Clinical Psychiatry has long been the domain of the medical profession, firmly rooted in the medical model of pathology, nosology and biopsychosocial treatment strategies. Integration of clinical psychiatry with Christian faith, to many seems like a contradiction in terms. Prejudice and fear often dominate discussions on psychiatry in the Christian church, creating substantial tension between mental health professionals and theologians. Yet Christians are not exempt from mental illness. In their existential suffering they are looking for guidance and understanding against the background of their Christian faith. What are the issues the clinician has to address in treating Christian patients? What are the causal attributions regarding mental illness, and how can they be integrated into effective treatment strategies fostering both improved mental health and spiritual growth?

Clinical psychiatry, as it is practiced today, is caught in the tension between biological reductionism and the search for meaning and purpose in the individual (Freedman, 1992). Adolph Meyer (1928) referred to the „narrowing mind-shy and man-shy“ mechanistic philosophy of the nineteenth century as obstructing his vision of a psychiatry that keeps the person in the center. The call for „Rethinking Psychiatry“ (Kleinman, 1988), therefore is a timeless challenge to those who want to go beyond professionalism, coming from cultural category to personal experience, from pathology to coping, from nosology to existential suffering, from a medical model of disease to the personal experience of illness, from technology to empathy, from science to intuition.

This tension between neuroscience and psychiatry, between biological and psychodynamic views of mental suffering has become all the more accentuated with the declaration of the „Decade of the Brain“ (Pardes, 1986; Gabbard, 1992). Psychiatrists and psychologists around the world are fascinated, if not to say spellbound, by the promises of biological research in their field. The unraveling of the human genome, the colorful results of brain-imaging, the laboratory findings of neuro-endocrinology and neuro-immunology, the ever broadening field of psychopharmacology, to name just a few of the specialized areas of research, are the center of attention, and they are taking a vast amount of space in our professional journals.

These fields indeed are fascinating, and as a psychiatrist I would not like to miss the progress psychiatry has made in the knowledge of basic mechanisms of neurobiology, understanding the physiology of the synaptic cleft, the action of neurotransmitters in various psychiatric diseases, and the biological basis of seasonal affective disorders. Some imaging technologies, such as magnetic resonance imaging (MRI) are now broadly available to support our diagnostic search for organic causes of psychiatric disorders. Others, like positron emission tomography (PET) or Single Photon Emission Computed Tomography (SPECT) are only available in specialized research labs, but they help us better understand neurotransmitter activities during mental processes.

Advances in psychopharmacology have enabled us to treat patients with severe depressions and schizophrenias in a way that was not conceivable just fifty years ago. Social psychiatry as it is practiced today would not be possible without drugs. All too often, however, the availability of potent drugs has led to a simple equation in medical practice: if somebody reports symptoms of depression, you have to prescribe an antidepressant. It is no wonder that anxiolytic and antidepressant medication are now among the leading sources of revenue for the pharmaceutical industry.

Critics of the ever growing „psychological society“ (Gross, 1978) even speak of the „manufacture of  madness“ or the „myth of mental illness“ (Szasz, 1961/1974) alluding that psychiatric diagnoses were constructions of psychiatrists, enslaving patients, placing them in psychiatric institutions against their will, or forcing them to swallow medication, thus destroying their personality. Criticism is not only aimed at psychiatry but at psychotherapy as well. Thus, Zilbergeld, in his landmark book „The Shrinking of America“ (Zilbergeld, 1983) challenges the myths of psychological change, and states that professional therapy is „overpromoted, overused, and overvalued.“ (p. 271). Paul C. Vitz (1977), in his classic „Psychology as Religion“, talks of the „Cult fo self-worship“. „Psychotherapy,“ he writes, „once a restricted and specialized activity, is now generalized to all of life’s relations.“ (p.21).

Such arguments are readily welcomed by those who are not only critical of psychiatry and psychology but also critical of Christian attempts to integrate psychology and Christianity ([1]). Their concern not only touches on professional issues regarding diagnosis and treatment but also the question of the philosophical or rather the spiritual foundations of professional help in the area of psychiatry and psychotherapy. Do Christians, who are firmly rooted in their faith, really need psychiatry? Don’t they have everything in Christ? Anti-psychiatry and anti-psychotherapy statements from influential pastors and writers have created a great deal of confusion among the Christian community. In a study that we conducted at our clinic this critical attitude against psychology and psychotherapy was especially high in those who had never been in the situation in which they had to consult a professional for emotional problems (Table 1).

