On the nature of arguments for mental illness:
Dr. Terrell is Assistant Professor of Family Medicine at the McLeod Regional Medical Center in Florence, S.C.
"The brain you stole from my laboratory was a criminal brain."
[from Frankenstein (the movie)]
In this issue Dr. Andy White discusses mental illness, taking a positive view that the term is valid, covering a spectrum from those which primarily originate in the physical body to those which arise primarily in the human spirit. Whereas his article begins with a creditable review of the tripartite vs. bipartite issue, the remainder of it calls for considerable correction. An underlying issue is that of human responsibility. Dr. White takes nouthetic counseling to task for relating virtually every counseling issue to sinful behavior. Such treatment, he indicates, practically omits the possibility that the counselee could, in fact, be victimized by someone else's sin or by bodily illness. Jay Adams and other nouthetic counselors are charged with an overemphasis on the "sinful agency" of counselees and with minimizing the fact that humans are also the victims of the sinful agency of others.
I would like to begin by highlighting one distinction implied by Dr. White followed by critique of his argument, an alternative to it and, finally, a prediction of the results of following his reasoning.
First, a distinction must be recognized between that which a person experiences, including his subjective experiences, and that for which a person is responsible. We are not responsible for all of our experiences. The literature of nouthetic counseling teaches that we are accountable for our thoughts and actions. Our actions often determine our experiences, but not always. A person may be held accountable by a counselor or physician for his behavior, but not for the feelings he experiences.
It may seem that a counselor is holding a person accountable for his feelings when he connects a counselee's feeling state with certain behaviors, but it is the behavior which must be the issue on which the change is focused. Some nouthetic counselors may not make the distinction plainly enough; none should require a counselee to repent of acts committed against him, nor to repent of feelings. Dr. White presents no evidence against that school of counseling that these errors have been taught by it or widely practiced in it.
A person's subjective experience of anger may be his response to something someone else did, or it may be the result of a mess he has created for himself. In either case the person may "be angry and sin not." Or, a person may be angry and behave sinfully in that anger. Someone may feel blue or dispirited because of things that have happened to him, including bodily disease, known or unknown. Or, the feelings may arise because of something he has done wilfully, or because he knows he has responded sinfully to wrongs against him. That person may be depressed and not sin in how he acts during his depressed state. Or, the person may behave sinfully in the midst of his depression. A person may feel panicky, and respond sinfully or righteously.
The origin of the anger, depression or panic is a separable issue from the way the person manages them. Such inner feelings as these may arise from behaviors for which the person experiencing them is culpable, or they might not. If the person is culpable in the origin of the situation which provoked the anger, then the logical remedy is counsel for the situation, not chemicals for the body. If the person is innocent of the origin of the unhappy situation, he is still accountable for the way he manages his behavior while experiencing the feelings.
Sometimes my patients request tranquilizers to reduce feelings of anxiety when that anxiety is, in their opinion and mine, engendered by a situation of chronically disturbed interpersonal relationships. My approach is to point out that it is inconsistent to use chemicals to change a body which is merely responding normally. It is the situation which is abnormal and which needs to be normalized. The body is not the problem. The solution is to be found in straightening out the problematic relationship. It is recognized that the person may, through no fault of his own, be unable to normalize the relationship. However, insofar as it lies with him, he should do so (Cf. Romans 12:18).
Secondly, Dr. White must be corrected in his epistemology. What is the method, or methods, by which physicians and counselors may know anything about the non-material aspects of those who seek their help? Second Timothy 3:15 - 17, reads in part, "All Scripture is given by inspiration of God, and is profitable for doctrine, for reproof, for correction, for instruction in righteousness, that the man of God may be complete, thoroughly equipped for every good work." Righteousness is a spiritual issue. Reproof is for the spirit. If a matter is in the spirit, then the method for knowing how to tackle it can only come from God's revelation in Scripture.
