This is the second of two articles seeking to answer some of the questions that Christian students raise when they start psychiatry attachments. In my first article[1] I outlined a biblical model through which we can begin to make sense of the different secular models for mental illness from a Christian perspective. I also discussed the role of sin and Satan in causing mental (and physical) illness. In this article I will try to answer the following questions:

• How do we evaluate different psychiatric treatment approaches as a Christian?
• Why do Christians suffer from mental illness?
• Are voices demonic?
• How do you respond when your lecturer suggests that Christian beliefs are delusional?

Psychiatric treatments

To help us think through some of the most commonly used therapies, I will try to identify their underlying philosophical assumptions and the way in which they seek to explain and treat mental illness. Finally I will look at their value and their weaknesses from a Christian perspective. However, whole libraries have been written about each of these therapies and in reducing them to a few paragraphs I do risk over-simplifying them. For a more comprehensive Christian analysis I recommend Modern Psychotherapies by Jones and Butman (see Further Reading).

A. Classical psychoanalysis - Sigmund Freud

Philosophy - Naturalist and determinist. Naturalism is a worldview that rejects the supernatural and spiritual, and sees the universe as being explicable purely in terms of matter and energy. Determinism excludes the possibility of free will and sees current behaviour as entirely determined by the environment or past events such as childhood conflicts.

Aetiology of mental illness - Freud believed that at the heart of the personality (the id) there are two basic drives Eros and Thanatos (sex and aggression or sex and power). Denying these drives leads to emotional problems. People are fundamentally motivated by selfishness, but often hide this from themselves and their superegos (consciences). When an unacceptable impulse eg ‘I wish to kill my father’ comes close to the surface (ie it attempts to move from the unconscious to the conscious) there is an imminent clash between id and superego and this results in anxiety. Subsequent workers have defined a whole range of ‘defence mechanisms’ used to reduce anxiety eg projection, displacement, denial etc.

Treatment - Psychoanalysis attempts to reconstruct the personality by reliving childhood experiences, often through abreaction. Interpretation of ‘defences’ by the therapist is critical. By making the unconscious conscious, the ego (the bit of the personality that interfaces with reality and the outside world) is strengthened, and better able to manage the id. The therapist is aloof and uses transference to replay and work through critical relationships. Put crudely, therapy seeks to uncover motivation, soften up the conscience and promote self-gratification within social limits and reality.

A Christian response

• Value - Before Freud our understanding of mental health problems was in terms of either the organic or the demonic. He introduced the concepts of the unconscious, of symptoms caused by conflicts, and of our being profoundly affected by our childhood experience and relationships. In these areas psychoanalytical psychotherapy has made an invaluable contribution to our understanding of the human mind. Furthermore his view of personality may be a realistic view of unredeemed man, for example the id drives for sex and power being fallen man’s distortion of the Genesis commands to ‘be fruitful and increase in number; fill the earth and subdue it’.[2]
• Weaknesses - Firstly as Christians we must reject the underlying naturalistic philosophy because it denies God and ignores the spiritual aspects of man. We must also reject the underlying determinism because it removes any sense of personal responsibility for our thoughts and behaviours. As a treatment, classical psychoanalysis lacks a sense of morality; the goal is removal of conflict, regardless of the consequences for others. At best it produces socially acceptable hedonism. In its pure form it requires hundreds of sessions from a highly trained therapist, making it expensive and time consuming.

B. Person-centred, humanistic psychotherapies - Carl Rogers

Philosophy - Liberal humanism is central; this embraces naturalism and places man at the centre of the universe. Humanistic psychotherapies assume that we have absolute freedom of action. The key figure is Carl Rogers, who thought Freud was wrong and that people were intrinsically good. He believed that we have an inherent ‘self-actualising’ tendency (ie a tendency to develop our capacities to the fullest) that, freed from restriction and discipline, will lead to personal satisfaction and social harmony - parents might doubt this!

Aetiology of mental illness - Rogers sees failure to be oneself as the main problem. Anxiety arises when visceral feelings such as hatred are denied access to consciousness because of a learned negative evaluation of those emotions eg childhood instruction that it is wrong to hate people.