In my conversations with secular professionals, Christian theologians, and lay persons, I have  encountered four distinct attitudes toward the question of integration of Psychiaty and Christian Faith:

1. Psychiatry and Christian Counselling are separate fields and cannot be integrated. Psychiatry can help those with mental illnesses and emotional problems, the church and Christian counseling are for those who have faith-related questions.

2. Psychiatric problems can be caused or at least deteriorated by religion. German authors speak of the „ecclesiogenic neurosis“ (for a critique of the concept see Pfeifer, 1994a), others of „toxic faith“ (Arterburn & Felton, 1992). Research in the field has demonstrated, however, that with a decrease in religious commitment in our society, religious content in schizophrenic or depressive delusions is declining, too. If people feel guilty, they do not refer to God any more, but rather to their own failure. A god-centered world view is increasingly being replaced by a narcissistic way of functioning creating new forms of causality.

3. The other extreme: Mental illness is a spiritual problem and healing can only come through faith. Causes are attributed to personal sin, to a lack of holiness, or to the influence of an „occult bondage“, to name a few. This approach of an exclusively spiritual causal model of mental illness carries detrimental consequences for the patient: Not only do they have emotional problems, but they are constantly under the weight of religious requirements which they cannot fulfil. Often, as a consequence, they are slowly excluded from the fellowship of those believers who are healthy enough to live by the external ideals of their church. It is this deeply uncaring attitude which can substantially increase the problems of mentally suffering patients.

4. Mental diseases are a reality of our existence in this fallen world. Christians are not exempt from psychological problems and mental illness. It is my conviction that the Christian church has a calling to serve these people in their existential weakness both in a professional and a spiritual way.

The primary key to such a ministry to the weak is compassion, not the search for presumptive causes. This is exemplified in the encounter of Jesus with the man who was blind from birth in John 9:2. The first question the disciples asked was a question for causality: „Rabbi, who sinned, this man or his parents, that he was born blind?“ Today, they would perhaps ask: „Rabbi, who is under demonic oppression, this man or his forefathers to the third and the fourth generation?“ — Jesus did not give them a causal answer; rather he directed their focus on a goal oriented view of meaning: „Neither this man nor his parents sinned, but this happened so that the work of God might be displayed in his life.“ In the simple words „This Happened“ he accepts the reality of suffering in an existential way without judging the help-seeking person, without blaming the parents; without pressing a moral concept of guilt and redemption; without laying the burden of the right religious creed or right religious emotion on him. — But the text goes on with the words „So That“ — so that the work of God may be displayed in him. What is the Work of God in the weak and the helpless in our days? How can we, in the specialized field of medical psychiatry and psychotherapy do „the work of God“?

If we want to help Christian patients in a professional way, we have to take their anxieties serious, building bridges for them to get the treatment that will benefit them without loosing their faith in God and the fellowship of a supporting Christian church.

The Needs of Religious Patients

What is going on in Christian patients when they suffer from serious mental illness? Are there differences between Christian and non-religious individuals? Let me illustrate my approach with the most common disorder in our field, depression. When religious individuals suffer from a depression, they often do not only display the well known symptom complex of depression (as for example measured in the HRSD = Hamilton Rating Scale for Depression or the BDI = Beck Depression inventory). One of their major complaints pertains to the fact that their faith which was so important and sustaining to them, is now like a distant conviction without power to console any more. More than that, they do not dare to share this with their physician if he is not a Christian (Spence, 1992). He would not understand me and could possibly despise me.

How can we meet them both as professionals treating their depression and as counsellors who go beyond professionalism. Three factors seem to be crucial:

a) Being knowledgeable concerning the clinical picture of depression or other mental problems, thus enabling the clinician to distinguish the basic symptomatology from individual content which may or may not be religious.

b) Being knowledgeable concerning the subcultural causal attributions of religious patients. Often religious patients describe their problems in a terminology of spiritual emotions and religious causal attributions (Pfeifer, 1994b; Pfeifer & Waelty, 1994). The clinician often has to become an translator for the patient, applying the principles of „collaborative empiricism“ (McMinn & Lebold, 1989).

c) A pervasive attitude of compassion, accepting the patient in his or her existential suffering without prematurely interpreting content that the clinician is not familiar with.

