Back in 1975, when I started my psychiatry training, it wasn't long before I met my first patient requesting to see 'a Christian psychiatrist'. At first I sympathised: suspicion of atheistic Freudianism had led me to commence my training with a 'Christian' consultant too. But with experience I began to realise that, for many patients, wanting to see 'a Christian psychiatrist' meant not really wanting to see a psychiatrist at all. Some used a spiritual smoke screen to camouflage difficult family and personal dynamics while others adopted a conspiratorial tone of 'special' relationship that expected privilege and personal treatment.

As these experiences accumulated, I found myself beginning to challenge the very idea of the 'Christian' psychiatrist. What people needed, surely, was a 'good' psychiatrist rather than one who shared their faith or, more pointedly, their particular churchgoing habits. A 'good' psychiatrist, Christian or not, would respect the spiritual beliefs of a patient and where necessary refer them for appropriate 'spiritual' help elsewhere. There was nothing to fear from the 'good' psychiatrist because they, too, shared many of the common values that had shaped our western (Christian) culture.

A 'levels of explanation' model

I adopted what might be termed a 'levels of explanation' model. Here, psychiatry approaches human suffering at one level of explanation and the pastor approaches it from another. The two perspectives reflect different dimensions of human experience: psychiatry seeks to understand how the brain functions and how we, as responsive agents, react to our different experiences and environments. Faith, on the other hand, deals with our experience of God and how we seek to relate to him. Working at these different, but complementary, levels was all part of a day's work for the 'good' psychiatrist, as opposed to the explicitly 'Christian' one. Or so I believed.

It was never a very satisfactory approach. The 'levels of explanation' model works reasonably well for reconciling the discoveries of laboratory based neuroscience and some experimental psychology with Christian faith. 1 When applied to counselling or psychotherapy, though, it runs up against the philosophical challenge of how we understand the telos, or end-point of human experience. (2) As soon as we enter a therapeutic arena and invite a client to consider how they might change, or what they 'ought' to do in response to life experiences, we find ourselves reaching for some concept of overarching purpose. And the 'levels of explanation' model just doesn't address that central issue.

Think about the question: 'Is this a good screwdriver?' It is possible to analyse the screwdriver's physical composition, its shape and its weight etc, but we are floundering to know whether it is a 'good' screwdriver until we know what a screwdriver is actually for. It's the same in therapy. As soon as we invite the client to consider what he 'ought' to do, or think, or feel, we run into the larger philosophical problem of what we are actually here for. What is our purpose? And psychology as a science, and particularly psychotherapy as an art, cannot engage with our telos without reference to larger questions that are essentially philosophical and, indeed, 'spiritual'.

While these questions have received renewed attention with the recent interest in 'spirituality' among psychiatrists generally, they have been addressed most cogently by the 'biblical counselling' movement. And because 'biblical counselling' – currently attracting growing interest in the UK – polarises the issues quite interestingly, I am going to examine the movement and its history in more detail.

Origins of the 'new biblical counselling'

The 'new biblical counselling', as I've called it, grows out of the earlier work of Jay Adams. His name does not elicit a great deal of affection from older UK psychiatrists who recall early assertions such as 'depression comes as a result of failure of self control and self discipline'. (3)

Adams coined the term 'nouthetic counselling' in his influential book Competent to counsel first published in 1970. (4) A prolific author, he pioneered the view that modern psychological theories depend essentially on quasi-religious narratives of human nature. Echoing the teleological challenge to therapeutic psychology, Adams argued that you can't work out what a person ought to do, until you have some overarching concept of what a person is for. Christians have been created for worship of the one true God, and all human malaise ultimately stems from our idolatrous rejection of that telos. Adams therefore dismisses modern psychologies that promise psychological 'wholeness' as futile attempts to replace biblical categories of creation, fall, redemption and holiness with secular categories of health and illness.

