and challenges blame-shifting.

If suffering is largely a result of the sins of other people, you will probably find that sorting out responsibility is very important. The stage cannot be set for forgiving if victims don’t believe they must forgive, and victims will be paralysed in their spiritual growth if they have an underlying sense that they are responsible. You will probably be surprised at how difficult it is to actually sort out responsibility. Victims are notorious for trying to find blame in their own actions: “If only I had ___, then that person would not have done ___ to me.”Sometimes this can get to the point where they believe they were responsible because they simply existed! It is difficult to proceed to other biblical truths until responsibility has been sorted out.

Homework Ideas

  • Know what the Bible says about perpetrators of evil. Read Jeremiah 23:1-8, Ezekiel 34:1-16, Luke 17:1-2.
  • Whom do you think was responsible for what happened to you? What does God say about it? Do you believe what God says about it?

3. God says, “I am with you and love you.”

The momentum of biblical counsel is outward. It directs our hearts toward the Lord, and it leads us in loving God and loving others. The two themes discussed so far express this outward-reaching momentum. Putting suffering into speech before God proceeds from faith and is an expression of obedience. Rather than a purging of emotions intended to alleviate pain. It is a response to God. Likewise, in cases of overt victimization, accurately identifying the perpetrator as a prominent cause of suffering can be an important part of interpreting our circumstances biblically. Rather than self-righteous revenge or self-condemning acceptance of all responsibility in order to protect the perpetrator, knowing we have been sinned against can be a critical step in brining glory to God. Now it is time to be pulled farther outside of ourselves and to behold Chris Himself. Specifically, God calls us to see His goodness and love as expressed through His Son.

This gaze does not come naturally. Satan – the grand deceiver – constantly whispers that God is not good. Satan desires nothing more than that we become fair-weather friends, momentarily appreciating God’s manifest blessings during the good times but questioning His beneficence in the bad. So, as counselling turns to see God’s love in Christ, counsellors must be aware that the”counselee will often be very reluctant or even angry, and counsellors might first expose the spiritual warfare that hinders hearing God.

Consider reading Genesis 3:1-7. Notice how Satan directly contradicts God’s word to Adam. The serpent essentially calls God a liar and implies that God is holding back good things from His people. Satan says that God is not good. But the gospel of Christ is the definitive statement that God is shocking in His love. This is the dominant battle that many sufferers will face. Satan will consistently use suffering to challenge our faith.

In concert with Satan another difficult challenge is the infamous question, “Why me?”There are a number of ways to address this question. One possibility is to suggest that the sufferer temporarily avoid it. It is not that the question is unimportant. It is that there is a logical priority to the questions we ask of God. Before “Why?”we should be asking “Who?”Who is the King of Kings who indicates that He is the God who loves us? The sufferer asks, “How do I know He loves when all I have is misery?”“Trust me,”says the God of love and power; and in order to trust Him we must know Him.

Perhaps you can begin by asking the sufferer if he or she would like to know a fellow suffer. Have you noticed that suffering seems different in the presence of someone who understands? And have you ever observed that suffering is lighter when you are close to someone whose suffering is greater than your own? Have you known people in pain who have gone to visit a paediatric cancer ward, and the suffering they saw made their own suffering seem bearable, or even insignificant? This is what happens when we are introduced to the Lamb of God. All our suffering, however tragic, is less monstrous than what happened to the Son of God. Jesus begins to transform suffering because of His own suffering.

Here are a number of passages that might be helpful.

  • Yet it was the Lord’s will to crush Him and cause Him to suffer (Isaiah 53:10)
  • He [Jesus] began to teach them that the Son of Man must suffer many things and be rejected by the elders, chief priests and teachers of the law, and that He must be killed and after three days rise again (Mark 8:31).
  • In bringing many sons to glory, it was fitting that God, for whom and through whom everything exists, should make the author of their salvation perfect through suffering (Hebrews 2:10).

More extended passages for meditation include Isaiah 40-53 and John 10-20. The Psalms could be used, as they are ultimately the songs of the Messiah. The painful suffering revealed in the Psalms finds its fullest expression in Jesus becoming sin for us.

