A Psychiatrist Looks at Religion
111
A Psychiatrist Looks at Religion
ELIHU
S. H O W L A N D
This paper presents some impressions I have gathered from the unusual experience I have had as a staff member of the First Presbyterian Church of Evanston as well as psychiatrist to its pastoral counseling service. I would like to discuss in some detail the nature of the relation between religion and psychiatry as I see it and the aspects of counseling or therapy in which religious orientation and understanding seem to me most helpful. T h e Academy of Religion and Mental Health was chartered in 1954. That was hailed as a significant step in interdisciplinary relations; it may serve as an appropriate landmark for an attempt to assess what has happened between religion and psychiatry in the succeeding fifteen years. There is no question that during this time developments between the two professions have been taking place. There is some difference of opinion as to the precise nature of these developments, and whether they are good or bad. T h e view that seems to prevail is that the relationship between psychiatrists and clergy has definitely improved , with greater mutual cordiality, understanding, and trust; and that it is expected to become even better. This is quite at variance with my own observations and those of some others. As Ralph Burhoe ELIHU S. HOWLAND,M.D., is a staff member of and psychiatrist to the Pastoral Counseling Service of the First Presbyterian Church, Evanston, Ill.; associate in psychiatry, Northwestern University Medical School; lecturer in psychiatry, Chicago Theological Seminary; and a member of the Academy. This paper was read at a seminar on Psychiatry and Religion at the Veterans Administration Hospital at Downey, Ill., November 19, 1969.
112
Journal of Religion and Health
declared a year ago, it is seldom openly admitted that beneath the surface of the polite public face of the co-operative movement between psychiatrists and clergy lies a considerable degree of mutual dislike, disdain, distrust, and fear? I, too, find these attitudes most characteristic of the relationship. I believe further that, if this state of affairs is allowed to go on behind the scenes, the relationship will have a seriously destructive effect on both professions and collaboration between them will very likely come to a complete halt. In order to understand the discrepancy between things as they appear to be and as they actually are, I think it would be helpful to review three different reactions of individual psychiatrists and. clergy to the idea of interdisciplinary collaboration. The first reaction is that religion and psychiatry are two different things and should, therefore, have nothing to do with one another. The second is that religion and psychiatry are two different things but may have some legitimate relationship as long as the emphasis is on the differences between the two so that the identity and individuality of each profession may be maintained. The third is that religion and psychiatry have similarities as well as differences, and in order to have any really meaningful relationship between the two professions certain interdisciplinary barriers must be taken down as a calculated risk, bringing the two quite close together with the hope that both disciplines will thereby be enriched to the benefit of mankind. It would seem at first glance that the greatest danger to the relationship would lie in the first reaction I mentioned, namely, that religion and psychiatry should have nothing to do with one another. However, that particular stand was clearly invalidated when the Joint Commission on Mental Health and Illness showed that the greater number of people with personal and emotional problems go for help first to their clergyman. This made it obvious that some sort of relationship between psychiatrists and clergy is necessary. The second reaction, namely, that such a relationship should emphasize the differences between the two, appears to be the position of the vast majority of representatives of both professions. On the face of it, it would seem to be a moderate, logical, and sensible approach. Yet it is precisely here that I see the greatest danger to interdisciplinary collaboration existing--a far greater
A Psychiatrist Looks at Religion
113
danger even than there was in the first stage, that of prohibited communication. That stage actually never presented much of a problem. Being ordered to have no dealings at all with members of a certain group may simply arouse an insatiable curiosity in us to discover just what it is these other people do that is considered so dreadful; and with a little patience and persistence we usually manage after a while to find ways not only to observe them but also to establish communication with them. Knowing that we are not supposed to be doing this usually does not make us feel guilty, but merely adds to the zest of the adventure. But it is my experience that a relationship continually underscoring differences sooner or later leads to a serious misunderstanding, even a misuse, of each profession by the other. As I have mentioned, I see this already going on. In m y opinion, the crucial factor here is misunderstanding of the function of the clergyman in the relationship; and, strange as it may sound, I think that this misunderstanding is shared by both professions. Since I am not a clergyman, I may be open to the charge of having some temerity in making such a statement; but I believe I can explain what I mean. In the current relationship between the clergyman and the psychiatrist, it is the psychiatrist who dominates. The clergyman is not just a junior partner, but an extremely junior partner. Most of the conversation between the two I perceive to be a monologue in which the psychiatrist tells the clergyman what to do, in such stereotyped phrases as "don't get in over your head," "know when to refer," and "remember you're not a psychiatrist." This kind of advice I find is not really helpful to the average parish pastor, who often has no choice but to "get in over his head" because the psychiatrist is either nonexistent in the pastor's geographical area or not accessible because of already existing commitments, so that the pastor is the only source of help available. I further question whether any relationship operating on a street that is so exclusively one-way can be productive. It seems to me that psychiatry does not talk down to other disciplines (for instance, psychology, neurology, cultural anthropology[, and even social case work) to the extent that it does to the clergy.