Adams believes that the Bible contains all that we need to know about how human beings can flourish in line with God's purpose. His emphasis is strongly behavioural: we may bring all kinds of past experience into the consulting room, but ultimately we need to take responsibility for how we respond to that psychological inheritance. So the nouthetic counsellor, having helped us tease out sinful (and self-destructive) responses to the 'sin done to us', needs to challenge us to change our behaviour and thinking in line with biblical teaching.

Take the example of a 66-year-old man who presents with depression in the setting of his recent retirement from a lifetime of work in industry and management. The 'nouthetic counsellor' might acknowledge vulnerability factors in early life experience but they would move deftly to refocus the client toward the 'idols of his heart'. How much has he idolised the status and security provided by his role and his standing in his company? Will he embrace biblical wholeness by re-imagining his identity and purpose around worship of the one true God? In Adams' view, antidepressants and secular counsellors tinker around the edges of the heart, but they don't deliver real heart 'change'.

The next generation

After founding the Christian Counselling and Education Foundation (CCEF), linked with Westminster theological seminary in the States, Adams eventually left in the mid 1970s. Since then a new generation of thinkers has arisen. Authors such as David Powlison and Paul Tripp moved CCEF in the direction of increased sensitivity to suffering, and a more nuanced understanding of how sin blights the human condition. But while the next generation are more willing to 'look behind' presenting issues, they continue to insist that biblical counselling is a distinctively biblical 'psychology', offering a particular understanding of people, problems, influences, suffering, motives and change processes. (5)

The fundamental critique of modern psychology remains: only the Bible provides a view of man that shows us why we should change and how we should live. And if we are to change in line with God's purposes for us, we must address the sinful idolatry of the human heart and seek to grow in a spirit of repentance and obedience. Biblical counsellors also continue to insist, with Adams, that we can't 'sector off' any sphere of human mental experience as the province of 'the theories, practices, and professions of modern psychologies'. And, although they recognise that God's providential 'common grace' brings many goods to humankind, including the provision of insights about the workings of the human psyche, they argue that when torn from their biblical foundations these insights can only provide a deficient, false theology of human nature. Hence, where modern psychotherapies claim to bring 'wholeness', they are in effect 'competing with Christ'.

Is biblical counselling 'biblical'?

Biblical counsellors make some hard-hitting points and challenge us to think again about the models that underpin our day-to-day practice. But their approach has some potentially serious weaknesses.

First, despite paying lip-service to the gifts of 'common grace', biblical counselling continues to create an impression of being at best grudging and at worst dismissive of modern psychological insights. Take again the example of our 66-year-old depressed retiree. It would be reckless to neglect the potential importance of a positive family history of major depression, early life 'loss experiences' that may have shaped biological vulnerability, and the role of synaptic neuro-regulation in the genesis of his disorder. And to speak prematurely of 'responsibility' and 'sin' seriously risks accentuating a depressive mindset that is already biased toward self blame and despair.

Biblical counselling can become crudely dualistic, too. For example, while research has shown that optimal brain development depends upon a positive psychological and social environment, including relational stimulation and affection in early life, biblical counselling too readily partitions off emotional responses as being all a problem of the 'heart', as if the 'heart' stands aside from the brain. The human 'heart', in the biblical sense of the embodied seat of character and will, may be rendered biologically vulnerable to disorder by a whole range of genetic and experiential factors. Statements such as 'even those who suffer mentally disabling medical problems need godly counselling' 6 imply there is a clear recognisable demarcation line between 'medical problems' and 'conditions of the heart', but such a distinction is not sustainable. Human 'heart' experience overwhelmingly results from complex interaction between biological, social and psychological mechanisms that remain incredibly hard to unravel.