Treatment - Therapeutic characteristics include an emphasis on the whole person. Experience is all important and therapy stresses intuition and empathy, rather than a detailed analysis of past history. By encouraging trust, acceptance and expression of one’s own feelings, one will eventually be led to self-acceptance and self-actualisation. Rogerian qualifications for counselling are empathy, genuineness and an unconditional positive regard.

A Christian response

• Value - Exposes the real problem of hypocrisy and faked feelings. For example, as Christians we know that we should love and forgive people, so when we have feelings of hate we try to deny them, thus fragmenting ourselves and preventing confession and forgiveness. We need to acknowledge all our bad feelings, then label them as wrong, confess them and learn to love. Sadly, many groups that encourage expression of hate or anger do not go on to do anything with these emotions. The emphasis in person-centred therapy is to be valued, as are the Rogerian qualifications for counselling. However a biblical understanding of the human condition provides a much more realistic framework for these to operate in.
• Weaknesses - These are firstly those of the underlying humanism. The supreme importance given to the self is in conflict with the scriptural view of man, and worship of the self is the ultimate idolatry. Secondly, Rogers is delusionally optimistic in denying man’s fallen state. He believes that the fruits of the flesh (self-actualisation) are love and joy, whilst the Christian believes these are the fruits of the spirit.[3]

C. Behavioural therapy – B F Skinner

Philosophy - This is underpinned by naturalism and logical positivism (the only truth is that which can be empirically verified, so if you can’t count it then it isn’t worth bothering about!). These in turn lead to a rejection of any study of the mind and to reductionism, which breaks down complex phenomena into elemental phenomena - eg language is verbal behaviour. They also produce determinism. Thus there is no real free will. Man is not good or bad - he is completely controlled by his environment.

Aetiology of mental illness - Behaviourists look not at feelings or thought processes, but at behaviours. Problem behaviours are those that prevent us from dealing constructively (or ‘adaptively’) with challenges in the environment. These problems are caused by faulty learning, such as:-

1. Inappropriate responses that place individuals at a disadvantage.
2. Failure to learn appropriate responses because of previous learning environments.
3. Responding to the wrong environmental stimuli.
4. Inappropriate reinforcement of bad behaviour.

Treatment - Behaviourists believe that to change people you need to change their environments. This has led to the development of a range of treatments based on classical and operant conditioning eg:-

1. Token economies, which reinforce desired behaviour (operant conditioning).
2. Using functional analysis and ABC charts to identify events that may precipitate problem behaviour, or which positively or negatively reinforce it.
3. Systematic desensitisation, which seeks to associate a relaxed state with a previously feared stimulus.

A Christian response

• Value - The underlying philosophy is wrong, but much of the science is right! Behaviourists have identified how behaviour can be influenced by environment. It has provided a range of successful treatment techniques for problems with a substantial behavioural component. These are particularly valuable in situations where the patient is not reachable through verbal reasoning, for example young children or individuals with severe learning disabilities. But we must always remember that we are more than a set of conditioned reflexes. When behavioural therapy fails it is because it fails to take account of the whole person.
• Weaknesses - The overall problems of behaviourism are those of naturalism and determinism, rejecting God, the supernatural and human dignity. One can sometimes explain wrong behaviour by examining environments but the responsibility still belongs to the individual. In behaviourism man is robbed of all significance and personal responsibility and it is only a short step to nihilism and despair. A society based on behaviourism eventually produces tyranny where the ‘behavioural controller’ regulates all positive and negative reinforcers. But who is qualified to be the controller if there are no free agents? If one wants to achieve change then this assumes a value system to know which way to go.

D. Biological psychiatry

Philosophy - This has no philosophical standpoint on whether man is good, bad or neutral. As far as it outlines any philosophy, it is largely naturalistic and deterministic.

Aetiology of mental illness - All psychiatric disorders are due to genetically mediated or pathologically acquired neurological or biochemical abnormalities. This fails to recognise the relevance of spiritual, social, psychological and environmental factors in the aetiology and maintenance of mental illness.