114
Journal of Religion and Health
The clergy have expressed their dissatisfaction with the situation, but they are so confused that they often directly contradict themselves. There is a very clear example of this in last May's issue of Pastor'al Psychology, which was devoted to the subject of "Community Mental Health and the Pastor," and in which a past president of the American Association of Pastoral Counselors said: "As [the church] attempts to deal with the gross needs of people it should not provide second class social welfare, or quasipsychiatry, but what is unique to the church's ministry. What is needed is that the church not seek simply to provide good mental health, but rather something deeper than this. ''2 I agree completely. Unfortunately he has totally contradicted himself two pages earlier by saying, "The local parish clergyman is an ancillary mental health professional." (The adjective "ancillary" is an interesting one, coming from a Latin word meaning "handmaiden.") Here is the crux of the difficulty: these two statements are absolutely incompatible with each other. If the clergyman is a spiritual leader, which I believe is his proper position, then he is not a subordinate in the field of mental health. In fact, I do not regard mental health and illness as the clergyman's affair. "Mental health and illness" are ill-defined, poorly understood terms on which there is little consensus, and they are based on a medical model that is utterly irrelevant for the clergyman, since he is not a physician. Most psychiatrists have little or no exposure to theology, and therefore do not recognize that the clergyman has a unique leadership function of his own that is obscured and impaired by training him as an ancillary or subordinate mental health worker. This problem is pointed up in a review written by a Jesuit priest who is now in psychiatric residency training of a book entitled Psychiatry, the Clergy, and Pastoral Counseli~zg edited by Farnsworth and Braceland, two of our country's distinguished psychiatrists who are sincerely interested in developing constructive co-operation between psychiatry and religion2 Yet curiously enough, as the reviewer states, the important question of what the role of the clergyman is in the overhall picture of integrated community mental health services is not dealt
.4 Psychiatrist Looks at Religion
115
with, and instead the clergy are simply told how psychiatrists work. The reviewer then asks very appropriately, "Is the clergyman most helpful by acting as ill-fitted psychiatrist, or does he have a more precise role and function that he can fulfill better than anyone else [and] which has a unique utility in time of crisis?" I think we should attempt to answer this question now. It is interesting that the reviewer declares that he does not yet have such an answer. It will also be apparent from what I have already said that I believe I do have at least a preliminary answer. I believe that both professions are hurt by the one-sided relationship that exists at present between them. The clergyman, who indeed does have a unique and essential function that he can perform better than anyone else, cannot possibly carry it out as long as he remains the perpetual subordinate of psychiatrists who do not recognize and understand this function. Instead he is subjected by these psychiatrists, though not with malevolent intent, to a brain-washing process based purely on psychotherapeutic theories leaving the clergyman not only confused but also a less effective minister of God than he was before. The problem is compounded because brain-washed clergy in their teaching inevitably participate in the brainwashing of other clergy. The two contradictory statements I have quoted from Pastoral Psychology illustrate, I think, the dilemma of an able and dedicated but also brain-washed clergyman. The end result of all this is that the clergyman is assigned a permanent secondary position by the psychiatrist, not just in counseling, but in the arbitration of morals, too. If this last statement sounds fantastic, let me refer you to Perry London's book, The Modes and Morals of Psychotherapy, in which he declares that the clergy have already abdicated their claim to moral competence in favor of the psychotherapists, and that he sees nothing wrong with psychotherapists setting our moral standards and believes, furthermore, that they will do a good job. 4 Certainly psychotherapists have morals; but I am sure we would want to think a long time before setting ourselves up as the primary arbiters of morality without having anything in the nature of a uniform moral code to guide us.
