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- Herausgeber: IVP Academic
- Kategorie: Geisteswissenschaft
- Serie: Christian Association for Psychological Studies Books
- Sprache: Englisch
Modern Psychopathologies is addressed to students and mental health professionals who want to sort through contemporary secular understandings of psychopathology in relation to a Christian worldview.Written by well-known and respected scholars, this book provides an introduction to a set of disorders along with overviews of current research on etiology, treatment and prevention. Prior chapters explore the classification of disorders in historic pastoral care and contemporary mental health care. The authors explain the biological and sociocultural foundations of mental illness, and reflect on the relation between psychopathology and the Christian understanding of sin. Modern Psychopathologies is a unique and valuable resource for Christians studying psychology and counseling or providing counseling services, pastoral care, Christian healing ministries or spiritual direction.The revised second edition is fully updated according to DSM-5 and ICD-10. The authors have expanded the analysis to include problems associated with trauma, gender, addiction and more.Though fully capable of standing on its own, the book is a useful companion volume to Modern Psychotherapies by Stanton L. Jones and Richard E. Butman. Christian Association for Psychological Studies (CAPS) Books explore how Christianity relates to mental health and behavioral sciences including psychology, counseling, social work, and marriage and family therapy in order to equip Christian clinicians to support the well-being of their clients.
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MODERN PSYCHOPATHOLOGIES
A Comprehensive Christian Appraisal
SECOND EDITION
CONTENTS
PREFACE TO THESECOND EDITION
This book has been a work in progress since the mid-1990s, when the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association was published in its fourth edition. It was at that time that the three of us came together in initial discussions about what it means to think as Christians about psychopathology. One of our favorite discussions took place, memorably, during a kayak trip to Door County, Wisconsin. Rich, who at that time was professor and mentor to Barrett and Mark in their graduate studies, had a passion for adventure in God’s creation and (like his professor and mentor Newton Maloney, who took Rich and a group of his fellow students on mountain-climbing expeditions) for deep conversations about life and faith that could be explored in such contexts untethered by the distractions of daily life. On that trip we wrestled with our questions and hopes for the work of caring for those who are people in pain. And, as has been true throughout the centuries for people of faith, we engaged in the intergenerational process of seeking and passing on understanding about the nature of human suffering and hope for healing.
We wrote this book to sort out the convictions that emerged from that conversation and many others since about integration of faith in the study of psychopathology, desiring to engage other Christians in a dialogue about ways of thinking about categories of human suffering (diagnosis and psychopathology) through the eyes of faith. Rather than creating a radically new approach to the study of psychopathology, we wanted to draw attention to the resources already present in historical pastoral care, including an understanding of sin and its relation to contemporary categories of psychopathology.
To do this, we took several steps. The first was to consider ways in which the church has historically approached symptoms of psychological and spiritual concerns that are in some ways evident in contemporary nosologies. The next step was to clearly explain what we know about psychopathology from the best scientific studies conducted to date. We attempted to summarize existing explanatory frameworks—ways in which professionals today tend to make sense of symptoms of psychopathology. An additional step involved reflecting on these explanatory frameworks in an intentional manner—to think truly and thoroughly Christianly in our analysis of contemporary psychopathology, and to do so in a way that would help other Christians in the field move forward in the task of integration.
This book is intended for a broad audience that includes students and clinicians in the mental health fields (e.g., psychology, counseling, social work, marriage and family therapy, and so on), pastors, and ministers of pastoral care.
OVERVIEW
As we mentioned, we wrote this book in the wake of the publication of the fourth edition of the DSM. In 2013, the American Psychiatric Association released DSM-5, containing numerous substantive changes to the diagnostic categories of the previous edition. We decided to revise this book partly to align it with the changes in the DSM system and partly due to changes in the ways we think about some of the disorders codified in the DSM. We have also changed our thinking about how we structured some of the chapters in the first edition.
The book is now divided into three parts. In part one, “Historical and Contemporary Categorization” (chapters one through five), we set the stage for discussion of the major symptom presentations as organized by the DSM. Chapter one addresses the various ways in which the authors of the Scriptures and pastoral theologians throughout history have classified the “wounds of the soul.” In chapter two, we explore the various ways in which the disciplines of contemporary mental health have classified human suffering. Chapters three and four address the multifaceted nature of the foundations of psychopathology in biological and sociocultural realities. Chapter five, “Sin and Psychopathology,” is our effort to unpack the implications of sin in the study of psychopathology from a Christian perspective.
Part two of the book, “The Psychopathologies: Categories of Psychological Problems” (chapters six through sixteen), devotes one chapter to each of the major symptom presentations discussed in contemporary psychopathology (e.g., problems of mood). Each chapter contains a brief introduction to the problems in that category cluster, followed by an overview of the disorders in contemporary classification, including research on etiology, treatment and prevention. We then offer an appraisal of the problems in that cluster in light of themes from pastoral care literature and integrative themes, tying the discussion back to the foundational chapters from part one of the book.
Part three (chapter seventeen) reflects our desire to cast a vision for Christian mental health professionals and for the pastoral care ministries of the church in light of the imperfect systems of classification available to us. In this book, we hope to bring together the best resources from the church and the best understandings from science and clinical practice.
ACKNOWLEDGMENTS
We feel very fortunate to have worked together on this project and to have seen our friendships strengthened over almost twenty-five years. We have been blessed by stimulating conversations with students and colleagues for many years now. In particular we want to thank the many students we have learned with at Wheaton College and Regent University. Your insights, narratives and questions have influenced us more than you may ever know.
We would like to thank the many people who read and critiqued various chapters of this book. Barrett would like to acknowledge his research assistants Lucas Bossard, Andy Jack and Spencer Nelessen. He would also like to thank the colleagues and mentors whose wisdom and guidance have laid the foundation for his contribution to the views of pastoral care expressed in this book: John McRay, Mark McMinn, Stan Jones, Jim Cassens, Ken Phillips, Fran White, Jerry Root, David Norton, Terri Watson, Stew Morton, Ed Dunkelblau and Peter Bouman.