Let me describe a model that builds the bridge for Christians to better understand mental problems and their treatment:

The effect of depressive symptomatology on faith

Religious individuals do not only suffer from the general symptomatology of depression but especially from the fact, that faith which has been a source of strength and coping is now darkened and losing it’s supportive function. The general tendency of feeling guilty and a failure is then related to a failure in their spiritual life. It is important to understand this mechanism and to help patients see the correlations between their subjective spiritual suffering and the depressive disorder. Let me describe a few of these correlations:

a) Sad affect, loss of joy and interest can lead to a loss of joyful emotion in regard to God and his creation. This pertains especially to those theological traditions which emphasise emotions as a proof of salvation or predestination.

b) Ruminating and doubting, inner restlessness and endless brooding can lead to a loss of the conviction of salvation or predestination.

c) Self reproach and ideation of guilt are experienced as real guilt before God and can lead to fear of being eternally lost without a way of reconciliation and forgiveness.

d) Lack of energy and inability to make decisions obstruct participation in regular Christian activities, increasing a sense of inadequacy. Even bible readings and prayer become a burden.

e) Fear and regression, or inadequate clinging to others can severely hinder the fellowship with other christians which would normally be the social network of support.

f) Worries and a lack of perspective take away the confidence which the person had through faith. Bible quotations telling them not to worry, can increase the sense of disobedience and inadequacy.

g) Irritability and hypersensitivity can result in dysfunctional behaviour, which is perceived by the afflicted person and family and friends as well as not compatible with the love and gentleness of a Christian life.

h) A lack of hope and the wish to die are sometimes supported by Bible quotations out of context, which seem to encourage suicide.

i) Often patients or their Christian subculture interprete their emotional and vegetative complaints as the activity of demonic powers, thus adding a dimension of terror to the depressive experience which goes far beyond bare human experience (Pfeifer, 1994.

All this can make a depressive episode in a religious person a very traumatic and desperate experience, strung between personal inadequacy, divine rejection, and satanic oppression. The parallels of general experience of depression and religious equivalent can be understood in terms of the general vessel of psychopathology being filled with the content of personal concerns and values, which can be primarily religious in the Christian patient. In his excellent paper on „The phenomenology of religious psychopathology“, Meissner (1991) wrote: „Consideration should be given to how patients use their religious belief systems as a vehicle for the expression of neurotic needs and conflicts, in particular to identify patterns of symptomatic and characterological expression with their particular religious phenomenology.“ (p. 268).  Interpretative disentanglement of religiosity and personal functioning helps the person to gain new insight in the nature of his or her problem, taking out some of the conflictual potential of the religious tension. Explaining the „spiritualized“ symptoms as basic correlates of a depressive episode with bio-psycho-social dimensions can become very helpful to the afflicted person and his or her family, thus relieving the fear of a spiritual crisis with all the negative cognitions of rejection, guilt, and anxiety directed toward God.

Thus, going beyond professionality in psychiatry, among other things, means to give the patient a culturally sensitive interpretation of his suffering. Eisenberg (1981), in an excellent essay described the function of the physician as an interpreter: „The decision to seek medical consultation is a request for interpretation... . Patient and doctor together reconstruct the meaning of events in a shared mythopoesis... Once things fall in place; once experience and interpretation appear to conincide; once the patient has a coherent ‘explanation’ which leaves him no longer feeling the victim of the inexplicable and the uncontrollable, the symptoms are, usually, exorcised“ (p.245). Well, it might be not that easy, but the Christian psychiatrist and psychotherapist certainly does have a calling to help people understand their illness on background of their Christian values. It is on this basis, that one can start a form of integrated psychotherapy, such as interpersonal therapy (Klerman et al., 1984). The above model gives the patient alternative ways to understand his or her problems. Although some patients are reluctant to accept medication on the grounds of personal fears and dogmatic considerations, one should try to win them in their own interest to take advantage of this aspect of therapy.

Case vignette

Table 1:

Some selected results of a study on the interaction of faith and neuroticism in patients diagnosed with affective disorders, anxiety disorders and personality disorders and a healthy control group (Pfeifer & Waelty, 1995).

Conclusions

To conclude, I should like to give us four elements that should guide us as professionals in order to go beyond professionalism in the integration of psychiatry, psychotherapy and Christian faith.

1. We should be open for a deep personal awareness of human suffering beyond all categorical and theoretical considerations, moving us to compassion and motivating us to find new ways for creative caring.

2. We should be aware of new developments in our professional field, able to communicate with the world, to examine the philosophical underpinnings, critically evaluating what we can apply in our everyday practice.

3. We should be guided by the Word of God as an eternal source of wisdom and truth, practicing an exegesis that applies to the burdens, the questions and the spiritual hunger of our patients.

4. We should be guided by the principle of hope, hope which is not only rooted in the prospect of restored health, but hope in the midst of existential weakness, hope which is not only based on well-being in this world but hope that goes beyond all that our limited professional activity can achieve.

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