116
Journal of Religion and Health
On the other hand, the psychiatrist, too, is hindered by the one-sided relationship and by his exclusive allegiance to the medical model which engenders that relationship. Psychiatry, although related to medical science, is not identical with it. Some areas of psychotherapy do seem to be essentially scientific and to constitute what might be fairly described as "psychological medicine." W e all know, however, that there are other areas of therapy or counseling in which what takes place is a matter of personal opinion that cannot be scientifically validated. It is in these areas that I believe the psychiatrist needs to take a closer look at religion than he has heretofore done. T o illustrate what I mean, let us consider the nature of "mental illness." As I have said before, there is no uniformity of opinion among psychiatrists as to iust what "mental illness" is, or whether everything that is commonly called "mental illness" is truly illness. "Mental illness," as we know, is broken down into different categories. Organic brain disease is obviously an illness. It seems reasonable to consider psychosis also an illness, because it usually becomes necessary at some point to treat the psychotic as a sick person with hospitalization and/or drugs and perhaps electric shock. Organic brain disease and psychosis, since they are forms of illness, are plainly the province of the psychiatrist. The clergyman may be of some help, especially with the patient's family, but it would ordinarily not be appropriate for him to undertake the management of such patients if referral is at all possible. W h e n we come to neurosis, however, it is less clear as to whether we are dealing with illness or with something else. I personally am not c o n v i n c e d that all forms of neurosis represent illness. Particularly, I have come across a number of anxious and depressed people whose underlying concern seemed to be related to a theological problem, namely, a reluctance to accept the fact of their mortality. 5 I have learned that for such people a therapeutic approach based purely on principles of psychological medicine is not satisfactory. The existence of the theological problem has to be recognized and some attempt made to help the troubled person resolve it. Here is where, as a psychiatrist, I have had to take a close look at religion.
A Psychiatrist Looks at Religion
117
The most clear-cut instance of this kind of situation I have encountered was in the case of a young clergyman who was afraid that he might have an incurable cancer. He had been examined repeatedly and told, "You do not have cancer, and you have nothing to worry about." But this did not reassure him at all. The physician who sent him to me thought that the man had a phobic fear resulting from psychological conflicts. Conflicts he had, indeed, of which he himself was well aware; they had to do with his parents and his choice of vocation. However, what struck me most forcibly was that shortly before his fear of cancer began one of his parishioners to whom he had been ministering for several months had died of an inoperable cancer. It seemed to me that he was trying to tell me that for the first time in his life he had received the full impact of the realization that this could happen to him, too, and perhaps without warning and much sooner than he might have expected. In this context it was easy to see why repeated normal physical examinations had not reassured him, because they could not provide any guarantee that he would not develop cancer later on, perhaps in the near future. Nothing in his lifetime, not even his seminary education, had prepared him to grasp and accept the shattering fact that he would some day have to die. This I felt was the primary problem, and that all other matters, including his ambivalence toward his parents and profession, were secondary to it. Therefore, our discussions centered around the question of how one can reconcile his inevitable finitude with a conviction that his life nevertheless has a real purpose that should be pursued as long as he has the opportunity to do it. During these discussions I was well aware of the apparent paradox in that, as a psychiatrist, I had engaged myself in the task of helping a clergyman arrive at a better understanding of his religious faith. Together we were able to arrive at such an understanding; and it was most interesting that, having accepted his mortality and all the implications thereof, he quite spontaneously resolved his family and vocational problems with no pressure whatever from me and concluded that his true calling did lie in the ministry. Another situation involved a woman in late middle life who had had a
118
Journal of Religion and Health