Mark wishes to thank his research team members, including Erica Tan, Lisa Pawlowski, Stephen Russell, Heather Brooke, Lori Burkett, Robin Seymore, Edye Garcia, Lynette Bogey, Adam Hunter, Justin Sides, Emma Bucher, Tranese Morgan and Shane Ferrell. He would also like to thank members of the Christian education class at Galilee Church for their thoughtful consideration of many of these issues as he taught Pursuing Emotional Wholeness in Christ.
Richard would like to acknowledge his research and teaching assistants: David Hoover, Ariel Oleari, Brian McLaughlin, Luke DeMater, June Stroner, Amy Prescott, Justin O’Rouke, Alex Johnson, Stacey Gerberich, Sam McEuen and Kyle McCordic. He also thanks his colleagues for their feedback, including Bob and Terri Watson, Michael Mangis, Derek McNeil, Pamela Trice, Sandy Johnston Kruse, Victor Argo, Georgina Panting, Javier Sierra, Jairo Sarmiento, Guillermo Jimenez, Stanton Jones, Ward Kriegbaum, Dorothy Chappell, Randy Sorenson, Helen DeVries, Mark McMinn, Robert Gregory, Jack and Barb Van Vessem, Chip Edgar, Don Pruessler, Tim Brown, Alexandra Tsang, Don Bosch, Brent Stenberg, Newt Malony, Walt Wright, Steve Sittig, and Don Dwyer. He is grateful for the regular and helpful input of his wife, Sally Diann Griffen, LCPC, LMFT.
We would also like to express our gratitude to Shane Ferrell and Matthew McRay for their tireless work on the indexes of this manuscript.
Part One
HISTORICAL AND CONTEMPORARY CATEGORIZATION
1
CLASSIFICATION INHISTORICAL PASTORAL CARE
Why begin a book on modern psychopathologies with a chapter on historical pastoral care? Though the value of pastoral care for the life and ministry of the church may be obvious, what does it have to do with “modern psychopathologies”? What does historical pastoral care have to do with struggles people have with anxiety, depression or substance abuse? Pastoral care, also often referred to as the ministry of the “care” or “cure” of souls, has been described as “helping acts, done by representative Christian persons, directed toward the healing, sustaining, guiding, and reconciling of troubled persons whose troubles arise in the context of ultimate meanings and concerns” (Clebsch & Jaekle, 1964). Throughout Christian history, “representative Christian persons” have sought to understand the “troubles” of the persons under their care and respond with wise care and counsel. Those providing this care throughout the centuries have contributed to the development of ways of understanding human suffering and helpful responses to that suffering. This work of categorizing and responding is not dissimilar to the processes at work in the development of the contemporary field of psychopathology. Furthermore, those contributing to this developing nosology in pastoral care have most often interacted with contemporary understandings of human suffering accepted in the broader culture, thinking integratively about this task.
In every historic epoch, pastoring has utilized—and by utilizing has helped to advance and transform—the psychology or psychologies current in that epoch. . . . Nowhere in history has Christianity adumbrated solely from its own lore a distinct psychology, either theoretically or popularly understood. To appreciate traditional pastoring is to stand ready to adopt and adapt current psychological insights and applications without abdicating the distinctly pastoral role. (Clebsch & Jaekle, 1964, pp. 68-69)
We are committed to this ideal of integrative and collaborative study in the work of understanding the sufferings of persons. As we will explore in this chapter, Christian history has much to offer contemporary understandings of human suffering; however, the work of integration and collaboration has not always been well received by the broader culture. Ours is such a time, and our hope is that this book will contribute to changing that.
This book is about psychopathology, defined by the American Psychological Association as “the area of psychological investigation concerned with understanding the nature of individual pathologies of mind, mood, and behavior” (APA, 2015). The history of the mental health field, from its origins in Greek philosophy to the development of contemporary theories of psychotherapy, reveals an intensifying focus on systematic understandings and categorizations of the problems people experience in their psychological health (see Jones & Butman, 1991). This field of study provides the basis for the diagnostic categories and terminology used by contemporary health and mental health providers worldwide (accepted most widely in the DSM and ICD [International Classification of Diseases, World Health Organization] systems). These diagnostic categories have evolved through numerous iterations and revisions and continue to do so as theories mutate, societal values change, and continuing research offers a greater breadth of understanding. However, notably absent from these systems is any attention to spirituality or religious understandings of health and suffering.
The word “psychopathology” is a derivative of three Greek words: ψυχή (psychē), πάθος (pathos) and λόγος (logos)—which translated literally would be something like “soul suffering study.” Modern psychopathology, as defined above by the APA, has a more reductionistic focus limited to the study of “mind, mood and behavior.” It is our belief that the task of Christians in the mental health fields and pastoral ministry is to think more holistically about human suffering and to integrate the understandings of classic Christian literature with that of contemporary research and practice in psychopathology. We believe that the history of pastoral care provides us with insights into the human condition that predate contemporary psychology and specific theories of psychopathology. Further, we believe that Christians interested in the study of human experience, including various dysfunctions and psychopathologies, need to be informed by these insights and pastoral reflections on the experiences of “troubled persons” and the church’s concern for their everyday and ultimate needs.
Historical pastoral care and reflection was quite different from what we think of as modern psychology. It was based chiefly on reflection and deduction from principles derived from Scripture and pastoral experience, whereas the modern psychologies, while also indebted to reflection and theorizing, are grounded more in behavioral science investigation characterized by inductive, empirical study. In other words, the pastoral language, categories and methodologies for understanding human experiences are significantly different from those used by contemporary mental health professionals. These differences led to the neglect of historical pastoral care, in part out of disdain for premodern wisdom and its tendency to privilege reductionism, naturalism and empiricism (Oden, 1980). Although much has been gained through advances in the behavioral sciences, we wish to make connections that have been all but lost as Christians attempt to think as Christians about contemporary mental and spiritual health concerns. Toward that end we consider historical pastoral care and the insights of pastoral writers on the human condition.
