Many Christian medical students find their psychiatry attachments daunting. They are in an environment where people talk about feelings, emotions and values, but in a way that may seem hostile to the gospel. This article aims to answer some of the questions that often confuse Christian students. For example:

• How do we make sense of all the different secular models for mental illness from a Christian viewpoint?
• What is the role of sin and Satan in causing mental illness?

A second article will answer the following questions:

• Which psychiatric treatments and therapies are consistent with Christianity?
• Are voices demonic?
• Why do Christians suffer from mental illness?
• Are Christian medical students who speak about God talking to them at risk of being sectioned?

One in four people will have a significant episode of mental illness at some time in their life. Over 50% of GP consultations and over 25% of general surgical and medical consultations have a major psychiatric component. Most people reading this article will have a close friend or family member with mental health problems.

As Christian doctors, we can make a big difference to the care of people with mental illness. This is true whether we are working in psychiatry, in general healthcare or within our churches. I believe there are three principle areas in which we can contribute:

Firstly, we can show Christ’s love to those who are psychiatrically ill. We can treat them as unique individuals whom Jesus loved enough to die for. Sadly mental illness still carries with it significant stigma both in society and particularly in the health service. As Christians, we have a particular responsibility to those who are stigmatised and marginalised.

Secondly, our biblical knowledge of man, and of his condition before God, gives us a special insight into the causes of mental illness and an extra, spiritual, dimension to its treatment.

Thirdly, we have a responsibility to help our churches develop their ministry to people with mental illness. Sadly, the stigma of mental illness is just as real within the church as in the rest of society. Christians can be confused and frightened about seeking psychiatric help, and at times, the church can add to people’s misery by ascribing their depressive illness to ‘deep rooted sin’ or a ‘spirit of depression’.

Secular models of mental illness

One of the first things that strikes the new psychiatry student is the bewildering array of differing explanations for mental illness. There are at least five major groupings including existential, sociological, behavioural, psychological and biological.

1. Existential models of depression were suggested by:

• Frankl, a concentration camp survivor who noted that those who survived were individuals who had a sense of meaning to their life. Loss of meaning led to despair, depression and death.
• Jung, who stated that once one reached the age of 35 the main problem in life was searching for some kind of meaning.

2. Sociological models of depression include:

• Social isolation (Brown and Harris) - increased depression in unemployed single mothers. Durkheim’s work also showed an increased risk of suicide in the socially isolated and dislocated.
• Excess life events (Paykel) - too many major life events in a short time predispose to depression. Medical students beware - graduating, starting a new job, moving city and getting married all within a fortnight may not be a bright idea!

3. Behavioural models of depression include:

• Learned helplessness (Seligman) - unpleasant dog experiments suggest that if you cannot get away from pain you soon despair and give up trying.
• Negative cognitive set (Beck) - a cognitively distorted view of the world leads to habitual negative thoughts and interpretations of events. Rectifying this is the underlying basis of cognitive therapy.

4. Biological models of depression:

• Impairment of biogenic monoamine function leading to depression, requiring drug intervention.
• Twin studies show strong genetic predisposition to depressive illness in some families.

5. Psychological models of depression include:

• Classical psychoanalysis (Freud) - aggression turned inwards.
• ‘Breaking the bonds of love’ (Bowlby) - early loss of mother leads to susceptibility to depression.
• Loss of self-esteem - ego collapses when it is unable to attain its goal.

So, what are we to make of all these models? Can they all be true?

There is some scientific evidence for many of the above views, making them worth consideration, but there is also a tendency for their proponents to regard them as exclusively true and to be reluctant to acknowledge any place for other secular models, let alone for a wider spiritual framework. Furthermore, many of the models have been developed far beyond any scientific basis and have become embedded in underlying philosophies that are positively antagonistic to the gospel. How can we sort the wheat from the chaff?

A spiritual framework for mental illness

In the beginning, God created man and he was physically and mentally perfect. However, man was created with fundamental needs.