Sciences based on empirical observations of the natural world are by definition excluded from having any say whatsoever about the things of the spirit (the non-material). Our bodies are part of the physical world. To the extent that psychology, as an empirical science, does not deal with the physical body, its epistemology is no longer empirical but theological. To the extent that psychiatry attempts to deal with the non-material aspects of a person, it, too, is theology. On what ground do these professions stand to help us understand anything about the nature of the human spirit? If they have systematic observations and conclusions about the human physiology as it relates to special functions of the nervous system, they can offer something of value. In so doing, however, they are not truly psychology or psychiatry but a section of physiology. In matters of the mind they cannot use the methodology of the natural sciences. If they want to speak to the metaphysical issues of human nature they are engaged in philosophy or in doctrines of theology. Honest psychologists should turn their collars around backwards to indicate to the world what their calling is. They should also turn their epistemology around so that it leaves any pretense at a base in natural science and focuses on the Bible's revelation to us of the nature of our spirit.
Introspection is the examination of one's own thoughts, which does not include revelation of them. The counsellee's verbalization of his thought as a means of knowing about the spirit cannot be validated. Even if it could be validated, our experiences are not normative for right behavior. Our method of knowing about the culpability of ourselves and the persons we deal with, therefore, is by comparing behavior to Scripture. Rather than being normative, our own experiences are brought to Scripture for examination and judgment. That includes the experiences we have as physicians with our patients as well as the collective reports of experiences gathered and sifted by psychology and psychiatry.
One simply cannot judge the issue of the existence or non-existence of an illness of the mind, which is a spiritual entity, by citing, as Dr. White does, "My experience ... has taught me..." It is a metaphysical issue. Right knowledge of the issue must stand on normative revelational information, not something decided on the basis of one's experience. To allow anyone's experience into the argument as a basis for a decision on the existence of mental illness circumvents a root issue. Our own introspections and our inferences from the behavior of others are full of error. As a means of "general revelation" they are not a judge of Scripture.
A "general revelation" which supersedes special revelation in Scripture is not a general revelation, but a general misconception. If the "general revelation" of our experience tells us that we are not responsible for our moral behavior, then we are under a general misconception, for Scripture indicates that we are accountable. It follows that what we would be calling "general revelation" is not a revelation at all. If our experience tells us that a feeling we experience is not under our direct control, then we may be correct. We remain accountable, however, for how we behave in our feeling state. A general misconception rampant in the nation, fostered heavily by the medical profession, is that the empirical methodology of the medical sciences may apply to the non-material aspect of human beings. We are trying to make metaphysics obey physics!
We sometimes speak of our feelings as if they were irresistible juggernauts, pushing aside our will and causing us to behave in this or that fashion. "She made me so angry that I just had to tell her off." "This whole affair has gotten me down so much that I couldn't follow through with it, even though I had said I would." Such is careless talk, not biblical talk. It is granted that feelings can be very powerful, but to denigrate the position of the will to the role of victim is to treat persons in a way the Scripture does not allow. Physicians or counselors may legitimately discuss feelings and how they may be controlled, may infer, discuss, and admonish regarding underlying attitudes, but may only make decisions on overt behaviors, including speech. God alone is lord in the privacy of one's conscience.
Re-dissecting a case history
Dr. White cites an illustrative case from his practice, showing how, in his opinion, a nouthetic counselor missed the diagnosis of agitated depression with panic disorder and unsuccessfully treated a counselee for "sinful defensive responses" instead. He asks the rhetorical question, "What is considered the right response to being sexually molested at a tender age by someone who is supposed to love and care for you - someone who is supposed to show you by example something of what God is like, i.e., Father?"
The operative phrase here is "sinful defensive responses." We are not told what the woman was actually doing. For Dr. White's critique to be valid, it must be that he does not actually believe that the woman was engaged in anything sinful. For, if she was engaged in sin, he has proposed that: (1) she had nothing to repent of, only the father had and, (2) he fixed it instead with antidepressant medication, which of course is no remedy for sin. If she was not engaged in "sinful defensive responses", then there is a valid critique if a counselor was selling sin as an interpretation of her behavior where there was no sin. Without describing the behavior the counselor was addressing, we can make no fair judgment of the aptness of his example. Biblical counseling, while recognizing the awful situations people may be caught in even as victims, examines the situation and the behavior of the woman in the light of Scripture - what does God require of her - to determine whether or not there is sin.
