Psychotherapy and Spiritual Values

When the American Psychiatric Association met last month in New York City, evangelical psychiatrists found an opportunity to discuss the moving frontiers relating Christianity and psychotherapy. Assistant Editor Frank Farrell conducted a panel discussion with the following three psychiatrists: Dr. Truman G. Esau, director of the Covenant Counseling Center of the Swedish Covenant Hospital, Chicago, Illinois; Dr. E. Mansell Pattison, senior psychiatrist, National Institute of Mental Health, Clinical Neuropharmacology Research Center, Washington, D. C.; Dr. Orville S. Walters, professor of health science, lecturer in psychiatry, and director of health services, University of Illinois, Urbana, Illinois. On the following pages is an abridgment of the discussion.—ED.

DR. FARRELL: If there is one thing modern man should know by now, it is that he is living in an age of crisis. This is pointed out to him on every hand, and if he is not benumbed by the constant repetition of the “news,” he is staggered by the terrible toll of the crisis in mental hospital statistics alone. Men seem often to be living on their fears, but they are obviously not thriving on them. In the providence of God, the rising tide of tension and personal disintegration is now being countered to some degree by advances in psychology, and Christian ministers are more and more equipping themselves with the tools of knowledge and experience in this field. The need of a person in distress generally is not confined to a single category but may extend to the fields of religion and ethics as well as to psychology, medicine, physiology, and sociology. What do you men consider to be the role of religious values in psychology? How should Christian values be utilized professionally in psychotherapy?

DR. PATTISON: Religious values play a very important role in almost everybody’s life, whether he says so explicitly or not. These values affect people’s behavior in virtually every sector of living. Therefore people’s religious values, whatever they may be, are an important consideration in any sort of psychotherapy and cannot be ignored; they must be reckoned with no matter who is doing the therapy or who the patient is, and regardless of the religious values of the patient or the therapist.

DR. ESAU: I think you can amplify that by saying that it is incumbent on the psychotherapist to inquire in this area. This is not traditionally taught in psychiatric residencies. But if religious values are an important part of the patient’s life, the therapist is well advised to know how important they are to the person, and then what role they play, whether it be a healthy role or detrimental to his mental health.

DR. WALTERS: Freud took the position that his patient’s values and ethics were none of his concern, but this viewpoint is passing in psychiatry. An important factor in the change of climate is Report Number 48 produced by the Group for the Advancement of Psychiatry. This report stated that the patient’s values are important to the therapist; that the therapist’s values become known to the patient; that it is quite impossible for the therapist to remain neutral; that in the practice of his profession he is constantly making value judgments and moral decisions. This is a most significant admission by a very influential group in psychiatry.

DR. PATTISON: It is no longer naively held that values can be kept out of therapy or that there is no influence of patient on therapist or therapist on patient. We recognize that each influences the other during the course of therapy. The important question is not how to eliminate all influence on the patient but how to control and regulate and define the sorts of influence you are going to have on the patient. The whole point of therapy is that you do influence the patient. How you influence him and what sort of standards and morals determine your goals are the important things that have yet to be thoroughly discussed by professionals.

DR. ESAU: There must be mutual respect for the value attitudes that each brings to the psychotherapeutic situation. I think that we would be opposed to an evangelistic kind of approach in which the therapist seeks to alter the value structure of the individual in the guise of psychotherapy. This doesn’t mean, however, that there can’t be an honest expression of what values the two persons hold.

DR. WALTERS: I wouldn’t consider the influence of the patient’s values on the psychiatrist very significant. Rather, the patient himself is hyper-susceptible to suggestion in a therapeutic situation by the very nature of the physician-patient relationship. I think it is quite impossible for the therapist not to influence the values of his patient, whether he does this overtly or not. If he is not a Christian, his influence is being exerted upon the patient whether he says anything to that effect or not. If he is a Christian, his influence is similarly being exerted, so that when you say the therapist should not take an evangelistic attitude toward his patient, this is a relative matter. If he is a Christian, there is a Christian influence—if you will, an evangelistic influence—being exerted. I think it is unrealistic to rule this out of the relationship.