These passages can introduce the theme that there is something deeper or more profound than our suffering. Specifically, the sufferings of Christ are deeper than our sufferings. God does not promise to remove suffering, but as He points us to His own suffering we are reminded that we do not live before a stoic God who is distant from His creatures. Rather, we live before the God-who-suffered. His words should have credibility to sufferers because they come out of His own familiarity with pain, and His understanding and love is undeniable. Glimpsing this, counselees, once hesitant, may now be more open to hearing what God says.

Next, God surprises sufferers by saying, “You be- long to me, I am your God.”This is a precious promise to all who have put their faith in Jesus, but it can be especially meaningful to someone in pain. Suffering isolates. Those affected often feel like they must be outcasts to have experienced such treatment. They feel shamed and rejected. It is as if they are neither children nor slave, but they have a kind of stepchild, Cinderella-like status. Victims often feel as if they are trapped behind thick impenetrable walls that partition them from the rest of the world. Jesus goes through these walls and assures sufferers that they belong to Him (I John 3, Luke 15). They are part of His family.

As children who belong to Him, Jesus listens and understands. He sympathizes (Hebrews 4:15). He shepherds the hurt and lame, and even carries the wounded and weak in His arms (Psalm 23, Jeremiah 23, Ezekiel 34, John 10). He promises to never leave or forsake (Hebrews 13:5), and He assures us that nothing can separate us from His love (Romans 8:38,39). God’s promise to be with us is the ultimate solution to suffering (Revelation 21:3,4).

God also covers the shame of those who have been sinned against or defiled by others. The Bible is filled with passages that talk about shame (also defilement, nakedness, or being dishonoured). Shame is a consequence of our own sin, but there is also a shame that is a consequence of people sinning against us. For example, in Genesis 34 Dinah was shamed or “defiled”by Shechem. In Psalm 79 the temple is shamed or defiled because of its contact with people and objects that were unclean. Jesus himself experienced this kind of shame on the cross (Hebrews 12:2). In fact, the Bible can be legitimately viewed as a story of God covering the shame of His people (e.g., Isaiah 61:10, Zechariah 3:1-5). The premise is that all of us must be covered before God. Either we will be covered by mountains that destroy (Luke 23:28-30) or we will be covered with Christ, himself (Romans 13:14). God, through His initiating grace, transforms the naked one into a beautifully dressed bride (Revelation 21).

Another feature of God’s adopting love is that He remembers our suffering and will bring justice. Sufferers feel forgotten, without anybody willing to rescue them from oppression. Their complaint seems to go no farther than their own lips (e.g.. Psalm 10); and, if they have been victimized, they often express anger toward both perpetrators and witnesses. It is an anger that says, “\ will get justice.”The Father, however, does hear. Furthermore, to “hear,”in the biblical sense, means to hear and to respond. Hearing is accompanied by action. God’s love is expressed by His unfailing promise that He will rule justly, and He is provoked to anger by injustice and oppression (Isaiah 1). He acts on behalf of His people, and He promises that there will be ultimate justice against His enemies (Romans 12:19).

The questions about “why me”and “why didn’t He stop it”may still be raging. And the thoughts, “If this is family. God has a funny way of showing it”are commonplace. But as you surprise those who suffer with the suffering and grace of God, many will begin to hear the voice of God over the cacophony of their own questions. The weight of suffering may not yet be completely offset at this point; but as a counsellor, you are beginning to point the way to the ultimate answer to the problem of suffering: “trust me”is God’s most prominent plea. At this point the sufferer is beginning to see that God can be trusted.

Homework Ideas

  • Remember your enemy? Satan prowls and wants to deceive you into thinking that God is not good. Read Genesis 3. What is Satan’s strategy? Where do you see it in your own life? How might you combat him?
  • Read through the Psalms. This time read them through the lens of Jesus. He is the final Psalmist. The words are His words. Especially notice Psalms where he speaks about His own suffering. Go back to the Psalms that captured your own experience. Now read those Psalms as the words of Jesus.
  • If suffering is characteristic of the life of Jesus, the only begotten Son, then we should not be surprised that God does not fence us from suffering. Where in your own life do you find the belief, “I have a right to less pain and suffering“?
  • Read Isaiah chapter 1. Notice God’s prominent concern for justice and His anger at injustice.