From the church’s birth at Pentecost, its writings bear witness to the significance given the task of care for one another and especially for those in need. Recognition is given not only to the importance of this work but also to the knowledge and skill needed to provide care to those who are suffering. Christ and his apostles laid the foundation for a church committed to the care of each member and instructed believers to make this a central aspect of life within the body of Christ. The early church fathers taught about the need for “physicians of the soul” skilled in the care of those whose woundedness hindered their faithful obedience to Christ or deprived them of fullness of life in the community of faith (Clebsch & Jaekle, 1964). For example, Origen wrote in the third century that Christians should look carefully for a “physician” of souls to whom they could confess their sin and “lay bare the cause of [their] ailment, [one] who knows how to be infirm with the infirm” (quoted in Kemp, 1947, p. 27). Similarly, in the fourth century, John Chrysostom wrote, “So the shepherd needs great wisdom and a thousand eyes, to examine the soul’s condition from every angle . . . [and] must not overlook any of these considerations, but examine them all with care and apply all his remedies appropriately for fear his care should be in vain” (Chrysostom, 1977, chap. 2, sec. 4, p. 58). Throughout the history of the church, this ministry of soul care has been central to its life and mission.
In our day, pastors, elders, ministry leaders and Christian mental health professionals, in their desire to better understand how and why people hurt and ways to be helpful in response to their pain, have sought to understand the diagnostic categories of psychopathology and to appraise them in light of the truths of the Scriptures and the teachings of the Christian church. It is our hope that this book will serve as a resource to those who wish to better grasp this integrative endeavor and as a guide to those who wish to join in the ongoing task of understanding the nature of human suffering and responding to those in distress.
Western society’s growing fascination with popular psychological understandings of the person has catapulted concern about psychopathology and wounds of the soul into the mainstream. Many people when faced with emotional problems will turn to mental health professionals to sort out the complexities of their concerns. Symptoms are almost without exception organized and conceptualized with reference to contemporary diagnostic nosology (e.g., the Diagnostic and Statistical Manual of Mental Disorders, APA, 2013), and this may inform case conceptualization and treatment planning, though it may also foreclose prematurely on other resources, including those found within the historical pastoral care literature. As Oden observes, “It is time to listen intently to the scriptural text and early Christian writers. It is time to ask how classical Christianity itself might teach us to understand the providence of God in the midst of our broken and confused modern situation” (1991, p. 36).
It is toward this end of “listening intently” to the Scriptures and the voices of Christians who have gone before us and paved the way for our understanding of human experience that we consider the historical ministry of pastoral care and understandings of “soul suffering” that emerge from its literature. Unfortunately, contemporary societal trends toward reductionistic understandings of human experience, coupled with numerous other forces such as the advancement of the empirical study of human behavior, have led to the segregation of psychological and spiritual aspects of care and understandings of mental and emotional suffering. We will address this concern following a brief exploration of biblical foundations for soul care and an overview of the literature of pastoral care.
SCRIPTURAL FOUNDATIONS
The Scriptures, of course, do not use the language of contemporary psychopathology. Furthermore, it is not the intent of any of the biblical writers to offer a systematic categorization of psychological dysfunctions. Therefore we must be careful not to look to the Scriptures to find evidence of “God’s view” of psychopathology. It apparently was not the intent of the authors of the Scriptures to teach us the exact nature and breadth of our psychological functioning. However, in many places the Scriptures do offer instruction about the nature of our human condition before God and before one another. These truths have tremendous bearing on our understanding of issues related to psychopathology, and these teachings laid a foundation for the development of the church’s understanding and approach to human suffering and eventual categorizations of these experiences.
A number of theological truths emerging from the pages of the Scriptures have bearing on our understanding of these issues. These include the nature of humans as created beings and image bearers of God and the impact of sin on that nature. These truths also include teachings about the church’s response to the suffering that results from the evil that is now part of this world.
The nature of humans. It is beyond the scope of this book to offer a comprehensive theological anthropology. However, we affirm the Christian view that human beings are created by God, that they are “created persons,” to use Hoekema’s phrase (1986, p. 6). That is, human beings are dependent on God (created) while relatively independent and capable of making decisions and setting and meeting various goals (persons).
Also, to be human is to be created in the image of God (imago Dei). Numerous scholars have proposed various ways we image God—through reason, will, the soul, relationality and so on—but suffice it to say that there are many aspects of human nature and being that set us apart from other creatures and seem to reflect something of who God is. There may be many facets to human beings’ imaging of God, and we affirm that God intended from creation to set humanity apart for his purposes.
As created persons, as image bearers of God and in a number of other ways, human beings, whether or not they acknowledge it, are always in relation to God and to transcendent reality. We assume, then, that God created human beings to function in certain ways and that those functions include both “internal” thoughts, feelings and the experience of one’s conscience and “external” behaviors and ways of relating to others. When we are not functioning properly, we place ourselves at risk of spiritual, emotional and physical health concerns, and these domains are not discrete but interrelated and complex.
The impact of sin. Although we were created as image bearers of God and were made in relation to him, we exist in a fallen state. This fallen condition is referenced by Paul in Romans: “Sin entered the world through one man, and death through sin, and in this way death came to all people, because all sinned. . . . Through the disobedience of the one man the many were made sinners” (Rom 5:12, 19). Sin refers to both a state (of fallenness) and specific acts. We have all “sinned and fall short of the glory of God,” and we face the consequences of that sin, which is death (Rom 3:23; 6:23).
Specific acts of sin not only remind us of our fallen condition but demonstrate specific, concrete ways in which we fail to act according to God’s will for our lives and relationships. Sin undoubtedly interacts with a number of other dimensions of human experience, and we will discuss these issues further in chapter five.
The impact of sin as a state is everywhere and experienced by everyone. But the message of the gospel is that God has not left us in this state of hopeless despair. He had compassion on us (Ps 145:9; Is 30:18; 49:13; Rom 5:8). “All have sinned and fall short of the glory of God, and all are justified freely by his grace through the redemption that came by Christ Jesus. . . . For the wages of sin is death, but the gift of God is eternal life in Christ Jesus our Lord” (Rom 3:23-24; 6:23).
The Scriptures acknowledge that sin has left us in a state of brokenness and helplessness (not worthlessness, as some would assert). We are unable to change our condition. God alone can redeem us; he alone can bring hope and healing. Our intended nature was changed as a result of Adam and Eve’s sin, and we each at some point willfully participate in that legacy of sinfulness. Our condition is not as it was intended to be, and God responds to this condition in two seemingly opposing ways—wrath and judgment for the evil at work within us (Rom 1:18) and compassion and comfort for the suffering that we bear (2 Cor 1:4).