DR. ESAU: I partially agree with you, and yet you wouldn’t say that the psychiatrist would make an attempt to bring specific religious dogma into the psychotherapeutic situation. This is what I meant by evangelistic. I don’t think it’s my right as a psychotherapist to make a direct effort at the conversion of my patient while he is in psychotherapy. Now obviously, the patient may in the course of psychotherapy, due to a variety of influences, come to some realization of his relationship to God, or lack of it, and I wouldn’t want to withdraw from that. On the other hand, I wouldn’t maintain that one of my principal purposes is to bring specific religious content into psychotherapy and hope to make a Baptist out of him or a Presbyterian or what have you.

DR. PATTISON: There is now a significant amount of professional literature demonstrating that changes in religious values do occur during the course of therapy, or as a result of therapy, and that sometimes the religious experience of patients deepens and they become more effective in their religious behavior. On the other hand, there are times when patients will give up their religious profession as a result of therapy. This leads to misunderstandings, because people conclude that therapy is aimed at getting rid of their religion, which is a misinterpretation. My own experience and reports I have seen indicate that most patients who give up their religion had a very neurotic form of religion in the first place, and that what they give up is not something very vital and central at all. I think it’s important to differentiate between the consequences and the goal of therapy. The goal of therapy is not to change people’s religious convictions, but as a consequence of therapy people may deepen these convictions or give them up.

DR. WALTERS: I don’t agree with Dr. Esau that Christian faith should be kept out of psychotherapy. He speaks of Baptist, Presbyterian, and so forth. This is not exactly the Christian faith; this is denominationalism, and that far I would agree with him. But the Christian faith is more basic than that. There is a core of Christian belief and doctrine on which most Christian denominations agree. This deals with the basic verities of existence, of human personality, and out of these depths grow most neurotic conflicts.

DR. ESAU: Would you expand that?

DR. WALTERS: I think that value conflicts are at the root of much neurosis, and that the moral conflicts in which men find themselves frequently result in neurotic conflict. Moreover, Christian people often entangle neurosis with their religious faith. One finds the fabric of personality interwoven between wholesome religious activity and neurosis, until the two may need disentangling, separation and reweaving, so to speak, into a proper pattern of life. Here I think it is important that a Christian help to do this disentangling, because the secular therapist, far from being able to help in disentangling, may not even be able to differentiate wholesome and unwholesome religious observance and activities.

DR. FARRELL: Along that line let me ask you this: How would you men sum up the distinctives of a Christian psychotherapy? What psychotherapeutic theory best reflects in practice a Christian concern for people?

DR. ESAU: Your use of the phrase “Christian psychotherapy” is, I think, premature. I don’t think there has been enough dialogue in depth on these things for us to speak of this with any authority. We all have some elements that are right and some elements that are wrong.

DR. WALTERS: I wouldn’t agree. I would say the time has come—with pastoral counseling having taken aboard almost more psychiatry than it can hold—for psychotherapy to establish some kind of combination with Christian theology. I think that the Christian psychiatrist has some obligation to deal with the value conflicts of his patients, and I think that as a Christian he is bound to find that the answer to many of these conflicts is a Christian answer. I think that Christian psychotherapy has its roots in Christian theology. Our doctrine of God, our doctrine of creation, our doctrine of man—these are all parts of Christian theology. If you are a Christian, even if you make no overt effort to involve Christian theology in your psychotherapy, the fact that you are a Christian still tacitly brings theology into the relationship. I believe that it is appropriate to call this Christian psychotherapy.

DR. ESAU: Well, I think you are over-reading what I have said. I agree completely on the need of bringing together psychotherapy and theology. I’m just saying it hasn’t been done yet.