4. God says, “Know that I am God.“

To solidify this outward focus, to weigh the scales against suffering even further. God comforts us with the fact that the world is not chaotic. He is the sovereign God who reigns. Neither suffering nor Satan is above Him.

It is at this point that many theologies of suffering fail. They embrace God as a God of compassionate love, but they cannot marry that with a God who is all-powerful. They say that it can’t be both. As such, modem thinking cherishes the neatness of our minds more than the truths of God’s word. When we encounter a conceptual difficulty, we revise it so it becomes more palatable. Perhaps the most notorious example of this is found in the popular book. When Bad Things Happen to Good People, by Rabbi Harold Kushner.3 In his comments about the book of Job he says, “forced to choose between a good God who is not totally powerful or a powerful God who is not totally good, the author of the book of Job chooses to believe in God’s goodness.”And the book was a best seller!

The biblical response, of course, is that God says both: He is love, and He is the sovereign God over all creation. This neither makes God the author of sin nor suffering; but it is to say that He is over it, working all things together for the purpose of His glory. This apparently posed no obstacle to the people of the Bible. Joseph indicates that God’s plans were higher than the evil of his brothers (Genesis 50:20). Naomi says rightly but without a full understanding of God’s grace, “The Lord has afflicted me, the Almighty has brought misfortune on me”(Ruth 1:21). Jeremiah, a consummate human sufferer, says, “Who can speak and have it happen if the Lord has not decreed it? Is it not from the mouth of the Most High that both calamities and good things come?”(Lamentations 3:37,38). The Psalmist finds rest in God alone amidst his persecution, and is confident: “You, O God, are strong, and you, O Lord, are loving”(Psalm 62:11-12).

Finally, Job had all his questions answered, or at least rendered insignificant, in a one-sided conversation where God essentially said, “Know that I am God”(Job 38-41). There was no skeptical academic musing, “If God is God He is not good; if God is good He is not God.”Instead, the overwhelming weight of God’s glory made Job’s suffering seem less. When Job was languishing in the question, “Why me?”and actually setting up an earthly courtroom to question the Most High, God surprised Job with a courtroom where God Himself was the prosecutor. “Will the one who contends with the Almighty correct Him? Let him who accuses God answer him!”God revealed His glory to Job; and upon seeing God’s glory. Job saw that there were spiritual realities deeper than his suffering. In fact, this glory-weight was so profound that Job was utterly humbled and silent. He repented of justifying himself and accusing God. His troubles were certainly “light and momentary”in light of God’s revealed power.

Does this end the questions? For many people, no. The question often lurks in the shadows, “If God is over all things, why did He allow this evil to happen to me?”Amazingly, God invites this wrestling with Him. His response, however, will continue to be, “I am your deliverer, your saviour, your friend, your God. Trust me. Ultimately the very existence of evil will provide a demonstration of my glory and love and power, for I will save my children and destroy my enemies.“4 Then, God reveal vistas showing how our suffering precedes our glory.

Homework Ideas

  • God’s thoughts are higher than our own. In suffering God doesn’t supply in depth answers to the “why”questions, but He does comfort us with the fact that He is greater than the suffering. God is in the suffering but without being the author of suffering. Read Job 38-41 until you can take comfort that the world is not chaos.
  • Read the courtroom encounters in Ezekiel 1, Isaiah 6, and Revelation 4. What were the responses of the witnesses? Why?
  • Practice− or ‐perhaps for ten minutes a day− or ‐the spiritual discipline of quieting the questions in your mind and listening to what God says.

5. God says, “There is a purpose in suffering.“

In his book. How to Handle Trouble,5 Jay Adams summarizes a biblical approach to trouble this way:

God is in it. God is up to something, and God is up to something good. Since God is the God of the gospel of grace as well as the King over all creation, it follows that He has kingdom purposes in suffering, and these purposes are good. “The lions may grow weak and hungry, but those who seek the Lord lack no good thing”(Psalm 34:10).