Eric Johnson (1987) has proposed that these two aspects of our fallen nature (that for which God holds us accountable and that for which he does not) have significant implications for a Christian understanding of psychopathology. He suggests that the Scriptures teach a distinction between “sin” and “weakness”: “sin” (ἁμαρτία—hamartia) refers to the changes in our nature and behavior for which we are responsible, while “weakness” (ἁσθένεια—astheneia) refers to those changes in our nature for which we are not responsible. God responds to our sin with judgment tempered by grace, while his response to weakness is tenderness and compassion (Rom 8:26; 1 Cor 15:43; 2 Cor 12:9-10; 13:4; Heb 4:15; 11:34). This latter category and the overlap between the two, Johnson concludes, may have relevance for the many manifestations of human brokenness that are the focus of contemporary psychopathology. In other words, we have weaknesses that place us at risk of sinning, and we live in a world that is tainted by sin (as a state of affairs), and these dynamics, taken together with a variety of other factors, may account for a person’s susceptibility to psychopathology.
The church’s response. As Jesus observed crowds of oppressed people, he was moved to compassion for them because of the many ways they suffered and because of their need for a shepherd (Mt 9:35; 14:14; 15:32; 20:34). His response to people in pain is the model for the church.
In the ministry of Jesus is found the source, the inspiration, the ideal. . . . No other influence in the history of humanity has done so much to relieve human suffering, to create a spirit of compassion, and to inspire others to give themselves in an attempt to understand and to serve their fellow-men. . . . The stories and incidents revealed in the four gospels present one who had a unique insight into the needs and problems of people, one who understood with a clarity that has never been equaled or surpassed the meaning of life and human nature. . . . Jesus felt that . . . his mission was to relieve human suffering . . . to alleviate suffering in any manner in which he met it, whether it might be physical, mental, moral, or spiritual. (Kemp, 1947, pp. 6-7)
The Scriptures assume the reality of suffering and the need for care and make it clear that this is not only central to the mission of the church but a “law” of Christ—“Carry each other’s burdens, and in this way you will fulfill the law of Christ” (Gal 6:2). Jesus’ summation of his teaching on numerous occasions to his followers was to love as he loved them. The prevailing scriptural metaphor for the care and comfort of the wounded, weak and oppressed is a shepherd’s care for the flock: Jesus referred to himself as the “Good Shepherd” in John 10, and Peter referred to God as the “Shepherd and Overseer of [our] souls” (1 Pet 2:25). Isaiah wrote that God
tends his flock like a shepherd:
He gathers the lambs in his arms
and carries them close to his heart. (Is 40:11)
Ezekiel rebuked the leaders of Israel, “Woe to you shepherds of Israel. . . . You do not take care of the flock. You have not strengthened the weak or healed the sick or bound up the injured. You have not brought back the strays or searched for the lost” (Ezek 34:2-4). Peter extols elders to be “shepherds of God’s flock that is under your care” (1 Pet 5:2).
In Psalm 23, David gives perhaps the most vivid picture of this metaphor of tender care as he describes God’s love in response to his weakness and woundedness as the love of a shepherd who provides so that he will “lack nothing” and will be able to “lie down in green pastures” and drink from “quiet waters” without fear, who leads along “right paths,” who protects so that he “will fear no evil,” who comforts through his presence “with” him, who heals by “anoint[ing] [his] head with oil” and “refresh[ing] [his] soul,” and who gives hope in the promise that “goodness and love will follow [him] all the days of [his] life.” This is the pattern for the ministry of “shepherds” among the people of God and the foundation for the ministry of pastoral care throughout church history.
The word pastor appears only once in most English translations of the Scriptures. Paul wrote to the church in Ephesus, “So Christ himself gave the apostles, the prophets, the evangelists, the pastors and teachers, to equip his people for works of service, so that the body of Christ may be built up until we all reach unity in the faith and in the knowledge of the Son of God and become mature, attaining to the whole measure of the fullness of Christ” (Eph 4:11-13). The word translated here as “pastor” is the Greek word ποιμήν (poimēn), which literally translates as “shepherd.” English translators have chosen to use the word “pastor” (an English transliteration of the Latin pastor, which means shepherd) instead of “shepherd” in order to acknowledge what they believe is Paul’s intent to identify a specific role in the early church—that of “pastoring.” It is noteworthy that this role is differentiated from that of evangelists and teachers as well as apostles and prophets.
Those who would be pastors among God’s people must see themselves as shepherds. Within the culture of Old and New Testament Israel, shepherds were social outcasts, considered unclean because they lived among animals. Yet it was a shepherd whom God chose as king over Israel, and it was to shepherds that an angel first announced Jesus’ birth. Though people of humble position, their example of service and sacrifice are the model in the Scriptures for ministry. “Shepherds lead their sheep to places of nourishment and safety, protect them from danger, and are regularly called upon for great personal sacrifice. They are characterized by compassion, courage, and a mixture of tenderness and toughness” (Benner, 1998, p. 25). Through this metaphor of a humble shepherd we see the breadth of God’s compassion and his call for us to be people of compassion, and this metaphor provides the foundation for the church’s response throughout history to people in pain.
We are to be people of compassion who seek to comfort one another with the comfort we have received from God—a comfort that produces “patient endurance” to persevere amid trials and sufferings (2 Cor 1:3-7). We are to serve one another with the humility Christ displayed in his sacrifice (Phil 2:5-11). And those entrusted with the specific responsibilities of “shepherding” are to “keep watch over yourselves and all the flock of which the Holy Spirit has made you overseers” (Acts 20:28). In the New Testament church, shepherding was not about status or position but about a vital responsibility of service. That service included leading by demonstrating a life of trustworthiness and Christlike service (1 Tim 3:1-7; Tit 1:6-9; 1 Pet 5:1-3) and preserving unity in the church so the spiritual gifts of all the believers could be brought together to meet the needs of the community and glorify God (1 Cor 12; Eph 4:1-16). This mutuality of caring in community, facilitated and overseen by the pastoral leadership of shepherds, formed the foundation for the ministry that has been referred to throughout the history of the church as “the care of souls” or “pastoral care.”