What is not determinative of whether or not she is engaged in sin is the consequence of her counseling. That she "improved promptly and has not relapsed" is no proof that the counselor was wrong and Dr. White correct. Both, or neither, may have been correct. The woman may have been engaged in sinful behaviors and have had a bodily illness causing feelings she did not like. The former may respond to biblical counsel and the latter may change with the administration of chemicals. He seems to admit that the counselor had a point, then he retreats from that admission to point out that the counsel did not relieve her. Further, Dr. White did not certainly indicate that the lady actually followed the biblical counsel she received.
Again, it is key that we are not told exactly what "it" was for which she received relief through chemicals. He has used medical terminology to name whatever "it" was - "mental illness," "agitated depression," "panic disorder," "patient." That usage begs the question of illness vs. sin. The counselor presumably used words relating to sin and responsibility. Does the outcome determine whose terminology was correct? To determine that it does is to submit the definition of sin to empirical observation. That is, if one applies the "treatment" for sin and there is no desirable response, it must be concluded that there was no sin. Don't tell Isaiah! Contrarily, if one applies chemicals and the person is relieved, it must be concluded that a chemical issue was primarily the problem, not sin. From the invention of heroin to methadone, we have tried that reasoning on opiate abusers with no success. From the data given, one could conclude, if one did not know Dr. White's character, that he was just a "Dr. Feelgood," who prescribes chemicals to produce good feelings without due regard for identifying and rectifying the actual problem. Instead, one must conclude that he has lapsed unwittingly into a pragmatic definition of sin -- if medical therapy "works" it must be our guide to truth.
Did the woman have bad feelings only - something entirely subjective? It is not a sin to feel bad, even to feel very bad for a very long period of time. There is nothing in principle which would preclude the use of chemicals to relieve such. Physicians have done it for millennia, even when we do not know how the chemicals work, though with a due consideration for the known risks and benefits. Did the woman exhibit bad behavior? Alteration of that with chemicals a dehumanizing manipulation of persons.
Dr. White has an excellent point in his assertion that the "neurochemical component of the dysfunction might have become the primary dysfunction, even though it was not the cause of the dysfunction." Though the use of the word "dysfunction" indicates that we are in the realm of speculation, it is definite that the central nervous system is the one system of the human body that is designed to be plastic. It is designed to be changed by our experiences. It may be molded by willful experiences we create for ourselves, both good and bad, and it may be molded by experiences created for us by others, good and bad. It seems likely that the "molding" would be in the form of chemical changes. Once the chemicals are changed, there is the option of chemical intervention. That the chemical change might have been wrought by sin would not mean that the option of chemical treatment is voided. Physicians routinely and properly treat persons chemically whose bodies bear changes wrought by sin. We treat cirrhosis of the liver wrought by alcohol, seizure disorders from head injuries earned by fractious behavior, and emphysema brought on by smoking.
It is reasonable to further suppose that the changes in the central nervous system may constitute a "pull" from our body toward something evil or toward something good through the medium of what we call "habit." For example, a central nervous system engram established by habitual lying might constitute an internal enticement to repeat the behavior. The person with such an (in this case self-created) experience might describe the powerful feelings which are now being labeled "addiction." It is biblically essential, however, to comprehend the effect of the central nervous system as an enticement, not a cause of behavior. To suppose that any part of the body becomes a cause of behavior is to remove that behavior from the province of reproof and correction. It is to make "the word of God of no effect." [Mark 7:13] In a section detailing some objections to the Pelagian view of sin, Louis Berkhof states, "It is an undeniable fact that, as a man increases in sin, his ability to do good decreases. He becomes in an ever greater measure the slave of sin. According to the theory [of Pelagianism] under consideration this would also involve a lessening of his responsibility. But this is equivalent to saying that sin itself gradually redeems its victims by relieving them of their responsibility. The more sinful a man, the less responsible he is. Against this position conscience registers a loud protest. Paul does not say that the hardened sinners, which he describes in Romans 1:18 - 32 were virtually without responsibility, but regards them as worthy of death." If you wish to get away with murder in the United States today, do not murder your intended victim only, but several others. You will be adjudged mentally ill. Along with his concern that we not illegitimately further damage a suffering person with counseling, Dr. White needs to show us how to stay clear of this hazard.