The problem for many people is that “good”may not include an immediate end to their suffering. Rather, the, good is that suffering will be used by God to conform us into the image of Jesus and, as a result, bring glory to the Father. To paraphrase C. S. Lewis, we settle for too little We want nothing more than the immediate alleviation of suffering, but God wants to give us so much more. He wants to give us things that will last all eternity. He wants to give us a new obedience to His word (Psalm 119:67,71), holiness which will lead to righteousness and peace (Hebrews 12:10,11), perseverance, character and hope (Romans 5:3-5), and a knowledge of His presence in our lives by His Spirit (John 14-16). In short, He wants to give us the kingdom.

This is where I bring the familiar passage. Romans 8:28, to counselees: “For we know that in all things God works for the good of those who love Him. Who have been called according to His purpose.”The less familiar verse 29 then tells us what this “good”is. “For those God foreknew He also predestined to be conformed to the likeness of His Son.”This is the greatest way that God can show us His love.

As you journey with a counselee toward a greater understanding of God’s purposes, it is wise to keep one eye on the adversaries: the world, the flesh, and the devil. The world is constantly communicating that this is the only home that we have, and we deserve freedom from pain while we are here. The flesh finds pleasure in autonomy from God and resists submitting to His will. And the devil constantly takes our circumstances and suggests that they constitute evidence that God is not really good, that God is holding out on us, that God does not love. With such adversaries it becomes obvious that the battle cannot be waged without the prayers of God’s people.

Suffering exposes hearts. One-way God does damage to these adversaries is that He uses suffering to expose our hearts. Suffering is a pressure that can squeeze us, revealing either faith or pockets of unbelief and sin that were previously hidden. Trials test our faith (James 1:2). As Luther said, “Where the battle rages, there the loyalty of the soldier is proved.”God uses suffering “to humble and test you in order to know what was in your heart, whether or not you would keep His commands”(Deuteronomy 8:2). This is not to say that personal sin always causes suffering. Job’s counsellors were wrong. It is to say that God uses suffering to reveal and to purify those whom He loves. So Job repents of his self-righteousness.

Perhaps you have heard Christians say of suffering, “This is exactly what I needed.”They are referring to the exposing of sin that often occurs with suffering. It took precisely that suffering to teach dependence on God rather than self. No one is thankful for severe illness or an uninvolved spouse or a tragedy, but many have learned to be grateful, even joyful, for the spiritual training that these circumstances induce. Without the ongoing exposure of our lingering sinful flesh, we gradually get lulled into thinking that we are okay. We are. good people who occasionally do not-so-good things. Then the problem of evil becomes something that is “out there”rather than “in here.”The frightening danger of this thinking is that the gospel of Christ becomes little more than a nice present from God to people who have been doing pretty well. It is no longer seen for what it is: the gospel of grace given to desperate beggars.

To frame it like the book of Job, suffering places us at a spiritual crossroads. When all the pleasurable accoutrements of life are removed, will we still worship God? During the good times the answer seems easy: “Of course I will trust God!”But suffering exposes the unbelief and self-worship of our hearts. It can reveal that our faith is more accurately “you scratch my back and I’ll scratch yours.”It can reveal that our apparent obedience may actually be a happy coincidence, occurring when our desires happen to coincide with God’s law. With this in mind. God’s gracious purpose becomes more obvious. God uses suffering so we know when we are worshiping God for our sake or for His.

The Apostle Paul put it this way: Suffering forces us to answer the question, “On whom will you rely?”His response, “Indeed, in our hearts we felt the sentence of death. But this happened that we might not rely on ourselves but on God, who raises the dead”(II Corinthians 1:9). Paul was more passionate about conformity to Christ by faith than he was about the immediate alleviation of his own suffering.

Therefore, one purpose of suffering is to produce repentance, faith, and obedience. These responses to suffering have eternal longevity. They please God and bring the blessing of peace. Also, this purpose reveals more glory-weights that unbalance the scale against suffering. The glory-weight of forgiveness of sins is

heavier than the weight of our affliction and the glory-weight of gaining wisdom and sharing in God’s holiness becomes a beautiful gift that further tips the scale.