persistent depression for some years unaltered by drugs, shock treatment, and conventional psychotherapy. She expressed her despair and bewilderment in her constantly repeated question: "I always used to be the strong one. Everyone in trouble came to me and I knew what to tell them, But now I'm just as upset as any of them ever were, and I don't see any way out. H o w did this happen to me? Please help me!" She had reached the age when her relatives and friends were being overtaken by tragic and fatal illnesses, several of which had happened in her immediate family, and she was shaken by the thought that this might happen to her, too, and in fact with the depression this was precisely what seemed to her to be happening. Our focus in counseling was on the fact that one does not "snap out of" a depression or "shake it off," but rather that, by means of gradual involvement with something or someone outside oneself, one moves through the depression and out the other side of it, and thereby gains faith and a new perspective on life. Since discussion of this in theological language seemed to confuse her, I did not try to use such language, but regardless of that I felt we were on theological ground the whole time. In caring for a disturbed relative, she was ultimately distracted from her own extreme self-concern; her depression lifted and she now has a balance that I suspect she never really had before. A third problem concerned a much younger married woman whose first depressive episode responded well to electric shock treatment, but shortly afterwards the depression recurred. [ could find no evidence of serious conflict with her husband, her children, her parents, or anyone else. What I did sense was that the rather naive and unrealistic concept of religious faith she had absorbed while growing up was not adequate to sustain her in a world that, she was beginning to realize, contained much more uncertainty and danger than she had ever dreamed of. Her two greatest fears were of death and of losing her mind. Regarding the latter, she had the very common misconception that a truly religious person is never supposed to have doubts or become depressed. Consequently, she had spent a good deal of her available energy in fighting with the depression, which, of course, simply
A Psychiatrist Looks at Religion
119
made it worse. We concentrated on helping her understand that doubt and depression are natural reactions that are not at all incompatible with religious commitment, and that her salvation lay not in fighting her feelings of depression, but in leaving them alone so that they might dry up like an unwatered plant while she continued with her ordinary household responsibilities. As she gradually learned that she could leave her feelings alone without being overwhelmed by them, the depression went away. I did have her on an antidepressant for a time, but its benefit was limited. What seemed to make the most difference to her was understanding that religious faith is not so much a panacea for depression as a capacity to keep purposefully moving in the face of it until the depression eventually dispels itself. These three cases I have described are by no means rare or isolated instances. People with problems of this kind actually constitute a very significant part of my own practice, and I believe there are far more of them in the community than is generally realized. I am sure that my affiliation with the pastoral counseling service of a church has been a major factor in my becoming aware that these problems are basically theological. It would appear to me that a clergyman with his theological background would be more helpful to these people than a psychiatrist who never includes theological discussion in his counseling. At this point someone might ask very reasonably why I have not sent such people directly to the clergy instead or working with them myself. My answer is that many clergymen do not recognize the difficulties of these people as being fundamentally theological, so that they refer them to me with the assumption that the problem is psychological and beyond their level of competence. In the process of trying to determine for myself what the situation is with these troubled people, I have had to do some theological research of my own, which has been illuminating and very helpful to me. In so doing, I have felt reassured and encouraged by Paul Tillich's statement that "the relationship [between psychiatry and religion] is not one of existing alongside each other; it is a relationship of mutual inter-
120
lournal of Religion and Health
penetration. ''6 This I found to be true; and it indicates to me that we have n o w reached the stage where psychiatry and religion should understand that they have similarities as well as differences, and that some interdisciplinary barriers can be taken d o w n without harm to either discipline, and to the advantage of both. People w h o are mentally ill come to the clergyman, w h o then will need the help of the psychiatrist. But it also happens that people with theological problems come to the psychiatrist, w h o then needs the help of the clergyman, not as a subordinate mental health worker but as the appropriate person, the ultimate authority. I believe the true nature of psychiatry will become clearer to everyone w h e n psychiatry realizes that it has a close relationship to religion as well as to medicine and takes advantage of the opportunity for really intimate dialogue with the clergy. References
1. Burhoe, R. W., "Bridging the Gap Between Psychiatry and Theology," ]. Religion and Health, 1968, 7, 215-2261 2. Hathorne, B. C., "Critical Issues in Developing Pastoral Services and Consultation," Pastoral Psychology, 1969, 20, 10-12. 3. Meissner, S.J., W. W., review of Psychiatry, the Clergy, and Pastoral Counseling, edited by Dana L. Farnsworth and Francis J. Braceland, Psychiatric News, Sept., 1969, p. 9. 4. London, P., The Modes and Morals of Psychotherapy. New York, Holt, Rinehart and Winston, 1964, pp. 171-173. 5. Howland, E. S., "Psychiatry's Responsibility to Medicine and to Religion," Bull. ]okns Hopkins Hospital, 1965, 117, 137-139. 6. Tillich, P., Theology of Culture. New York, Oxford University Press, 1959, p. 114.