The body as musical instrument
Jay Adams has likened the physical body to a musical instrument which is played by the spirit. Work on that image for a while. That is a decidedly different concept than Dr. White's image of the body causing a spiritual dysfunction. If morally significant behaviors are an issue, just what is in charge? The body or the spirit? Can the body "play" the spirit? Does a musical instrument play a musician, or vice versa?
There is no reason to suppose that we would all have exactly the same type or quality of instrument. Some are athletic. Some have poor eyesight. Some are subject to seizures. Some have excellent memories. In every case, the body would limit what music we can play. We are created finite beings and are, furthermore, fallen in Adam and under a curse. There is no reason to exempt the central nervous system from the effects of the curse. Due to the effects of the fall some of us may be born with a genetic tendency to be more or less subject to certain elements of our environment -- sexual lusts or alcohol or what have you. God does, nonetheless, hold us all accountable to obey Him in our wills.
In addition to the siren call to sin which may be inborn through genetic defects, our bodily musical instrument may acquire damages through victimization by others or through our own misuse of it. While it would be foolish to deny the damage wrought by victimization, the will may be still held accountable to make the best "music" possible with the damaged instrument.
There is a valid issue here for medicine. It is our job to discover the hidden defects which account for disabilities. We must do our job carefully, however. It will not do to push aside biblical admonitions and encouragements used in counseling as inappropriate based merely upon speculations as to the presence of an illness. The empiricism of medicine is a clumsy tool to stir the hermeneutic pot. There is a great difficulty in understanding the contribution of the body and the spirit in our feeling state. Dr. White's attempt at explaining it via a "unity of duality" hopelessly fogs the issue of accountability. The contribution of the medical profession most needed is progress in producing material pathology, not in pharmacologic manipulation of feeling states. Biblical counselors, likewise, need to recollect that patients do have bodies, that bodies do get sick, that the sicknesses represent temptations to disobedience, and that by no means all sicknesses are known.
The Journal of Pastoral Practice is a publication of the Christian Counseling and Educational Foundation which accurately reflects the position of nouthetic counseling. For years, that journal has run a medical article in every issue in order to alert counselors to organic problems they must know about in order to refer to a medical doctor. That Dr. Adams does not deal extensively with bodily illness in many of his books is simply that it is not his subject matter. One finds more attention to organic illness in nouthetic literature than one finds attention to spiritual issues in psychiatric literature.
Where we are going if we don't resolve the issue
Christians who believe with Dr. White that the mind can be ill have a responsibility to show how we maintain accountability before God, if our behaviors can be attributed to the illness. Illness is a result of our sin nature, if not always of our particular sins. As a consequence, it is not ever itself sin. Since illness is not sin, it is under no condemnation and we are not accountable to God for it. If there is no sin, then we have no need of repentance, confession and restitution. To the extent that we can transform our outwardly sinful behaviors into victimizations by others, to that extent we have no need of a Savior.
As a nation we are far from a hamartiology which is unbalanced in the direction of overemphasizing sin. Instead, we are far down the path of removing our sense of sin and responsibility. The contrast that nouthetic counseling offers to our culture's position creates the sense of imbalance only for someone who has been shifted from a biblical sense of the pervasiveness of sin toward our culture's therapeutic society. For we are all now simply victims, right back to Adam, who, if he joined our modern chorus, might say that he merely suffered an attack of fruit-lust, or that he was afflicted with a bad case of oversusceptibility to his wife's suggestions.
While granting that it is a complex issue, the dangers of the route are so clear that we must have clear discriminators from those who would have us believe that morally significant behaviors can be caused by diseases. We are already overdue for guidelines. The plague of attributing everything to addictions is well-advanced in the nation, excusing as illness everything from lying to adultery and is inside the Church with excuses for sins only slightly less obviously sinful.