Of course, sin is not the only thing exposed by suffering. Suffering may also expose hearts that are full of faith. Many Christians who have been surprised by suffering find themselves immediately going to God’s Word for comfort, and they offer prayers of lament and praise that rival the Psalmists. In such cases we still mourn with people in pain, yet we can also rejoice that the sufferers visibly testify to themselves, to the church, and to the world that they are children of God.

Suffering exposes eternity. While suffering can turn the lights on and expose our hearts, it can also lend clarity by exposing even larger kingdom realities. It helps us see eternity. It provokes hope. It is as if our suffering urges us closer to eternity so we can see our present affliction from that perspective. This is where II “Corinthians 4:16-18 becomes most brilliant.

For our light and momentary troubles are achieving for us an eternal glory that far outweighs them all. So we fix our eyes not on what is seen, but on what is unseen. For what is seen is temporary, but what is unseen is eternal.

The weight of eternal glory far outweighs our temporary pain. Or as Mother Teresa has said, “from heaven, the most miserable life on earth will look like one bad night in an inconvenient motel.”So continues the outward pull of a biblical theology of suffering.

The encouragement to hope in suffering is a strong theme throughout all Scripture. It is obvious that if the Apostle Paul had a secret, this is it. The hope of eternity was deeper than his pain: “We rejoice in the hope of the glory of God”(Romans 5:2). The problem, however, is that we are a generation locked into the present. Preoccupation with temporal concerns, such as monthly bills, as well as temporal blessings, such as peace and freedom, makes it increasingly unnatural for Christians to be able to look past them. Yet this is where suffering can do its best work. Suffering reminds us that the world does not keep its promises. It reminds us that there is nothing in this world that is not tainted by sin and the curse. As such, hope can become, by God’s grace, more instinctive and settled.

Hope is the grand finale of suffering. Suffering makes what we hope for less shadowy. So it is not surprising that some of the best known Bible passages on suffering end on that note (Romans 5:3-5,8:18-39,1 Peter 4:12-14). For example, Romans 5:3-5 talks about the cumulative purposes of suffering. For those who have been trained by it, suffering produces perseverance, perseverance produces character, and character produces hope. Then the Apostle immediately proceeds to discuss the present guarantee of the substance of our hope. He indicates that hope is sealed because we have witnessed the cross of Christ and the resurrection of Christ from the dead. We have witnessed His love for us. Therefore, our hope is assured. With this Paul takes us back to the beginning of our theology of suffering and reminds us that sufferers must never take their eyes off of the cross and the love displayed there. There is no hope without a conviction of God’s love.

How does hope come to a person in pain? You can start by reading biblical passages about hope. Marvel at how the Apostles Paul (Romans 5:3) and James (James 1:2) even rejoice in their suffering when they hope. Then notice the expanse between the sufferer’s present hope and the hope of Paul and James. Reflect on how this distance cannot be bridged except trough prayer meditating on, the .consummation, and practicing the discipline of hope. Remind counselees that hope will not come in one week but with persistent encouragement and practice, hope will become more and more of a reality.

When you read the Psalms, it may seem like hope comes instantly. In many of the Psalms there appears to be a mere gentle reminder to hope in the Lord and suddenly the Psalmist bursts into praise. The Psalms, however, provide condensed summaries of an educational process. Also, they are written by people who were skilled in hope. Indeed hope is a skill. It is not an experience that simply comes over us; :It is a discipline that demands stamina and the constant encouragement of the scripture and God’s people if it: is to flourish (Romans 15:41).

This is the heart of God’s purposes in suffering: exposing our hearts, beholding and trusting the risen Lord, anticipating His return, and thus learning obedience. Yet there is one other purpose that can really excite some people. In Job’s situation one purpose of suffering was to silence Satan. Satan, the enemy and a prominent cause of suffering and evil, still lives to accuse us and persuade us to disobey the Most High God. The privilege of God’s people is to do violence to Satan by trusting and obeying God even in suffering.