111
A Psychiatrist Looks at Religion
ELIHU
S. H O W L A N D
This paper presents some impressions I have gathered from the unusual experience I have had as a staff member of the First Presbyterian Church of Evanston as well as psychiatrist to its pastoral counseling service. I would like to discuss in some detail the nature of the relation between religion and psychiatry as I see it and the aspects of counseling or therapy in which religious orientation and understanding seem to me most helpful. T h e Academy of Religion and Mental Health was chartered in 1954. That was hailed as a significant step in interdisciplinary relations; it may serve as an appropriate landmark for an attempt to assess what has happened between religion and psychiatry in the succeeding fifteen years. There is no question that during this time developments between the two professions have been taking place. There is some difference of opinion as to the precise nature of these developments, and whether they are good or bad. T h e view that seems to prevail is that the relationship between psychiatrists and clergy has definitely improved , with greater mutual cordiality, understanding, and trust; and that it is expected to become even better. This is quite at variance with my own observations and those of some others. As Ralph Burhoe ELIHU S. HOWLAND,M.D., is a staff member of and psychiatrist to the Pastoral Counseling Service of the First Presbyterian Church, Evanston, Ill.; associate in psychiatry, Northwestern University Medical School; lecturer in psychiatry, Chicago Theological Seminary; and a member of the Academy. This paper was read at a seminar on Psychiatry and Religion at the Veterans Administration Hospital at Downey, Ill., November 19, 1969.
112
Journal of Religion and Health
declared a year ago, it is seldom openly admitted that beneath the surface of the polite public face of the co-operative movement between psychiatrists and clergy lies a considerable degree of mutual dislike, disdain, distrust, and fear? I, too, find these attitudes most characteristic of the relationship. I believe further that, if this state of affairs is allowed to go on behind the scenes, the relationship will have a seriously destructive effect on both professions and collaboration between them will very likely come to a complete halt. In order to understand the discrepancy between things as they appear to be and as they actually are, I think it would be helpful to review three different reactions of individual psychiatrists and. clergy to the idea of interdisciplinary collaboration. The first reaction is that religion and psychiatry are two different things and should, therefore, have nothing to do with one another. The second is that religion and psychiatry are two different things but may have some legitimate relationship as long as the emphasis is on the differences between the two so that the identity and individuality of each profession may be maintained. The third is that religion and psychiatry have similarities as well as differences, and in order to have any really meaningful relationship between the two professions certain interdisciplinary barriers must be taken down as a calculated risk, bringing the two quite close together with the hope that both disciplines will thereby be enriched to the benefit of mankind. It would seem at first glance that the greatest danger to the relationship would lie in the first reaction I mentioned, namely, that religion and psychiatry should have nothing to do with one another. However, that particular stand was clearly invalidated when the Joint Commission on Mental Health and Illness showed that the greater number of people with personal and emotional problems go for help first to their clergyman. This made it obvious that some sort of relationship between psychiatrists and clergy is necessary. The second reaction, namely, that such a relationship should emphasize the differences between the two, appears to be the position of the vast majority of representatives of both professions. On the face of it, it would seem to be a moderate, logical, and sensible approach. Yet it is precisely here that I see the greatest danger to interdisciplinary collaboration existing--a far greater
A Psychiatrist Looks at Religion
113
danger even than there was in the first stage, that of prohibited communication. That stage actually never presented much of a problem. Being ordered to have no dealings at all with members of a certain group may simply arouse an insatiable curiosity in us to discover just what it is these other people do that is considered so dreadful; and with a little patience and persistence we usually manage after a while to find ways not only to observe them but also to establish communication with them. Knowing that we are not supposed to be doing this usually does not make us feel guilty, but merely adds to the zest of the adventure. But it is my experience that a relationship continually underscoring differences sooner or later leads to a serious misunderstanding, even a misuse, of each profession by the other. As I have mentioned, I see this already going on. In m y opinion, the crucial factor here is misunderstanding of the function of the clergyman in the relationship; and, strange as it may sound, I think that this misunderstanding is shared by both professions. Since I am not a clergyman, I may be open to the charge of having some temerity in making such a statement; but I believe I can explain what I mean. In the current relationship between the clergyman and the psychiatrist, it is the psychiatrist who dominates. The clergyman is not just a junior partner, but an extremely junior partner. Most of the conversation between the two I perceive to be a monologue in which the psychiatrist tells the clergyman what to do, in such stereotyped phrases as "don't get in over your head," "know when to refer," and "remember you're not a psychiatrist." This kind of advice I find is not really helpful to the average parish pastor, who often has no choice but to "get in over his head" because the psychiatrist is either nonexistent in the pastor's geographical area or not accessible because of already existing commitments, so that the pastor is the only source of help available. I further question whether any relationship operating on a street that is so exclusively one-way can be productive. It seems to me that psychiatry does not talk down to other disciplines (for instance, psychology, neurology, cultural anthropology[, and even social case work) to the extent that it does to the clergy.