Treatment - Use drugs and other physical treatments to correct or compensate for biochemical abnormalities.

A Christian response

• Value - Where used rationally drugs can give substantial benefits in serious mental illness. Organic illness is a result of the fall. If God has graciously given us the knowledge to ameliorate genetic or organically-driven illness then we should make use of it. In severe depressive illness drugs, and even electroconvulsive therapy, may be essential to prevent death. Even where the chemical imbalance is a mediator of other influences in producing symptoms, one may still need to provide relief from debilitating symptoms before an individual is able to tackle the underlying issues.
• Weaknesses - Again, these are largely those of determinism and naturalism. Biological psychiatry may relieve symptoms by correcting a biochemical abnormality, but it fails to recognise that the chemical imbalance may be a mediator of other influences in producing symptoms. This failure to recognise the relevance of spiritual, social, psychological and environmental factors in the aetiology and maintenance of mental illness means these factors go uncorrected and the recurrence of the illness is more likely.

E. Cognitive behavioural therapy (CBT)

Philosophy - As for behaviourism.

Aetiology of mental illness - Wrong thoughts lead to wrong feelings. Beck proposed that pathological depression and anxiety can be a consequence of distorted cognitions, which can lead to a cognitive triad of a negative view of one’s self, of one’s experiences and of the future. The patient has a negative schema through which he interprets information.

Treatment - The therapist helps the patient identify and correct the cognitive distortions and dysfunctional thoughts that are leading to symptoms. Cognitive errors are identified, such as magnification and minimisation (exaggerating problems and underestimating strengths), over-generalisation and selective abstraction. These errors are gradually challenged. As well as this ‘cognitive restructuring’, many therapists will also teach a range of coping and problem-solving skills to equip the individual to deal with difficult situations better.

A Christian response

• Value - There is strong scriptural support for the notion that our beliefs influence our emotions.[4] Christians have a shared belief with cognitive therapists that thoughts are actions and that they are under our control. Scripture also supports the idea that our thinking has a powerful effect on our spiritual state.[5] The rationality of CBT is a strength and the research evidence is very strong for its short and medium-term efficacy. Some of the techniques used in cognitive therapy can be found in a number of Christian counselling systems where they are anchored in a biblical worldview (eg Crabb, see Further Reading).
• Weaknesses - CBT shares many of the philosophical problems of behaviourism. But this erroneous worldview is less rigidly clung to and is far less pervasive within CBT, making it more readily adaptable for Christian use. However, an individual’s ‘negative schemata’ may in fact be correct and they may be right to feel guilty. Clearly however the morality of the therapy can be determined by the shared beliefs of the therapist and patient, again making the technique adaptable to the Christian counselling situation.

Overview of therapies

The therapies above represent just five of many different therapeutic models. I have, for example, not covered family therapy, the existential therapies, Jungian therapy, transactional analysis or the more contemporary psychodynamic psychotherapies. Christian critiques of these are to be found in the further reading suggestions referenced below. With so many secular therapies how can we decide what is right for use by Christian therapists?

Where a psychological or physical treatment is based on careful observation and has proven efficacy, we can learn from it and from its skilled practioners. The ever greater emphasis being placed on evidence-based medicine is an advantage in weeding out therapies with little validity. However we must always be aware of the philosophies underlying these treatments so that we can ensure that our practice is not antagonistic to the holistic view of man we find in the Bible. There are committed Christians using all of these therapies, modified to a greater or lesser degree, although it’s my opinion that some treatments, such as cognitive therapy, require a great deal less modification than others, such as classical psychodynamic psychotherapy! What we require is what Jones and Butman (see Further Reading) refer to as ‘responsible eclecticism’. We should first lay the firm foundation of a biblical understanding of the human condition and then make careful use of those aspects of secular psychiatry and psychology for which there is a strong evidence base, stripping them of their unhelpful philosophical baggage where necessary.

Why do Christians suffer mental illness?