A recent article in JAMA illustrates the pathway down which otherwise intelligent individuals are taking us medically. Reflecting on the interaction of psychiatry with the recent federal Americans With Disabilities Act, Dr. David Orentlicher, of the Ethics and Health Policy Counsel of the American Medical Association, opined that the noncompliant patient has a much broader scope for his noncompliance. Nonetheless, he continued, a noncompliant patient may retain his right to treatment on the grounds that his noncompliant behavior is part of his illness or is an illness in itself. After recounting some details of the persistent and flamboyant misbehavior of a couple of dialysis patients who disrupted their dialysis clinics, he states, "Dialysis patients are at substantially increased risk for depression, and they commit suicide at a rate more than 100 times that of healthy individuals. ... Psychiatric complications of dialysis are not surprising. Hemodialysis results in profound disruptions of the patient's life. The need for dialysis three times a week, 4 hours per session, can seriously compromise patient independence. In particular, it is difficult for dialysis patients to maintain gainful employment or to travel. In one study, only about half of the patients undergoing hemodialysis were able to work full-time or part-time. The strict dietary restrictions imposed to prevent fluid overload and electrolyte abnormalities are also burdensome. Dialysis patients typically respond to the psychological stresses of their disease and its treatment with the coping mechanisms of denial. Too much denial by a patient of his or her condition may cause rejection of therapeutic recommendations..."
Thus, a psychological defense mechanism called denial is raised to the status of a disease. By that elevation, a person is empowered by civil government to abuse the staff of a dialysis clinic routinely for years and commit other sinful acts, for it is not sin; it is a severe case of denial.
In the JAMA article we can see the implicit belief that a patient is a pawn of his/her condition, merely reacting mechanistically to environment through psychological mechanisms. The patient is unable to act by responsible choice. Further, there is the common circular reasoning employed in psychology. One knows that the patient has a psychological condition because of one's behavior. The behavior defines the condition. That task accomplished, the defined condition then is used to explain, or, in this case, excuse the behavior. The excuse of the irresponsible behavior is not by reference to an objective standard of proper vs. improper behavior, such as the Bible. It is an excuse by definition that such behavior should be excusable.
"If a patient's noncompliance reflects psychiatric dysfunction, then a denial of treatment because of noncompliance would in effect be a denial of treatment based on a psychological disorder. Under the Disabilities Act, such a denial apparently would be prohibited."
"Trying to provide care for a noncompliant patient can be exceedingly frustrating for physicians, and the patients need to be held accountable for their actions. At the same time, it would be problematic if physicians provided care only to patients who were easy to care for, especially since the most difficult patients may not be capable of exercising sufficient control over their behavior."
Here is the nub of the issue. It seems that those patients who exercise the least control over their behavior are exactly those who are decided, on that basis, not to be capable of controlling their behavior. If there is no physical pathology which can be reasonably implicated in explanation of their incapacity, then the presumption should be that the patient can indeed control his behavior. To do otherwise is to undercut the whole idea of responsibility.
A medical profession which departs from a line of evidential reasoning, has entered into the metaphysical, and has abandoned its particular expertise. It is part of the general office of believer for Christian physicians to do so, since to fail to do so is to treat people as mere mechanism. However, the physician must abandon the methodology of natural science and the trappings of authority which derive from that source in our society. He must utilize revelational data, and use it correctly.
There are a number of other corrections Dr. White's article calls for, such as his misrepresentation of Jay Adams' handling of the issue of organic illness (see Competent to Counsel, pp. 36 - 40) and the implication that nouthetic counseling extensively utilizes demonic explanations. While one appreciates the attempt to solve a knotty issue, his attempt to help by emphasizing the unity misfires. The Bible clearly identifies two parts in our being. That in medical or counseling practice it is not at all easy to separate the contributions of the two into the parts to be dealt with by two professions, does not justify the creation of a functionally new part. Neither does it permit the retreat from responsibility.
Should the foregoing arguments fail to dislodge Dr. White from his position, however, there may be a simple way to move him. We just do it the way he has managed the subject -- by definition. We need only define the practice of nouthetic counseling as itself a mental illness which renders the counselors so dysfunctional they cannot comprehend the obvious reality of mental illness. We know nouthetic counselors have the disorder because they do not accept mental illness as more than a metaphor, though nearly everyone else (the normative group) does. Therefore, we know they are sick. As mentally ill people we must see them as in need of medicine, not of condemnation or counsel. Applied thus to nouthetic counseling, Dr. White's argument could appear to be an attempt to counsel nouthetic counselors out of their disease, the very thing he is cautioning us in general against, lest we heap more difficulties on the heads of those who are suffering mental illness.