DR. WALTERS: God as Creator, man as creature, man as having an evil inclination and needing divine grace, the regeneration of man occurring through the operation of the Holy Spirit—these constitute a solid theological base for psychotherapy. It is this contribution that Christian theology can make to psychotherapy that constitutes, in my viewpoint, a Christian psychotherapy. You use any techniques you want to, but basically you are grounded and rooted in Christian theology.

DR. ESAU: I don’t think there is any question about the need of a philosophic premise rooted in Christian theology. But let me caricature what you said a little bit in order to try to bring it out in the open. Taking your statement about Christian theology, I don’t see why a person couldn’t then say: “Well, we understand theology and we understand the Bible; we have the Bible, we have pastors; why have psychiatry?” Because I don’t think there is anything you’ve said yet that speaks distinctively for the psychotherapy side of this phrase “Christian psychotherapy.” You have defined it as a philosophic premise, but what is there on the psychotherapeutic side that even justifies psychotherapy? Why not just have the pastor do all this?

DR. WALTERS: All right, this is no caricature; it’s a straight question. The answer is that not everybody needs the psychiatrist. Many people who are seeing a psychiatrist, as some of my patients have told me, would twenty years ago have seen a clergyman. Hence the psychiatrist frequently finds himself dealing with people with moral conflicts who need a clergyman, people a clergyman could handle if they were amenable to his ministration. In this scientific age people want a psychiatrist.

DR. ESAU: You are saying, then, that the Christian psychiatrist is performing the function the clergyman performed twenty years ago and is not bringing anything new on the scene?

DR. WALTERS: I’m saying that some people are amenable to the ministration of a psychiatrist who would not submit to the ministration of a clergyman.

DR. ESAU: But the psychiatrist then is performing or should perform the function of a clergyman because the clergyman is not now seen by the person as meaningfully related to his problem?

DR. WALTERS: If the psychiatrist is a Christian, if he recognizes that his patient is neurotic basically because of moral conflict in his life, can he do anything other than disclose this to the patient in an appropriate way, and can he suggest any other solution to the moral conflict than the Christian?

DR. PATTISON: I think we are getting now to a real core problem. In a paper presented at the meeting of the Christian Association of Psychological Studies this spring, I tried to develop the point that there has been a cultural evolution of the psychotherapy role which is such an issue in current religion-and-psychiatry dialogue. The pastoral function of the Church historically has been not only preaching the Gospel but also what we might call shepherding or guiding the people. Hence the pastor traditionally has been, if you will, a psychotherapist. Many neurotic conflicts, if not resolved, were at least ameliorated under the guidance of the minister. Now I think that in this sense the psychiatrist has become a secular pastor for many people who have no church affiliation. I think this is quite different, though, from what has taken place within the last half century of psychotherapy, that is, the development of specific technical skills to reorganize or resolve basic neurotic conflicts in the personality structure of the individual. I think this sort of therapy is unique to the psychiatrist—or rather, not to the psychiatrist necessarily but to the skilled psychotherapist, regardless of his professional discipline. He might be a trained social worker, a psychologist, a psychiatrist, or a clinically trained pastoral counselor. This task, then, is not a pastoral task of resolving conflict of moral values but a psychotherapeutic task of resolving structural conflict within the personality. It cannot be done by the pastor or by the untrained counselor because it requires very specific technical skills. I think, then, that psychotherapy involves two levels: One is, you might say, a common level of psychotherapy that pastors have performed throughout history and that I think we psychiatrists might like to be able to give up; the other is the highly technical psychotherapy task that is often a very long, tedious, and complicated procedure of reconstructing the personality.

DR. WALTERS: I think this is an artificial dichotomy. I don’t think there is any such highly technical skill in psychotherapy as you suggest. If you are talking about psychoanalysis, this is an esoteric and rather specialized and complicated form of psychotherapy. But you have just said that social workers, psychologists, and other people learn the techniques of psychotherapy, as indeed they do. So do clergymen. Studies of psychotherapy emphasize that it not a particular technique that is effective, but that one technique is essentially just as effective as any other. It is the relationship with the therapist that counts—not the way he conducts his investigation or the particular technical skill he uses. Granted that you have to be able to understand people and use a certain finesse in dealing with them. But the various psychotherapeutic orientations are roughly equally effective in bringing about relief in neurotic people.