114
Journal of Religion and Health
The clergy have expressed their dissatisfaction with the situation, but they are so confused that they often directly contradict themselves. There is a very clear example of this in last May's issue of Pastor'al Psychology, which was devoted to the subject of "Community Mental Health and the Pastor," and in which a past president of the American Association of Pastoral Counselors said: "As [the church] attempts to deal with the gross needs of people it should not provide second class social welfare, or quasipsychiatry, but what is unique to the church's ministry. What is needed is that the church not seek simply to provide good mental health, but rather something deeper than this. ''2 I agree completely. Unfortunately he has totally contradicted himself two pages earlier by saying, "The local parish clergyman is an ancillary mental health professional." (The adjective "ancillary" is an interesting one, coming from a Latin word meaning "handmaiden.") Here is the crux of the difficulty: these two statements are absolutely incompatible with each other. If the clergyman is a spiritual leader, which I believe is his proper position, then he is not a subordinate in the field of mental health. In fact, I do not regard mental health and illness as the clergyman's affair. "Mental health and illness" are ill-defined, poorly understood terms on which there is little consensus, and they are based on a medical model that is utterly irrelevant for the clergyman, since he is not a physician. Most psychiatrists have little or no exposure to theology, and therefore do not recognize that the clergyman has a unique leadership function of his own that is obscured and impaired by training him as an ancillary or subordinate mental health worker. This problem is pointed up in a review written by a Jesuit priest who is now in psychiatric residency training of a book entitled Psychiatry, the Clergy, and Pastoral Counseli~zg edited by Farnsworth and Braceland, two of our country's distinguished psychiatrists who are sincerely interested in developing constructive co-operation between psychiatry and religion2 Yet curiously enough, as the reviewer states, the important question of what the role of the clergyman is in the overhall picture of integrated community mental health services is not dealt
.4 Psychiatrist Looks at Religion
115
with, and instead the clergy are simply told how psychiatrists work. The reviewer then asks very appropriately, "Is the clergyman most helpful by acting as ill-fitted psychiatrist, or does he have a more precise role and function that he can fulfill better than anyone else [and] which has a unique utility in time of crisis?" I think we should attempt to answer this question now. It is interesting that the reviewer declares that he does not yet have such an answer. It will also be apparent from what I have already said that I believe I do have at least a preliminary answer. I believe that both professions are hurt by the one-sided relationship that exists at present between them. The clergyman, who indeed does have a unique and essential function that he can perform better than anyone else, cannot possibly carry it out as long as he remains the perpetual subordinate of psychiatrists who do not recognize and understand this function. Instead he is subjected by these psychiatrists, though not with malevolent intent, to a brain-washing process based purely on psychotherapeutic theories leaving the clergyman not only confused but also a less effective minister of God than he was before. The problem is compounded because brain-washed clergy in their teaching inevitably participate in the brainwashing of other clergy. The two contradictory statements I have quoted from Pastoral Psychology illustrate, I think, the dilemma of an able and dedicated but also brain-washed clergyman. The end result of all this is that the clergyman is assigned a permanent secondary position by the psychiatrist, not just in counseling, but in the arbitration of morals, too. If this last statement sounds fantastic, let me refer you to Perry London's book, The Modes and Morals of Psychotherapy, in which he declares that the clergy have already abdicated their claim to moral competence in favor of the psychotherapists, and that he sees nothing wrong with psychotherapists setting our moral standards and believes, furthermore, that they will do a good job. 4 Certainly psychotherapists have morals; but I am sure we would want to think a long time before setting ourselves up as the primary arbiters of morality without having anything in the nature of a uniform moral code to guide us.