In my view, the zeal of biblical counsellors for a robust biblically based model of human suffering fails to integrate modern biological perspectives, and risks depriving clients of some of the important 'gifts' of God's common grace, especially the gift of discovering his 'ways' through human inquiry and observation. They pay lip service to common grace, but one senses a grudging reluctance, rather than wholehearted celebration and integration of the vital fact that all truth belongs to God. In this crucial sense I would argue 'biblical counselling' is not fully 'biblical'.

But the challenge remains

But this does not mean biblical counselling presents those of us working in secular settings with anything less than a potent challenge. Take our depressed 66-year-old retiree once again. Let's suppose we have carefully taken our histories and prescribed our anti-depressants. Now what? We might decide to enhance our treatment by adopting a cognitive therapy approach to some of the unrealistic beliefs that are fuelling his low mood. But what is the realistic perspective for a man deprived of his sense of identity and sphere of competence, who faces an uncertain short term future and longer term certain death?

And what if, despite being a Christian, he had in fact been over-absorbed in his work, to the detriment of his wife and family whom he now barely knows? What if he has made an idol of his work? Is it good enough simply to refer him to the hospital chaplain for prayer and 'reflection'? How many pastors are competent to address the sort of heart issues that biblical counsellors are willing to raise or even inclined to do so? And, while for some an antidepressant may help him achieve 'recovery', what will he have 'recovered'? Should we as psychiatrists forego the opportunity to explore how this period of suffering could be a catalyst for more fundamental 'heart' change and spiritual growth? Any psychiatrist who wishes to grasp the teleological nettle will be forced to think hard about these issues.

Also, in recent years interest in notions of 'spirituality' has developed among psychiatrists generally. The Spirituality Interest Group of the UK Royal College of Psychiatrists has grown in numbers and influence, and the College has acknowledged the concept of incorporating a 'spiritual history' into patient assessments. (7) A range of spiritual philosophies is being drawn more explicitly into therapy, for example via Buddhist concepts related to 'mindfulness', and New Age 'spirituality' models. So by various means we are being challenged to re-examine how we relate our faith to our practice. And for me, the old concept of the 'good' psychiatrist will simply no longer do.

Re-visiting our models: from foundational to integrated

Drawing on the work of Richard Winter and others, 8 the figure above illustrates four possible models that lie between the extremes of 'psychology only' and 'Bible only'. First we have the 'levels of explanation' model outlined above. Despite its flaws, both Christians and non-Christians may continue to feel more comfortable within this kind of framework. But most Christians in secular practice probably work with the second model termed 'foundational'.

Here, to a greater or lesser degree, what we do in routine practice is viewed as being rooted in an essentially Christian view of the world, but at an implicit rather than explicit level. The client's 'spirituality' may be explored as an important part of an assessment, but the emphasis is upon encouraging reflection rather than direct engagement with the issues that emerge. The ethical obligation to respect the views of the client and avoid the abuse of power remains paramount, and the counsellor works carefully with the grain of his client's beliefs, drawing on the complementary skills of pastors and chaplains. The third model – 'integrative' –attempts a more explicit engagement with spiritual issues, but is harder to pin down. It includes a variety of approaches ranging from ad hoc eclectic blending of perspectives to more systematic integration of biblical precepts with cognitive or dynamic orientations.

'Biblical counselling' is our fourth model. It would clearly be unethical to pursue this approach in a secular setting where the client does not share the therapist's biblical worldview – integrated and explicitly 'biblical' models are more likely to be used in private settings. But does the 'free market' NHS offer new opportunities for developments in this area?

Conclusion

In the final analysis the models we adopt must be constrained by fully informed choices of the client and relevant guidance from the General Medical Council. But I hope I have illustrated why I am no longer content simply to offer those who want to see a 'Christian' psychiatrist the simplistic alternative of the 'good psychiatrist'. As the old certainties of counselling and therapy models continue to break down, psychiatrists are more ready to acknowledge their beliefs and the different ways they interface with their practice. And that is something I for one now welcome.

Glynn Harrison is Emeritus Professor of Psychiatry at Bristol University