THE LITERATURE OF THE CHURCH
Throughout the history of the church, understandings of the nature of human suffering and the human condition have varied, as have the responses of the church to those who are suffering. Both the need for a “remedy” for sin and the need for assistance in spiritual growth have been central to the church’s response to the human condition. The focus of this response, though varied in its precise theology and practice, has most often been on the need for redemption in the life of believers who suffer as a result of sin (Kemp, 1947; McNeill, 1951; Clebsch & Jaekle, 1964; Benner, 1998). This dual focus on remediation and formation in the ministry of pastoral care is worthy of consideration as we begin an exploration of historical pastoral care.
A common way of conceptualizing human functioning is to see it as a continuum from illness to wellness (see fig. 1.1). Within this paradigm, psychopathology and psychotherapy are generally considered to be focused on the illness side of the continuum. A common view of psychotherapy is that its primary aim is that of symptom reduction—intervening in the lives of symptomatic persons to the point of remediation of illness, a hypothetical neutral point where symptoms are no longer disabling. From this perspective, the work of formation (or increasing wellness) is beyond the scope of psychopathology and psychotherapy.
Figure 1.1. Illness and wellness continuum
Although somewhat simplistic in scope, this view is not far from the reality of contemporary research and practice in psychopathology and psychotherapy. Historical pastoral care, on the other hand, has viewed illness and wellness as interrelated and inseparable. Classification in pastoral care has always considered both the pathological and the apithological, and responses have focused on both remediation and formation.
The impact of sin. The theologians of the early church believed that the soul is stained with sin and that in the believer this arouses inner turmoil between the desires God created for humans to experience and the perversion of those desires through sin. All suffering, disability and trials can in the end be traced back to sin, and therefore an understanding of these struggles in life begins with an awareness of the sinfulness of the human condition. Origen, an Alexandrian theologian writing in the early third century, attempted to tease out the complexity of human dispositions that may impede one’s ability to live out life as God intended:
I do not think it is possible to explain easily or briefly how a soul may know herself; but as far as we are able, we will try to elucidate a few points out of many. It seems to me, then, that the soul ought to acquire self-knowledge of a twofold kind: she should know both what she is in herself, and how she is actuated; that is to say, she ought to know what she is like essentially, and what she is like according to her dispositions. She should know, for instance, whether she is of good disposition or not, and whether or not she is upright in intention; and, if she is in fact of an upright intention, whether, in thought as in action, she has the same zeal for all virtues, or only for necessary things and those that are easy; furthermore, whether she is making progress, and gaining in understanding of things, and growing in the virtues; or whether perhaps she is standing still and resting on what she has been able to achieve thus far; and whether what she does serves only for her own improvement; or whether she can benefit others, and give them anything of profit, either by the word of teaching or by the example of her actions. . . . And the soul needs to know herself in another way—whether she does these evil deeds of hers intentionally and because she likes them; or whether it is through some weakness that, as the Apostle says, she works what she would not and does the things she hates, while on the contrary she seems to do good deeds with willingness and with direct intention. Does she, for example, control her anger with some people and let fly with others, or does she always control it, never give way to it with anyone at all? So too with gloominess: does she conquer it in some cases, but give way to it in others, or does she never admit it at all? (The Song of Songs 2, quoted in Oden, 1987, 3:35)
Origen’s accounts reflect an appreciation not only for the complexities of human disposition but also of the importance of self-examination so that a person understands his or her propensity to act in ways that promote (or fail to promote) spiritual and emotional well-being.
Classifications of sin became a specific focus of the early church, and “in the experience of life and the practice of soul guidance, attention was inevitably drawn to a variety of grave offenses of thought or action for which repentance was required” (McNeill & Gamer, 1938, p. 18). Lists of these sins began to be circulated in the church and would form the foundation for the church’s response to sin and the formulation of appropriate guidelines for pastoral counsel. In the second century, Hermas identified twelve sins that required repentance: unbelief, incontinence, disobedience, deceit, sorrow, wickedness, wantonness, anger, falsehood, folly, backbiting and hatred. A list by Cyprian, the third-century bishop of Carthage, included eight sins: avarice, lust, ambition, anger, pride, drunkenness, envy and cursing (McNeill & Gamer, 1938, p. 18).
Augustine, bishop of Hippo in North Africa at the beginning of the fifth century, considered sin to be a disordering of that which God had originally created to be good. Thus the disorders of the soul could be described as the distortion of a virtue that God had ordained. In particular, Augustine wrote of what he called “disordered loves”:
The person who lives a just and holy life is one who . . . has ordered his love, so that he does not love what it is wrong to love, or fail to love what should be loved, or love too much what should be loved less (or love too little what should be loved more), or love two things equally if one of them should be loved either less or more than the other, or love things either more or less if they should be loved equally. No sinner, qua sinner, should be loved; every human being, qua human being, should be loved on God’s account; and God should be loved for himself. And if God is to be loved more than any human being, each person should love God more than he loves himself. Likewise, another human being should be loved more than our own bodies, because all these things are to be loved on account of God whereas another person can enjoy God together with us in a way in which the body cannot, since the body lives only through the soul, and it is the soul by which we enjoy God. All people should be loved equally. (1997, 1.59-60, p. 21)
This emphasis on disordered loves or disordered desires would characterize much of historical pastoral care, as theological insights aided pastors in their “understanding and interpretations of human experience” (Tidball, 1988, p. 493).
John Cassian, a fifth-century monk who introduced Eastern monastic life to the Western church, categorized the disordered desires under what became known as the eight capital vices of gluttony, fornication, avarice, anger, dejection, languor, vainglory and pride. He offered not only a description of these sins but guidance for their “treatment” (McNeill & Gamer, 1938). At the close of the sixth century, Pope Gregory revised Cassian’s ordering of sins and their remedy, giving emphasis to pride (a revolt of the spirit against God) and lust (a revolt of the flesh against the spirit). His list in order included pride, vainglory, envy, anger, dejection, avarice, gluttony and lust.