1. One needs to escape the mode of rhetorical questioning in which this is cast. One could ask if Dr. White believes there is no biblical answer to his question. If a molested girl were to ask, "How am I supposed to act?" must the Christian remain mute? Is the incestuous rape of children too hard for our God? Has He nothing to say? Where Dr. White did not choose to tread, let me dare the following partial and idealized answer: For all victims of rape the answer must include removal from the offender. For very young girls, that and locating a home with proper models may be all the specific answer they can absorb until later. While it may be that the child would experience disturbing and powerful feelings regarding the incident, and that these feelings might beckon her toward misbehavior, the child should not be indulged in misbehavior under the excuse that "she can't help it, poor thing." At an appropriate age, the offended person may be taught the gospel, including the sinful nature of mankind and our accountability before God. An important and neglected feature of the management of such hard cases is the didactic function of discipline. The church needs to discipline members who so victimize others, and the victim needs to be aware of it. So also the civil government should punish evildoers, and the victim and society at large needs to be aware of it. Psychiatrist Karl Menninger wrongly disparaged criminal punishment as a "morality play" in Whatever Became of Sin? Individually and corporately, we sorely need the teaching.
2. Use of the unqualified term "dysfunction" is a problem. Not functioning well for what purpose? Jay Adams' emphasis in depression is the sinful disregard of duties. There is a "dysfunction," for sure, but it is related to the functions God requires of the counselee in his/her situation. The functions he would see people fulfill are Biblically-defined. Medically, the same failure to do certain duties are transmogrified into "dysfunctions" with no specific normative reference function. If the failure to function is a failure in a legitimate duty, it is dangerous to excuse it on the basis of a bodily dysfunction with no proven lesion. It is doubly a problem to import medical terminology into the spirit and state that there is a "dysfunction" where moments before there was a sin. The same would apply to the multifarious uses of the term "disorder." One of the problems of psychiatry and psychology is that they each deal with "pathology" which is defined almost entirely by behaviors. There is no autopsy possible for the items in the DSM-IIIR. In a manner analagous to a Chinese restaurant menu, the diagnosis is established by two behaviors from list B and 3 from list A. The behavior is the only objective reality available to these professions. One result is that the taxonomy is churned more often than in other branches of medicine. A worse problem is that these professions first define their pathology behaviorally, then use their pathology to explain the behavior. It is a circular endeavor. At best they can state that they have delineated clusters of behaviors which predict that other behaviors are likely to accompany. A layman of equal intelligence and experience with people can do as good a job of such predictions as the professionals. The escape route is available if they would accept the "autopsy" of the human spirit laid out in Scripture and the taxonomy of sin and righteousness.
3. There are bare "behaviors" which do not require a mental participation. They are all on the order of reflexes, such as the startle reflex, or of stereotypical and very simple sequences, such as in temporal lobe epilepsy. These things the body can indeed cause, without mental input. They are virtually never at issue in assessing a person's accountability.
4. Berkhof, Louis, Systematic Theology, William B. Eerdmans Co., Grand Rapids, MI, 1941, p. 234.
5. That the will is also fallen is beyond the scope of this article to address. It is enough to demonstrate that the will is not in the body, to make the point. As example, it is conceivable that a criminal's brain might contain certain limitations which constituted a temptation to him, but it would never make him into a sinner.
6. Terrell, Hilton P. "A Caution Against Overstating a Case", Journal of Pastoral Practice, Vol. IX, No. 4, 1989, pp. 39 - 43.
7. Orentlicher, David, M.D., Denying Treatment to the Noncompliant Patient, JAMA, March 27, 1991, Vol. 265, No. 12, pp. 1579 - 1582. p. 1580.
8. What such reasoning does for all the responsible patients undergoing hemodialysis is also interesting. By the same reasoning, their behavior is merely their reaction to the powerful situational factors, based upon their genetics and prior conditioning. They are no more responsible for their compliant behavior than the noncompliant are for theirs.
9. Orentlicher, op. cit., pp. 1580 - 1581.
10. Ibid, p. 1582.
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