116
Journal of Religion and Health
On the other hand, the psychiatrist, too, is hindered by the one-sided relationship and by his exclusive allegiance to the medical model which engenders that relationship. Psychiatry, although related to medical science, is not identical with it. Some areas of psychotherapy do seem to be essentially scientific and to constitute what might be fairly described as "psychological medicine." W e all know, however, that there are other areas of therapy or counseling in which what takes place is a matter of personal opinion that cannot be scientifically validated. It is in these areas that I believe the psychiatrist needs to take a closer look at religion than he has heretofore done. T o illustrate what I mean, let us consider the nature of "mental illness." As I have said before, there is no uniformity of opinion among psychiatrists as to iust what "mental illness" is, or whether everything that is commonly called "mental illness" is truly illness. "Mental illness," as we know, is broken down into different categories. Organic brain disease is obviously an illness. It seems reasonable to consider psychosis also an illness, because it usually becomes necessary at some point to treat the psychotic as a sick person with hospitalization and/or drugs and perhaps electric shock. Organic brain disease and psychosis, since they are forms of illness, are plainly the province of the psychiatrist. The clergyman may be of some help, especially with the patient's family, but it would ordinarily not be appropriate for him to undertake the management of such patients if referral is at all possible. W h e n we come to neurosis, however, it is less clear as to whether we are dealing with illness or with something else. I personally am not c o n v i n c e d that all forms of neurosis represent illness. Particularly, I have come across a number of anxious and depressed people whose underlying concern seemed to be related to a theological problem, namely, a reluctance to accept the fact of their mortality. 5 I have learned that for such people a therapeutic approach based purely on principles of psychological medicine is not satisfactory. The existence of the theological problem has to be recognized and some attempt made to help the troubled person resolve it. Here is where, as a psychiatrist, I have had to take a close look at religion.
A Psychiatrist Looks at Religion
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The most clear-cut instance of this kind of situation I have encountered was in the case of a young clergyman who was afraid that he might have an incurable cancer. He had been examined repeatedly and told, "You do not have cancer, and you have nothing to worry about." But this did not reassure him at all. The physician who sent him to me thought that the man had a phobic fear resulting from psychological conflicts. Conflicts he had, indeed, of which he himself was well aware; they had to do with his parents and his choice of vocation. However, what struck me most forcibly was that shortly before his fear of cancer began one of his parishioners to whom he had been ministering for several months had died of an inoperable cancer. It seemed to me that he was trying to tell me that for the first time in his life he had received the full impact of the realization that this could happen to him, too, and perhaps without warning and much sooner than he might have expected. In this context it was easy to see why repeated normal physical examinations had not reassured him, because they could not provide any guarantee that he would not develop cancer later on, perhaps in the near future. Nothing in his lifetime, not even his seminary education, had prepared him to grasp and accept the shattering fact that he would some day have to die. This I felt was the primary problem, and that all other matters, including his ambivalence toward his parents and profession, were secondary to it. Therefore, our discussions centered around the question of how one can reconcile his inevitable finitude with a conviction that his life nevertheless has a real purpose that should be pursued as long as he has the opportunity to do it. During these discussions I was well aware of the apparent paradox in that, as a psychiatrist, I had engaged myself in the task of helping a clergyman arrive at a better understanding of his religious faith. Together we were able to arrive at such an understanding; and it was most interesting that, having accepted his mortality and all the implications thereof, he quite spontaneously resolved his family and vocational problems with no pressure whatever from me and concluded that his true calling did lie in the ministry. Another situation involved a woman in late middle life who had had a