Cassian’s and Gregory’s lists of capital sins, or vices, formed the foundation of the church’s classification system for centuries. Corresponding lists of virtues emerged that offered a “wellness” orientation to complement the “illness” orientation of the vices. The capital vices were considered to be “source vices . . . that serve as an ever-bubbling wellspring of many others” (DeYoung, 2009). Pride, considered to be the root of all other vices, gave rise to the seven others, which in turn gave rise to other vices considered to be the fruit of these. For example, lust was understood to lead to the vices of affection for the world, blindness of mind, instability, love of oneself, haste, hatred of God, petulance, inconsiderateness and lack of self-control. Similarly, humility was considered to be the root of the virtues. From it grew the four cardinal virtues (prudence, justice, temperance and courage) and the three theological virtues (faith, hope and charity). As with the vices, these virtues were understood to give rise to virtuous fruit. For example, hope was understood to lead to the virtuous fruit of discipline, joy, patience, contemplation, contrition, confession and penitence. These lists of vices and virtues were represented in medieval art as trees.
The branches of the tree of vices hung down toward the earth, whereas the branches of the tree of virtues lifted up toward heaven. The virtues and vices were understood to be more than mere wrong or right actions. According to DeYoung (2013), they were seen as “dispositional patterns of perceiving, thinking, feeling, and responding” that represent the “cumulative ‘groove’ our actions wear in us over time.”
Figure 1.2. The Tree of Vices, from Speculum Virginum,an early thirteenth-century manuscript
Figure 1.3. The Tree of Virtues, from Speculum Virginum
Pope Gregory extended his classification of human nature beyond the vices, acknowledging that people possess different qualities of character and therefore “one and the same exhortation is not suited to all” (Gregory, 1978, p. 89). This was an important pastoral insight. He suggested that the approach of the pastor in soul care should be “adapted to the character of the hearers, so as to be suited to the individual in his respective needs, and yet never deviate from the art of general edification” (Gregory, 1978, p. 89). He proceeded to offer a classification system for understanding various polarities of character or state that ought to be taken into consideration by the pastor giving counsel or admonition. In addition to gender, age and social position, these categories included such qualities as joyful and sad, wise and dull, impudent and timid, insolent and fainthearted, impatient and patient, kindly and envious, sincere and insincere, hale and sick, fearful and impervious, taciturn and loquacious, slothful and hasty, meek and choleric, humble and haughty, obstinate and fickle, gluttonous and abstemious, generous and thieving, discordant and peacemaking. These categories evidence conditions of the soul due to sinful vices as well as conditions due to what might be called temperament.
By the end of the sixth century, Celtic writers in Ireland were producing a flow of penitential books that would govern the experience of penance and the practice of guidance. Most of these books were written by followers of Cassian or Gregory, and their influence would shape the focus of pastoral guidance throughout the medieval period of the church.
The Middle Ages brought greater emphasis on sacramentalism, though this was hardly the only development in pastoral care. Other emphases included Bernard of Clairvaux’s (1090–1153) and Hildegard of Bingen’s work in practical spirituality (Hurding, 1995). Additional developments were in the area of concern for the destitute, and perhaps Francis of Assisi is most well known for his outreach to the poor.
In the sixteenth century, Ignatius Loyola described the nature of the soul as being subject to “desolation” and said it was only through the process of “consolation” that the soul could be restored:
I call it consolation when the soul is aroused by an interior movement which causes it to be inflamed with love of its Creator and Lord, and consequently can love no created thing on the face of the earth for its own sake, but only in the creator of all things. . . . I call consolation any increase of faith, hope, and charity and any interior joy that calls and attracts to heavenly things, and to the salvation of one’s soul, inspiring it with peace and quiet in Christ our Lord.
I call desolation all that is contrary to the third rule, as darkness of the soul, turmoil of the mind, inclination to low and earthly things, restlessness resulting from many disturbances and temptations which lead to loss of faith, loss of hope, and loss of love. It is also desolation when a soul finds itself completely apathetic, tepid, sad, and separated, as it were, from its Creator and Lord. For just as consolation is contrary to desolation, so the thoughts that spring from consolation are the opposite of those that spring from desolation. (Spiritual Exercises, quoted in Oden, 1987, Vol. 4, p. 73)
Advances in pastoral theology during the Reformation were seen in the work of Martin Bucer, Martin Luther, John Calvin and many others. Protestant pastors began to offer teaching on the nature of sin and the role of the pastor in guiding souls. Perhaps the most systematic writing on pastoral care is seen among the Puritans. Interestingly, the writings of the Puritans evidenced an awareness of the distinction between spiritual and natural causes of any number of concerns. For example, natural depression, called “melancholy” in Puritan times, was understood as a condition quite apart from depression due to spiritual causes. Natural depression had no known cause, though it was presumed to be due to what we might think of as psychological causes. Puritan writers focused most of their attention on spiritual causes and cures, viewing bouts with spiritual depression as best remedied through resources available to the Christian, such as the reading of Scripture, pastoral counsel, corporate worship, prayer and the work of the Holy Spirit.
This cursory glance at the literature of the church reveals our rich heritage in soul care and the study of the human condition from both an illness and wellness perspective. From this developing classification system, pastoral theologians developed corresponding remedial and formational strategies by which pastoral caregivers might respond to those in their care.
The church’s response. At the close of New Testament times, the church faced severe persecution as it grew and began to spread throughout the world. New offices and increasing structure emerged within the church in response to its growth and the persecution it was enduring. Pastoral ministry was often centered on sustaining people within the community in the face of tremendous trial. Anticipation of the imminent return of Christ gave the community strength and hope to persevere, and this anticipation contributed to the gradual rise of the practice of confession as central to the life of the church. By the second century, standard methods for private guidance and public confession had developed within the church (Holifield, 1983). The church’s response to and remedy for the condition of sin was confession to one another (Jas 5:16; 1 Jn 1:9) and repentance (Lk 5:32; Acts 5:31; 2 Cor 7:10; 2 Pet 3:9), and these would form the foundation of the church’s response until the modern era (Benner, 1998).
All indications are that confession was public and was a central element in the regular meetings of the church. The Didache, written about one generation after the close of the New Testament, instructed the church to gather on the Lord’s Day to “confess your sins, and not approach prayer with a bad conscience” and to “break bread and give thanks, first confessing your sins so that your sacrifice may be pure” (quoted in Richardson, 1970, pp. 173, 178). Gradually, however, confession became a more private practice. In the fourth century, Basil, bishop of Caesarea, suggested that confession of sins follow the same principles associated with physical illnesses. Just as persons do not disclose their bodily infirmities to everyone but only to those skilled in their cure, so confession of sins should be made to one who is able to offer a spiritual remedy. In the fifth century, Pope Leo the Great declared it sufficient that confessions be made in secret to a priest. He felt that continuance of public confession was dangerous, that many would avoid penance if public confession was required (Kemp, 1947).