In eternity we will hate the enemies of God. However, at this time we do not fully know who these enemies are. The only enemy that we know for certain is Satan himself. As one of the Puritans said, our task is to “do as much mischief to him as possible.“

Suffering certainly makes this battle of the Christian life more apparent; but God’s power. His victory over Satan, and His wooing us with His precious promises are more than enough to successfully engage the struggle. Also, we have the example of Christ as well as men and women of faith in both the Old and New Testaments to cheer us on. Furthermore, there are the lives of many people around us that are worthy of imitation.

One well-known example of a sufferer who can lead us is Horatio Spafford, the writer of the hymn, “It is well with my soul.”In 1873 he waved goodbye to his wife, Anna, and their four children as they were bound for France aboard the ocean liner, Ville du Havre. He had some business affairs in the United States to tend to before he could join his family in Europe. The trip proceeded smoothly until sometime in the middle of the night on November 22 the ship was rammed broadside by another vessel.

The rushing waters separated Mrs. Spafford from the three oldest children. She still clutched her youngest child, Tannetta, as they were swept into the cold Atlantic. Suddenly, the child was torn from her grasp. Mrs. Spafford was later pulled unconscious from the water by sailors from the other vessel. All four children drowned.

A few days later, Horatio received a telegram saying that only his wife survived. Although he fell into what seemed to be an unrelenting depression, he soon boarded a ship to meet his wife in Europe. At a certain point in the voyage, the captain announced that they were passing the site of the wreck. Then he went to his cabin and wrote the following poem. Notice how even in his great sorrow and depression, he found that hope in Christ ran deeper. There were glory-weights that gave him peace.

When peace like a river, attendeth my way,
When sorrow like sea billows roll,
Whatever my lot. Thou hast taught me to say,
It is well, it is well with my soul.

Though Satan should buffet, though trials should come,
Let this blest assurance control,
That Christ has regarded my helpless estate
And hath shed His own blood for my soul.
My sin-O the bliss of this glorious thought
My sin, not in part but the whole,
Is nailed to the cross and I bear it no more,
Praise the Lord, praise the Lord, O my soul.

O Lord, haste the day when the faith shall be sight,
The clouds be rolled back as a scroll,
The trump shall resound and the Lord shall descend,
“Even so,”it is well with my soul. 

The scales are now becoming increasingly lop-sided. Suffering still exists, and the pain may be great; but the glory-weights are addressing places in our hearts that are deeper than the pain (Figure 2).

Figure 2. God unbalances the scales of our suffering

Homework Ideas

  • Consider the life of Joseph. How do you see God’s loving purpose? Note especially Genesis 50:20.
  • Consider the life of Naomi in the book of Ruth. How do you see God’s loving purpose?
  • The walk of the Christian life is summarized in a number of ways.
      • “Man’s chief end is to glorify God and enjoy Him forever.”(The Westminster Catechism)
      • “Be holy as I am holy.“
      • “Be imitators of Christ.“
      How do these suggest that there are deeper purposes to your pain?
  • Develop a music library of worship music.
  • Read a biographical book about suffering, e.g., A Step Furlherbylom Eareckson,6 Through Gates of Splendor by Elizabeth Elliot.7
  • What are ways that you can silence Satan?
  • Begin to establish a pattern of praying Scripture. That is, if God says it and you don’t understand it or believe it, pray that the Lord would make His word alive to you. Consider starting with passages about hope.
  • Read Hebrews 10:37 to Hebrews 12:12. How do these brief biographies encourage you? What wouldthis hope look like in your life? What questions do you have from the passage?

Not bleeding heart victims,
not stoics,
but suffering servants of God
and responders to His grace 

So who are we? What is our identity? People of pain? People who are healing from pain? People who have been victimized and wounded? Or are we people who need to forget about pain and just get on with it? Do we need a tougher brand of Christian who ignores the pain and stays in the battle?

God clearly shows us another way. The incarnation speaks against the shallowness of the stoics (somebody who appears unaffected by emotions). Jesus’ presence on earth shows His sympathy with those who “suffer. His ministry was full of compassion and understanding. His ministry also exposes the shallowness the bleeding hearts. He demonstrates that pain, suffering, victimization, and death are not the pre-eminent features of life. Jesus points us to deeper realities, deeper spiritual needs.