DR. PATTISON: I have seen therapists with such overwhelming religious concern that they behave in a damaging manner while trying to conduct therapy. On the other hand, I know some therapists who make no religious avowal but who have been able to help Christian people grow tremendously in their Christian lives, although fundamentally they were at quite opposite poles in terms of a basic system of values.

DR. ESAU: I wonder if the latter therapists haven’t accepted something of Christian values at a kind of pre-theological level that they unconsciously communicate to persons who are coming for therapy—for example, the meaning and value of the individual, the meaning and experience of love and grace in the therapeutic relationship. Although the therapist may not give specific allegiance to a given theological structure, yet implicitly he has picked up real values that historically are an outgrowth of the Judeo-Christian heritage.

DR. PATTISON: I like what C. S. Lewis says, that our contemporary culture is still living basically within the Christian frame of reference, and that we still use Christian assumptions in our relationships. I think that most psychotherapy is still based upon Christian assumptions, even though this isn’t recognized or accepted verbally. I think this is the way therapists operate when you talk to them—at least it’s so in my personal relationships with my friends.

DR. WALTERS: What do you mean by that?

DR. PATTISON: I think that there is a general humanistic frame of reference in which love is an essential ingredient, along with the worth of the individual, the importance of trust, the respect for the dignity of the human person, and honesty, which is a very high value in most therapeutic relations. I think these are generally Christian, although not specifically Christian.

DR. ESAU: I think that our culture owes the emphasis on these things to its Christian heritage.

DR. WALTERS: All right. I’ll accept that. But I don’t think there is anything distinctively Christian about most psychotherapy. I wouldn’t agree to that at all.

DR. FARRELL: How important is dialogue between psychotherapists and theologians?

DR. PATTISON: I think it is very important, because I find that a theology always reflects the psychology of the times. If we read, say, the classical theologians of medieval times, we find that their theology reflects their medieval psychology. So it seems to me that our psychology is going to influence our theology—not necessarily change it but perhaps deepen and clarify our knowledge of it. As I tried to point out in a paper on forgiveness, I think our knowledge of the psychology of human relationships gives much greater depth to our theological understanding of forgiveness. Or to take guilt, an understanding of the mechanisms of guilt should give us a much broader and deeper understanding of theological concepts of guilt.

DR. WALTERS: There is a cacophony of voices in psychology today; you can’t possibly reconcile them. I submit that Christian theology has more to say to psychotherapy than the multiplicity of psychologies that we have, because each of these psychologies has a modicum of empirical findings that has been inflated into a theoretical system, and each one has its own technique of psychotherapy based on this modest groundwork. We have a Whole host of these psychologies, with a psychotherapy based on almost every one of them. How can you talk about modifying theology in harmony with these theoretical systems, none of which has very much empirical to offer?

DR. ESAU: One thing that the theological and the psychological spheres share is a multitude of voices! There are certain principles, however, that are absolute which underlie both these fields. These absolutes need to interpenetrate. It isn’t a question of one influencing the other primarily. Rather, it’s leaving a door open both ways.

DR. PATTISON: Wouldn’t you say that theology should influence psychology and psychology should influence theology? So it’s a mutual modification, hopefully, with a mutual synthetic growth out of this.

DR. ESAU: But it doesn’t mean to give up your absolutes in the process. If we were to say that theology encompasses and has encompassed all psychological understanding, this would be a very gross overstatement of what theology has attempted. It is correct, however, to say that theology can benefit from psychological insight.

DR. FARRELL: At one time theology was known as the queen of the sciences. This day has passed. You spoke, Dr. Pattison, of a mutual modification. When you say mutual, are you putting them pretty much on the same level? Or should theology ideally affect psychology more than psychology affects theology?