This change from public to private confession not only demonstrated movement toward the idea that value resides in individual confession of sin to a qualified caregiver but also acknowledged a growing desire for a confidential framework for confession. The second synod of Davin in Armenia ensured confidentiality by decreeing that any priest who divulged the content of a confessional should be anathema. This later became known as the Seal of the Confessional (Kemp, 1947).
With the rise of the confessional as a central focus in soul care came an emphasis on penance as part of the process of confession. This emphasis eventually was codified in the form of the “penitential” in about the sixth century. Perhaps inspired by Pope Gregory’s Pastoral Care (originally published in 591), numerous volumes appeared that functioned as handbooks for priests in their role as confessors. Whereas Pope Gregory’s work focused primarily on the qualities of pastoral leadership and the most effective ways for responding to people with various styles and temperaments, the penitentials that followed were largely composed of lists of commonly recognized sins and the penance necessary to receive forgiveness for each. In addition, they outlined methods for priests to use in receiving and dealing with penitents (McNeill & Gamer, 1938).
The penitentials were an important factor in the shift from public to private confession. Many used the metaphors, ideas and language of then-current models of medicine. For example, the Penitential of Columban from the seventh century stated:
For even the physicians of bodies prepare their medicines in various sorts. For they treat wounds in one way, fevers in another, swellings in another, bruises in another, festering sores in another, defective sight in another, fractures in another, burns in another. So therefore the spiritual physicians ought also to heal with various sorts of treatment the wounds, fevers, transgressions, sorrows, sicknesses, and infirmities of souls. (quoted in McNeill & Gamer, 1938, p. 251)
Similarly, in the eighth century a penitential attributed to the Venerable Bede suggested that a “physician of the soul” should allow for different spiritual and circumstantial conditions in the same way that a physician of the body prescribes varying remedies depending on the disease.
Though at times harsh in their instruction, the penitential authors demonstrated a “sympathetic knowledge of human nature and a desire to deliver men and women from the mental obsessions and social maladjustments caused by their misdeeds” (McNeill & Gamer, 1938, pp. 45-46). They sought to understand the conditions of sinners and the factors that might affect these conditions and the church’s response to them. The Bigotian Penitential from the eighth century suggested that the process of confession and penance should take into consideration “the age and sex of the penitent, his training, his courage, with what force he was driven to sin, with what kind of passion he was assailed, how long he continued in sin and with what sorrow and labor he was afflicted” (Kemp, 1947, p. 29).
The penitentials offered to the sinner the means of rehabilitation. He was given guidance to the way of recovering harmonious relations with the church, society and God. Freed in the process of penance from social censure, he recovers the lost personal values of which his offenses have deprived him. He can once more function as a normal person. Beyond the theological considerations, we see in the detailed prescriptions the objective of an inward moral change, the setting up of a process of character reconstruction which involves the correction of special personal defects, and the reintegration of personality. (McNeill & Gamer, 1938, p. 46)
As a group, the penitentials sought to cure souls by what they termed the “principle of contraries”: each vice must be replaced by a corresponding virtue. The theology behind them was clearly legalistic, and the penalties were often so severe as to be inhumane. Their goal, however, was to care for the spiritual health of sinners lost in their sin. The place of confession and penance in the life of the church also solidified the role of the priest as the physician of the soul.
In 1215 the Fourth Lateran Council dictated that everyone must confess their sins to their local priest at least once each year, and by the twelfth century a full sacramental theory of priestly absolution was developed. The systematized response of the church to sin and confession seemed to reach some completion in the sixteenth century with the elaboration of a complex body of casuistry—the application of general principles to particular cases—that undertook to remedy every spiritual dilemma imaginable (Holifield, 1983).
With the Reformation came a renewed emphasis on the role of the pastor as a “shepherd” in the community and a focus on mutual responsibility and care—the priesthood of all believers. The Protestant Reformers wrote that the primary role of the pastor was offering the same tender care to the flock as described by Paul in his first letter to the church in Thessalonica: “As apostles of Christ we could have been a burden to you, but we were gentle among you, like a mother caring for her little children. We loved you so much that we were delighted to share with you not only the gospel of God but our lives as well, because you had become so dear to us” (1 Thess 2:6-8 NIV 1984).
In the seventeenth century Richard Baxter wrote, “We must feel toward our people as a father toward his children; yea the tenderest love of a mother must not surpass ours” (Baxter, 1931, pp. 178-79). Baxter felt his success as a pastor was due to his efforts in pastoral care. He had a custom of family visitation and said, “I find more outward signs of success [from this ministry], than from all my public preaching to them” (Baxter, 1829, p. 80). Utilizing family visits, pastoral counsel and preaching, Baxter spoke to the spiritual condition of those under his care. Although the Puritans were known for their emphasis on theological truths, their concern was really that God work in the hearts of his people so that true faith would claim “the affections as well as the intellect” (Packer, 1990, p. 132).
Baxter’s Christian Directory (1673) is perhaps the most comprehensive and far-reaching Puritan work on pastoral care. It was written for pastors who were younger and less experienced in “practical divinity.” The Puritans viewed people as spiritually sick, and their remedy was to bring about healing:
Truth obeyed, said the Puritans, will heal. The word fits, because we are all spiritually sick—sick through sin, which is a wasting and killing disease of the heart. The unconverted are sick unto death; those who have come to know Christ and been born again continue sick, but they are gradually getting better as the work of grace goes on in their lives. The church, however, is a hospital in which nobody is completely well, and anyone can relapse at any time. (Packer, 1990, p. 65)
Emphasis was placed on self-examination so that pastors could accurately diagnose spiritual disease and offer biblical remedies. Biblical remedies were expositions of Scripture directed to the conscience through the conviction of the Holy Spirit.