1. Spiritual needs. Gn 1:27 - Man was created in God’s image, thus he is a spiritual being with spiritual needs. These are to love God and be loved by him. These needs were initially met by a direct ‘face to face’ relationship with him.

2. Social needs. Gn 2:18 - Man was created as a social being with social needs and in woman was given the perfect partner.

3. Need for meaningful occupation and purpose. Gn 1:28 - Man was created to work. He was to be fruitful and subdue the earth. In Gn 2:15, he is given the Garden to work and care for. Work was creative and adaptive. Man had control of his environment.

4. Harmony with nature. Gn 1:29, 2:9, 2:19 - There was no illness, no death.

5. Peace with himself. Gn 2:25 - ‘The man and woman were both naked and they felt no shame’. There was no anxiety, no inner conflicts, and no cellulite!

Thus in creation man and woman found perfect fulfillment in their relationship with God and with each other. Their need for love, purpose, security and significance were completely met and thus there was no predisposition to depression. But then comes Genesis 3 and the most cataclysmic event in human history, the Fall.

As a result of the Fall, we see the destruction of the previously perfect relationships:

• Gn 3:8 - There is separation from God.
• Gn 3:12,16 - There is social separation and exploitative relationships between men and women.
• Gn 3:17,19 - Work becomes a burden. Man is no longer in charge of his environment. Work becomes less creative and effective.
• Gn 3:18 - There is no longer a harmony with nature. Pain (3:16) and death (3:19) have come into the world.
• Gn 3:10 - ‘I was afraid because I was naked, so I hid’. There is separation from self leading to fear, shame and anxiety.

The choice to disobey God wrought a destruction that permeated every area of life - their genes, their personalities, their relationships, and their work. Guilt, shame, oppression, inner turmoil and conflicts were born (cf Rom 7:15).

Using this biblical framework we can begin to see how the various secular models can in part explain how the fall has sown the seeds for mental illness.

Existential illness models point us to our separation from God. He gives us meaning; without him we cannot be fulfilled. Where we attempt to derive our sense of meaning from something other than God, be it our job, money or romantic love, then this is idolatry. Eventually these things will let us down and this loss of meaning may predispose to depression.

The Fall’s disruption of relationships is highlighted in the social models of depression. Loss of a relationship causes bereavement. Early losses of parents, or poor parental relationships can make us more vulnerable to depression. Acute relationship conflict is a common cause of deliberate self-harm.

Separation from work and our environment means that not only do our actions become less effective, creative and appropriate in managing our environment, but that our environment begins to control us. These are the areas highlighted by behavioural models of illness and treatment.

Nature reflects man’s distorted relationship in the biological models of illness, including the genetic predisposition to schizophrenia and chromosomal defects leading to learning disability syndromes such as fragile X. Recent evidence also points towards gene defects causing Huntingdon’s chorea, and biochemical abnormalities causing symptoms of depression.

Separation from ourselves leads to anxiety, shame and inner conflict. These are areas that many of the psychotherapies attempt to address.

Thus, all these various secular therapies can be understood as attempting, with various degrees of success, to repair some part of the damage caused to man’s relationships by the Fall. Many of the therapies do have a sound research basis and used carefully and wisely can make a useful contribution to psychiatric treatment.

Clearly however, as Christians we can see the broader picture and realise that man’s overwhelming need is a cure for the disease of sin. For this there is only one treatment, restoration of a right relationship with God through Christ’s death on the cross. Where a particular therapy has an underlying philosophy that undermines the gospel, then we need to be very careful how we make use of it. The second article will look more closely at this.

What is the role of sin and Satan in mental illness?

Before answering this question, it would be useful to question the assumptions behind it. Why do we not ask ‘What is the role of sin and Satan in cardiovascular illness?’ The outline below would hold just as true for physical disorders as it does for psychiatric ones. The reason this question is asked more frequently for mental illness may owe more to fear and prejudice than to any theological insight!