We are people-who-have-been-shown-mercy. This certainly doesn’t sound new. It is an identity that even a child can see in the Scriptures. But its commonness belies its ability to revolutionize the sufferer’s perspective. For example, people who have suffered at the hands of others sometimes feel that life as a victim is certain. This is who they are, and the most they can do is try to protect themselves from the pain. But God reorients sufferers. He reveals that the grace they received does not compare to the pain they experience. Grace is weighty, suffering is light. Or consider people who are angry because they feel like they don’t deserve pain. As recipients of mercy and grace, these people are suddenly humbled by the astounding cost of the initiative of love taken toward them. They were reactive victims; they become loving responders. The foundation for the life of the Christian is God’s grace, not freedom from pain. We were enemies of God who were naked and blind, and He took the initiative toward us. “While we were still sinners, Christ died for us”(Romans 5:8).

Perhaps “responders”captures our new identity God is the relentless initiator of liberating grace; we respond to His grace by faith. As responders, the one who liberated us defines us, and we become His servants. This does not remove suffering. No indeed, suffering will cling to earthly life. But we are not defined or controlled by it. We are responsive, suffering servants.

Here is curious counsel for sufferers: we travel a path

that urges us to look outward, toward the triune God.

“Let us fix our eyes on Jesus, the author and perfecter of our faith, who for the joy set before Him endured the cross, scorning its shame, and sat down at the right hand of the throne of God”(Hebrews 12:2). This certainly does not mean we ignore suffering, but the weight of God’s glory does mean that our questions begin to change. The question, “Why didn’t God stop it?”becomes less urgent; and we begin to ask, “How can I respond to what God has done for me by loving God and loving others?”“How can I treat others the way Christ has treated me?”The questions for sufferers become the same as those for all Christians, “How do I enact the two great commandments, love God and love your neighbour as yourself?“

Responders Who Love Others. For people who have been victimized this is when you talk, about forgiving the perpetrator. “Do not be overcome by evil, but overcome evil with good”(Romans 12:21). The outward movement of biblical counselling makes this unavoidable. As you have been forgiven, you forgive others. As God has dealt with you “unfairly,”that is. He has loved you when you did not deserve it, you begin to love your enemies.

What will this love look like? There are dozens of possibilities. Sometimes it will take the form of confronting the person, either by letter or in person. Sometimes it will take the form of praying for the perpetrator and not giving up hope for full reconciliation. Sometimes it will take the form of calling the pastor and 911 for help in the middle of a crisis. Sometimes it will take the form of ministering truth and grace to people suffering similar woes. God’s love can inspire many creative initiatives.

Responders Who Love God. At the last supper Jesus told the disciples that they were soon to experience great grief; but shortly after that pain there would be a joy which could never be stolen, even during the tremendous persecutions all of them were to face.

I tell you the truth; you will weep and mourn while the world rejoices. You will grieve, but your grief will turn to joy. A woman giving birth to a child has pain because her time has come; but when her baby is born she forgets the anguish because of her joy that a child is born into the world. So with you: Now is your time of grief, but I will see you again and you will rejoice, and no one will ever take away your joy (John 16:20-22).

How could this be: constant joy overlaid with grief and pain? Certainly, it is a difficult experience to describe; but it is true nonetheless. It is because we worship the risen Lord. Jesus is alive. No matter what happens to us, our great God reigns. Personal hardships and afflictions cannot mute the resurrection. The greatest joy of the Christian is God himself and the fact that nothing can separate us from Him.

Evidence of this joy in suffering can be found at the funerals of many of God’s people. For example, consider the following comments given by the family of a child who died of cancer.

Lend your heaven-song to ours from earth, dear son, and worship Him whose love constrained Him to die for the likes of us so that you could enter into the paradise you now enjoy so much and live forever with him. We miss you but “we’ll be strong, and carry on, till the day when we’ll see you, up in heaven.”There is great sorrow because of the loss of a dear friend or loved one. There might even be anger because death is an intruder that doesn’t belong in God’s creation. But there is also joy. Joy in knowing that the one who died is home. Joy in knowing that in the resurrection of Jesus the greatest enemy, the most profound cause of suffering, death itself, “has been swallowed up in victory”(I Corinthians 15:54).