Thomas Oden, in his four-volume anthology Classical Pastoral Care, identified five recurring themes in the literature of pastoral care that he contended describe the historical view of the church on the nature of effective soul care. These themes bear a striking similarity to the findings of contemporary psychological research on effective therapeutic relationships. They include “(1) accurate empathic listening; (2) congruent, open awareness of one’s own experiencing process, trusting one’s own soul, one’s own most inward experiencing, enabling full self-disclosure; (3) unconditional accepting love; (4) rigorous self-examination; and (5) narrative comic insight” (Oden, 1987, Vol. 3, p. 7). The following examples highlight the wise counsel of pastoral theologians who recognized that the relationship between the shepherd or physician of souls and the one receiving care was central to effective pastoral care.
Catherine of Siena, a fourteenth-century Italian mystic who devoted her life to care for the poor and sick, wrote about empathy in pastoral care:
They made themselves infirm with those who were infirm, so that they might not be overcome with despair, and to give them more courage in exposing their infirmity, they would ofttimes lend countenance to their infirmity and say, “I, too, am infirm with thee”! They wept with those who wept, and rejoiced with those who rejoiced; and thus sweetly they knew to give every one his nourishment, preserving the good and rejoicing in their virtues, not being gnawed by envy, but expanded with the broadness of love for their neighbours, and those under them. They drew the imperfect ones out of imperfection, themselves becoming imperfect and infirm with them, as I told thee, with true and holy compassion, and correcting them and giving them penance for the sins they committed—they through love endured their penance together with them. For through love, they who gave the penance, bore more pain than they who received it. (A Treatise of Prayer, quoted in Oden, 1987, Vol. 3, pp. 8-9)
Ambrose, bishop of Milan in the fourth century, wrote in his work Duties of the Clergy about the need for those who care for souls to know themselves: “Blessed, plainly is that life which is not valued at the estimation of outsiders, but is known, as judge of itself, by its own inner feelings” (quoted in Oden, 1987, Vol. 3, p. 19). The apostle Peter reveals that if we love one another deeply, such love “covers over a multitude of sins” we may commit against each other (1 Pet 4:8). Thomas Aquinas in the thirteenth century offered similar words to those who care for souls: “When the people see that you unfeignedly love them, they will hear any thing and bear any thing from you. . . . We ourselves will take all things well from one that we know entirely loves us” (Commentary on Sentences, quoted in Oden, 1987, Vol. 3, pp. 8-9).
In the eleventh century, the Benedictine abbot William of St. Thierry wrote about the importance of examining oneself rigorously to know the motives of the heart and the actions that follow:
To try to escape ill-health of the soul by moving from place to place is like flying from one’s own shadow. Such a man as flies from himself carries himself with him. He changes his place, but not his soul. He finds himself the same everywhere he is, except that the constant moving itself makes him worse, just as a sick man is harmed by jolting when he is carried about. (The Golden Epistle, quoted in Oden, 1987, Vol. 3, p. 42)
George Herbert, a sixteenth-century Anglican pastor, addressed the need for some humor and “pleasantness of disposition” in the ministry of caring for the souls of others. He contended that “instructions seasoned with pleasantness both enter sooner and root deeper” (The Country Parson, quoted in Oden, 1987, Vol. 3, p. 47).
Throughout all of these we see evidence of a compassionate response of soul care physicians to the specific needs of people, with keen awareness of the nature of their sin and suffering.
Throughout Christian history the church has been dedicated to the care of souls; these efforts have been undergirded by the basic understanding that sin is the cause of human suffering and dysfunction and that the remedy can be found only in a compassionate pastoral response to the realities of both sin and pain. And, as we have already stated, pastoral care within the church has always utilized and benefited from existing understandings of the nature of humanity and the soul (what could be called “psychopathologies” of the day) and existing models of caring (what could be called “psychotherapies” of the day).
This is evident in the literature of the pastoral writers right up to the twentieth century. In his 1918 book The Disease and Remedy of Sin, W. M. MacKay described three categories of diseases of the soul—diseases of the flesh, diseases of the heart and diseases of the spirit—and their remedies in metaphoric language drawn from then-current concepts of medicine and psychology. In the preface, he explains his purpose this way:
It is the aim of these pages to show that true religion, so far from being apart from real life, is the very essence of it; that its truths are the laws of Spiritual Health, and that, far from being a dispensable luxury, they are more necessary than the bread we eat or the air we breathe. With this end, the various experiences of the soul in health and disease have been examined from a medical point of view. This volume therefore may be described as an Essay in the Psychology of Sin and Salvation from a medicinal standpoint. Christianity is everywhere regarded as the care and cure of spiritual disease. The prevalent category of thought is “spiritual health”: the commanding goal is “eternal life.” (MacKay, 1918, p. vii)
Nevertheless, the distinctly Christian nature of such understandings of the human condition and corresponding remedies for sin and suffering have been challenged in the twentieth and twenty-first centuries by the rise of contemporary psychopathology and psychotherapy. As a result, the current state of the pastoral care ministry of the church and its relation to contemporary models stemming from the mental health field is unclear.
CONTEMPORARY PASTORAL CARE
What curious fate has befallen the classical tradition of pastoral care in the last five decades? It has been steadily accommodated to a series of psychotherapies. It has fallen deeply into a state of amnesia toward its own classical pastoral past, into a vague absent-mindedness about the great figures of this distinguished tradition, and into what can only generously be called a growing ignorance of classical pastoral care. (Oden, 1984, p. 2)
The emergence of modern psychopathology and psychotherapy, rooted in materialistic ideologies and intent on disavowing religious or supernatural worldviews, offered a more “scientific” approach to understanding human suffering and its remedy. Distinctly Christian pastoral models began to fall into the background as the church slowly became fascinated with this “new” field of study. Clebsch and Jaekle contended that the presence and prominence of modern psychology in our culture silenced the church and produced a fundamental rift in the once vital ministry of the cure of souls (1964). Thomas Oden echoed this when he wrote:
What happened after 1920? It was as if a slow pendulum gradually reversed its direction and began to swing headlong toward modern psychological accommodation. . . . Pastoral care soon acquired a consuming interest in psychoanalysis, psychopathology, clinical methods of treatment, and in the whole string of therapeutic approaches that were to follow Freud. . . . Classical pastoral wisdom fell into a deep sleep. (1988, pp. 22-23)