Let’s return to the broad theological reasons for mental illness outlined in the first article. Man was created with a fundamental need for relationships but these have been damaged through the fall. As a result we experience separation from God, from each other, from ourselves, from nature and from meaningful work. Now there is no doubt that some of these separations may be healed when we become Christians. Certainly people whose symptoms were related to search for meaning can be dramatically transformed by their new relationship with the living God. However Scripture teaches us that we are still part of a fallen world, biologically damaged with damaged personalities, damaged relationships and evil desires, subject to demonic temptation and attack.

We are a new creation in Christ Jesus,[6] but that perfect new creation will only be seen in its fullness when we join him in eternity. We will one day be free of physical and psychological pain but the Bible does not say that this will occur before we die or Jesus comes again.

Nevertheless a living faith in the Lord Jesus, practised within a biblically-based and loving church, offers marvellous opportunities for psychological healing. There are real Christian answers for many of the problems that secular therapies accurately identify, but for which they can only provide partial answers:-

• A relationship with the living God meets man’s existential needs
• A realistic and biblical view of ourselves helps meet our psychological needs
• Healing of relationships and the opportunity to forgive improves our social health
• Social structure and opportunity for service within a church should give us a social identity and meaningful work
• People are hungry for love, acceptance and a purpose to life and all these should be met within the church - by koinonia (fellowship) and ministering to one another through the gifts God has given us.

A good church will be full of people with serious psychological problems because it is reaching out to those most in need, but the direction of travel will be towards psychological health. Sadly though, many people do not get the healing that they should receive as Christians. This is the result of inadequate teaching and poor nurturing and discipling, as well a lack of recognition of one another’s spiritual gifts. This is principally a matter for church leadership as much as counselling.

Many Christians with psychotic mental illness suffer because of the ignorance of their fellow Christians. Few diabetics are told to stop taking their insulin when they become Christians but such advice is not unusual to schizophrenics or manic depressives! It is important that we encourage Christians with serious psychotic illness to continue seeking appropriate medical help.

Many people who come to the church with serious neurotic mental illness are often given superficial or trite answers to their problems – the psychological equivalent of James 2:15. For these individuals there is a need for informed, compassionate biblical counselling - counselling that can identify the underlying cause of their symptoms and bring that before God for healing.

Are ‘voices’ demonic?

This is a common question that students ask when first confronted by the hallucinations that are a frequent symptom in schizophrenia and depressive psychosis. The short answer is ‘No!’

Auditory hallucinations are experienced by many perfectly healthy people on the edge of sleep (hypnogogic and hypnopompic hallucinations). They are also seen in those with physical illness eg the elderly man with a chest infection and an acute confusional state. Some people with temporal lobe epilepsy experience auditory hallucinations as part of their seizure if they have lesions in the speech areas of the brain. We know that drugs that affect dopamine such as amphetamines, can produce hallucinations in just about anyone.

In more serious mental illness there are a number of explanations for hallucinations. A common one is that people experience their own thoughts as an external voice. Some think that gedankenlautwerden, where an individual hears his own thoughts as a voice, but recognises them as his own, is an intermediate stage to this.

With respect to schizophrenia there is increasing recognition of the role of abnormal neurodevelopment during adolescence in both the aetiology and symptoms. In adolescence the brain ‘prunes’ millions of redundant synaptic cross-links. If this is not done, inappropriate cross-links can persist. As a result of this, signals generated in one part of the brain are perceived by another part of the brain as coming from the external world.

When you add to the above the fact that many hallucinations are resolved by drug treatment, it is clear that attributing the typical hallucinations seen in psychotic illness to the demonic is neither necessary nor helpful.

Are Christian beliefs delusional?

This appears to be a common point for lecturers to make and it is clearly designed to test out whether you have been listening during your teaching on phenomenology! For a belief to be a delusion it has to be:-

• false
• held unshakeably
• held despite evidence to the contrary
• out of keeping with the individual’s social, religious and cultural context

So your response to your lecturer will be that your belief in Jesus as the risen Son of God is not delusional because it is:-

• true!
• supported by the evidence!
• shared by over two billion people worldwide!

If you’re really lucky you’ll be asked for the evidence and, having done the CMF Confident Christianity course, you will be prepared ‘to give the reason for the hope that you have’.[7] Next year the lecturer will pick on Chelsea supporters!