There are, indeed, realities deeper than our pain. The understanding love of Jesus who became a man, forgiveness of sins, knowledge that God has a purpose; these are glory-weights that change our suffering. But the greatest of all glory-weights is God himself. To know Him as the true God who is to be worshiped and adored is the greatest glory-weight for any sufferer. It doesn’t end our temporal grief and pain, but it means that we neither exalt our pain nor ignore it. We exalt God amid pain.

“I consider that our present sufferings are not worth comparing with the glory that will be revealed in us”(Romans 8:18).

Propositions about the Problem of Suffering

The church needs a confession of faith for counselling that will define what Christians should and should not believe about the problem of suffering. Here are preliminary statements, that I hope will be refined through a process of discussion.

1. Pain and suffering entered the world after Adam’s sin.

We affirm

  • that although we did not actually, voluntarily participate in Adam’s sin, we share in Adam’s guilt and depravity. Therefore, we are never innocent sufferers.
  • that pain is now a permanent part of earthly existence because of the curse of God on sin. that pain extends to the believer and unbeliever alike.
  • that pain is an intruder on God’s creation, and it will one day be banished by Christ.
  • that pain, like sin, is a mysterious presence in our world that cannot be fully understood.

We deny

  • that God is the author of sin (sin being the cause of suffering).
  • that pain is ever the cause of sin.

2. Pain and suffering are variously attributed to Satan,

Adam’s sin, our own personal sin, being sinned against

  • by others, and God himself.

We affirm

  • that Scripture emphasizes how to live obediently in suffering rather than how to discern the precise cause of suffering.

We deny

  • that suffering is always a direct result of our own personal sin.

3. Regardless of the cause, pain and suffering call for compassion from God’s people.

We affirm

  • that Jesus was filled with compassion for those who suffered; and as imitators of Jesus, the church also responds with compassion.
  • that compassion is both word and deed.
  • that compassion includes encouraging those in pain to speak honestly to the Lord.

We deny

  • that compassion is a “stage”in counselling; It is, from first to last, our attitude toward those who suffer.

4. God is over all things, including pain and suffering.

We affirm

  • that God is above Satan, sin, and “accidents.”By the time suffering gets to us, it is God’s will for our lives.
  • that suffering leads us to humble dependence on God.

We deny

  • that God’s sovereignty in suffering in any way
  • diminishes His great love for His people.

5. The gospel of Jesus changes everything in our world, including our suffering.

We affirm

  • that in the sufferings of Jesus we find a suffering that is deeper than our own.
  • that in the gospel Jesus comes to us as a priest who thoroughly understands our pain.
  • that redemption is the deepest human need. Our sin problem far outweighs our suffering. As such, the blessings of redemption are deeper than our suffering.
  • that suffering is purposeful. It tests and exposes the human heart, and it is “good”in that it can strengthen believers and mould them into the image of Christ.
  • that Christians may suffer more than unbelievers. They will suffer more because their compassion will extend beyond the boundaries of themselves or their families, and they may suffer for righteousness sake.
  • that suffering leads to hope. As we grow through suffering, we leam to be dissatisfied with the present world and anticipate eternity. We look less to the cause of suffering and more to our risen redeemer…

 

  1. Vincent Gallagher, Three Compulsions that Defeat Most Men (Minneapolis: Bethany House, 1992), page 29.
  2. S. Hauerwas, Naming the Silences: God, Medicine, and the Problems of Evil (Grand Rapids: Eerdmans, 1990), page 82.
  3. Harold Kushner, When Bad Things Happen to GoodPeople (NewYork: Avon, 1983).
  4. See Jay Adams, The Grand Demonstration (Santa Barbara, California: EastGate Publishers, 1991″) for a fuller treatment of this issue.
  5. Jay Adams, How to Handle Trouble: God’s Way (Phillipsburg, New Jersey: Presbyterian & Reformed, 1982).
  6. Joni Eareckson Tada and Steven Estes, A Step Further (Grand Rapids: Zondervan, 1990).
  7. Elizabeth Elliot, Through Gates of Splendor (Wheaton, Illinois: Tyndale, 1986).