That said we can look at four different levels at which sin and Satan may cause disease:

1. The general effect of sin. Most psychiatric and physical illness is caused by the Fall as outlined above, rather than being a direct result of the sufferer’s individual sin. This relationship is suggested in John 9, during the account of Jesus healing a man who was born blind. Jesus said, ‘Neither this man nor his parents sinned, but this happened so that the work of God might be displayed in his life.’

2. The specific effects of sin, the evil desires within us. There is inevitably a proportion of both physical and mental illness that is caused directly by sin. Abuse of alcohol can cause both hepatic failure and Wernicke’s encephalopathy. Adultery, leading to divorce, can not only cause depression in the couple directly involved, but can lead to insecurity and a predisposition to depression in their children.

3. Demonic temptation and attack. The book of Job tells us quite clearly how demonic attacks can cause both physical illness (boils) and psychiatric illness (excess life events ie loss of health, wealth and children leading to depression). Let no-one doubt the reality of an intelligent, malevolent devil. 1 Peter 5:8 reminds us to ‘be self controlled and alert. Your enemy the devil prowls around like a roaring lion looking for someone to devour.’ A Christian colleague of mine was working late when an extremely attractive student nurse walked into his office and offered to have sex with him. A demonic attack? My friend resisted, but if he had not, what damage would have been done to his family’s mental health?

4. Demonic possession. ‘There are two equal and opposite errors into which our race can fall about the devils. One is to disbelieve in their existence. The other is to believe and feel an excessive and unhealthy interest in them. They themselves are equally pleased with both errors’.[1] Our current culture well reflects this quote with a scientific denial of the supernatural, contrasting with an increasing preoccupation with the occult. Our churches too often fall into one or other of these extremes, either denying the role of the demonic or becoming preoccupied with it and ascribing to Satan phenomena that have much more ‘natural’ medical or theological explanations.

When we look at Jesus’ healing ministry, we see that sometimes he heals, sometimes he forgives and sometimes he exorcises. This leaves us asking how much mental illness is caused by direct demonic influence? It is clearly very distressing if your church reacts to your biological mental illness with attempts at exorcism. As Christian doctors we have a role in advising our churches when an individual with frightening symptoms is actually showing a typical psychiatric illness. For example, the severely depressed Christian may believe God is dead or fight against recurrent blasphemous thoughts - but their sadness and distress at these phenomena is clue enough that they have an illness, not a demon.

I firmly believe that typical psychotic illness is not caused by demonic possession. Evidence for this includes firstly the increased correlation between psychotic illness and physical brain changes demonstrated on structural and functional scanning. Secondly the response of psychotic illness to treatment - unless you believe that chlorpromazine stuns demons! Thirdly is the experience of many involved in healing and deliverance ministry who recognise that schizophrenia responds extremely badly to attempts at deliverance and who increasingly ensure that they have mental health professionals as part of their team to ensure that individuals brought to them do not have typical psychiatric illness.

Discussing this with a Christian consultant colleague, we had each seen only one case in fifteen years of psychiatric practice that we felt might be directly caused by demonic possession. Interestingly the British Journal of Psychiatry did carry a case report of possible demonic possession in September 1994.[2] There is a definite tendency for Christian medical students to over diagnose ‘possession’ and the following advice may be given on assessment and management if you were part of a church counselling or ministry team:

a) Take a good history. Is there extensive involvement in occult or witchcraft activities? But note in Acts 19:18 that those heavily involved in sorcery needed to confess their sin, not be exorcised; hence occult involvement does not always imply possession.

b) Are there symptoms that are atypical of psychiatric or physical illness? A five-week psychiatry attachment may not be sufficient to determine this with confidence!

c) Is there agreement between a number of levelheaded Christians who have spent considerable time praying about the matter?

d) When we look at Jesus’ ministry, we find he only exorcised when asked to do so by the representative of the sufferer or when there was demonic manifestation in front of him. He is not recorded as going to people with the proposition that they have demons to be cast out.

In summary, I firmly believe in the reality of demon possession. However, we must be very careful not to overdiagnose this, as well as remembering that demonic activity may manifest itself in both physical and psychiatric illness.