DR. PATTISON: I’m not trying to make any qualitative equation here at all. I’m saying that here are two spheres or sectors of life and knowledge.

DR. FARRELL: Is one more basic than the other?

DR. ESAU: I would say yes.

DR. WALTERS: Well, I don’t think you are going to find much cooperation between these two, because psychology has for fifty years been trying to get rid of its philosophical origins and is trying to be an exact science.

DR. PATTISON: I can’t agree with you on that, Dr. Walters. I think there is a very significant new impetus within American psychology toward personality theory that is trying to get away from the physical science model. A number of personality theorists are trying to conceptualize man at a level that is not a physical science approach to psychology but is a holistic approach. The other important thrust is the existentialist influence, which is now becoming more important here in America. I think that existentialist psychology and therapy are having an important effect, and that we are going to see more of that.

DR. WALTERS: The emphasis on unconscious motivation has, I think, been greatly overdone. With the pre-eminence of psychoanalysis and psychoanalytic influence in so many areas of modern life, we have come to think of motivation by the unconscious almost to the exclusion of conscious activity. James J. Putnam in 1915, fifty years ago, struggled with Freud, labored with him, trying to get him to take a different approach, to involve psychoanalysis more in philosophical questions and not to subordinate the conscious to the unconscious. But Freud contended for the old iceberg theory, that there is more underneath the surface than above it and that the real psyche is down below. This has gradually been outgrown, I think, although it’s still the essence of psychoanalysis. But I see psychoanalysis as having passed the peak of its influence in this country, and I think two factors are concerned here: one is the prevailing influence of existential analysis in various forms and the other is the progress of some other theoretical orientations. In fact, psychoanalysis itself has made a 180 degree turn on some of the Freudian positions in its ego psychology. The emphasis now even within psychoanalysis has moved from the unconscious to the ego, which is said to have an autonomy of its own and not to be only the middleman between the id and the superego. So I think we need to tone down our concept of the influence of the unconscious and of unconscious motivation and give greater attention to the conscious. Many patients are looking for a psychiatric out; they want to be told that the way their mothers treated them is responsible for the way they are.

DR. ESAU: Yes, but you wouldn’t deny that the way mother treated them was one of the external relationship factors to which they reacted in personality formation?

DR. WALTERS: No, but this did not deprive the individual of all of his freedom.

DR. PATTISON: I like Freud’s statement: “I have been able to show that we are not only less responsible for how we became the way we are, but that we are also more responsible for doing with ourselves what we should.” I think it’s very important to note that we are more determined than we thought we were, but that we have more responsibility and freedom than we want to accept for ourselves.

DR. ESAU: I think that Freud was misused by his early followers in their attempt to do this very thing; that is, to excuse man from all responsibility.

DR. PATTISON: I think this gets back to the idea of sin. The distinction between responsibility for sin and culpability or punishability for sin is very important. In a sense we can’t escape the responsibility of our sinful behavior. But then comes the important thing: How much punishment is due us, if some is due us? There is the whole question of what one does with one’s sinful condition or state, with what he is.

DR. FARRELL: How do you tie this in with the fact that Christ bore the guilt for our sins?

DR. ESAU: Christ didn’t die just to remove the guilt of sins. He died because man was in a separated condition. He died to restore us to relationship.

DR. FARRELL: And when Paul says to the Corinthians, “Christ died for our sins”?

DR. ESAU: Both are true.

DR. PATTISON: Christ’s death had to do, it seems to me, with our basic nature, which then reflects upon our behavior.

DR. ESAU: Yes, this is why he had to give us a new nature.

DR. FARRELL: That’s a good note to end on—a note of grace and of divine, regenerating power. It’s a radical note that must serve as the basis for profound Christian healing. It involves more than a reshuffling of conscious and unconscious motives—it is the creation of a new life in Christ.

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