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persistent depression for some years unaltered by drugs, shock treatment, and conventional psychotherapy. She expressed her despair and bewilderment in her constantly repeated question: "I always used to be the strong one. Everyone in trouble came to me and I knew what to tell them, But now I'm just as upset as any of them ever were, and I don't see any way out. H o w did this happen to me? Please help me!" She had reached the age when her relatives and friends were being overtaken by tragic and fatal illnesses, several of which had happened in her immediate family, and she was shaken by the thought that this might happen to her, too, and in fact with the depression this was precisely what seemed to her to be happening. Our focus in counseling was on the fact that one does not "snap out of" a depression or "shake it off," but rather that, by means of gradual involvement with something or someone outside oneself, one moves through the depression and out the other side of it, and thereby gains faith and a new perspective on life. Since discussion of this in theological language seemed to confuse her, I did not try to use such language, but regardless of that I felt we were on theological ground the whole time. In caring for a disturbed relative, she was ultimately distracted from her own extreme self-concern; her depression lifted and she now has a balance that I suspect she never really had before. A third problem concerned a much younger married woman whose first depressive episode responded well to electric shock treatment, but shortly afterwards the depression recurred. [ could find no evidence of serious conflict with her husband, her children, her parents, or anyone else. What I did sense was that the rather naive and unrealistic concept of religious faith she had absorbed while growing up was not adequate to sustain her in a world that, she was beginning to realize, contained much more uncertainty and danger than she had ever dreamed of. Her two greatest fears were of death and of losing her mind. Regarding the latter, she had the very common misconception that a truly religious person is never supposed to have doubts or become depressed. Consequently, she had spent a good deal of her available energy in fighting with the depression, which, of course, simply
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made it worse. We concentrated on helping her understand that doubt and depression are natural reactions that are not at all incompatible with religious commitment, and that her salvation lay not in fighting her feelings of depression, but in leaving them alone so that they might dry up like an unwatered plant while she continued with her ordinary household responsibilities. As she gradually learned that she could leave her feelings alone without being overwhelmed by them, the depression went away. I did have her on an antidepressant for a time, but its benefit was limited. What seemed to make the most difference to her was understanding that religious faith is not so much a panacea for depression as a capacity to keep purposefully moving in the face of it until the depression eventually dispels itself. These three cases I have described are by no means rare or isolated instances. People with problems of this kind actually constitute a very significant part of my own practice, and I believe there are far more of them in the community than is generally realized. I am sure that my affiliation with the pastoral counseling service of a church has been a major factor in my becoming aware that these problems are basically theological. It would appear to me that a clergyman with his theological background would be more helpful to these people than a psychiatrist who never includes theological discussion in his counseling. At this point someone might ask very reasonably why I have not sent such people directly to the clergy instead or working with them myself. My answer is that many clergymen do not recognize the difficulties of these people as being fundamentally theological, so that they refer them to me with the assumption that the problem is psychological and beyond their level of competence. In the process of trying to determine for myself what the situation is with these troubled people, I have had to do some theological research of my own, which has been illuminating and very helpful to me. In so doing, I have felt reassured and encouraged by Paul Tillich's statement that "the relationship [between psychiatry and religion] is not one of existing alongside each other; it is a relationship of mutual inter-
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penetration. ''6 This I found to be true; and it indicates to me that we have n o w reached the stage where psychiatry and religion should understand that they have similarities as well as differences, and that some interdisciplinary barriers can be taken d o w n without harm to either discipline, and to the advantage of both. People w h o are mentally ill come to the clergyman, w h o then will need the help of the psychiatrist. But it also happens that people with theological problems come to the psychiatrist, w h o then needs the help of the clergyman, not as a subordinate mental health worker but as the appropriate person, the ultimate authority. I believe the true nature of psychiatry will become clearer to everyone w h e n psychiatry realizes that it has a close relationship to religion as well as to medicine and takes advantage of the opportunity for really intimate dialogue with the clergy. References
1. Burhoe, R. W., "Bridging the Gap Between Psychiatry and Theology," ]. Religion and Health, 1968, 7, 215-2261 2. Hathorne, B. C., "Critical Issues in Developing Pastoral Services and Consultation," Pastoral Psychology, 1969, 20, 10-12. 3. Meissner, S.J., W. W., review of Psychiatry, the Clergy, and Pastoral Counseling, edited by Dana L. Farnsworth and Francis J. Braceland, Psychiatric News, Sept., 1969, p. 9. 4. London, P., The Modes and Morals of Psychotherapy. New York, Holt, Rinehart and Winston, 1964, pp. 171-173. 5. Howland, E. S., "Psychiatry's Responsibility to Medicine and to Religion," Bull. ]okns Hopkins Hospital, 1965, 117, 137-139. 6. Tillich, P., Theology of Culture. New York, Oxford University Press, 1959, p. 114.
