The more I have worked on the topic I was asked assigned, the more I become convinced of the old adage that ‘fools rush in where angels fear to tread.’ The amount of material as well as the diversity of opinion and criticism on the subject of ‘mental illness’, or, as others prefer, ‘mental health’ – is enormous!

Where to Start?⤒🔗

Let’s jump in at the deep end so to speak with a case study. I want to explore what happens and what confronts you if you or a member of your family experience the condition broadly known as depression.

What are we talking about? Here is what Gary R. Collins¹ (a prominent Christian psychologist in the USA) tells his readers about it:

Depression (previously called ‘melancholia’) has been recognised as a common problem for more than 3,000 years. It is a worldwide phenomenon that affects individuals of all ages (including infancy), appears to be increasing among teenagers and young adults, and disrupts the lives of an estimated 30 to 40 million people in the Unites States alone. (Newsweek, May 4 1987) Some of history’s greatest military leaders, statesmen, musicians, scientists, and theologians have been its victims, but depression is no respecter of persons. It is known as the “common cold” of mental disorders and has been called “the most widespread, serious, and costly psychiatric disease afflicting humankind today.” On occasion almost all of us experience depression, sometimes when we least expect it. In its milder forms depression may come as a passing period of sadness that follows a personal disappointment. More severe depression may overwhelm its victims with feelings of despair, fear, exhaustion, immobilizing apathy, hopelessness and inner desperation. Collins, p 105

A Sense of Familiarity?←⤒🔗

Whilst more than willing to take issue with Collins on many of the ideas and presuppositions embedded in this statement, most of us here will, from experience, know and feel a degree of familiarity with the general condition he is describing.

Let me quote the next paragraph as well. Here he describes the symptoms.

Probably no two people experience this common condition in the same way. The word 'depression' covers a wide variety of symptoms that differ in severity, frequency, duration and origin. The signs of depression may include

• sadness, often accompanied by pessimism and hopelessness;
   
• apathy and inertia that makes it difficult to “get going” or face decisions;
   
• general fatigue, along with loss of energy and a lack of interest in work, sex, religion, hobbies, or other activities;
   
• low self-esteem, frequently accompanied by self-criticism and feelings of guilt, shame, worthlessness and helplessness;
   
• loss of spontaneity;
   
• insomnia and difficulties in concentration;
   
• loss of appetite.

To make sure that both ends are fully covered, Collins adds:

In what is sometimes known as masked depression, the person has many of the above symptoms but denies that he or she feels sad. The alert counsellor may suspect that depression is present even behind a smiling countenance. In many cases the symptoms of depression hide anger that has not been expressed, sometimes isn’t recognised and, according to one traditional theory, is often directed inward against oneself.Collins 105

How many of you recognised yourself in the picture just presented? May I suggest that those of you who say, ‘not me’ are definitely afflicted by ‘masked depression’ or are just plain chronic, pathological liars?² You may also note that, if I were a psychologist – a Christian one to boot – I have just established a nice new clientele whom I will see a bargain-base rates: $60.00 per hour – much less than half of the going rate for a good psychiatrist!

A (Simplistic) Survey of the Current Situation←⤒🔗

OK, enough of that. Time to get serious – if only because there is a more than serious side or dimension to depression and a number of other conditions commonly described in popular language as ‘mental illnesses’ or disorders.

Collins points out that ‘the word “depression” covers a wide variety of symptoms that differ in severity, frequency, duration and origin.’

Suppose that someone feels sufficiently ‘down’ and unable to find a way ‘out’ of what seems to be a deep ‘hole’ and that this person needs help. Where to turn?

A number of possibilities and alternatives present themselves at this point. Who does such a person turn to for help? A doctor? Psychiatrist? Psychologist? A good friend? Minister? Elder?

For the sake of exploring the possibilities, let us follow the route that is most likely to be taken by this person and his or her family.

The first and most common port of call will be your the local GP, usually the family doctor who, more likely than not, knows something of your history. You trust your doctor. Her/his area of training and expertise is in looking for things physical or organic. Therefore, after explaining ‘symptoms’ (‘I’m feeling really tired, worn out, lack of zip’ ... etc, etc) the doctor will, as he chats with you, look for organic causes and explanations: Brain damage (‘have you had your head knocked around lately?’), the condition of the thyroid, post-natal hormonal aspects, menstrual problems or whatever. What he is doing is looking for a causal link between depression and something physical (organic). Should he find that causal link (or think he may have found it) he will treat prescribe a course of treatment for this – e.g. medication to restore hormonal levels – and expect the mood patterns of the sufferer to return to a more ‘normal’ level as a result. Note that the emphasis and primary focus here in identifying a physical or organic cause.³ Because of his training and focus, the doctor is very unlikely to delve too deeply into non-organic causes of your feelings especially if your condition is reckoned by him to be severe or complex. That’s another speciality. Furthermore, he is even more unlikely to probe the spiritual realm! That’s none of his business. He draws the line carefully!!

Where the Specialist Comes In←⤒🔗

Suppose that the GP fails to find a satisfactory organic cause or explanation of the reported depression and that, as time progresses, the condition remains constant and/or even worsens. The word ‘chronic’ begins to loom large. At this point a specialist will be considered – more likely than not a psychiatrist. The psychiatrist has had initial general training in medicine but has, in an intensive and extensive post-graduate programme, focussed on ‘mental’ or ‘mind’ disorders/dysfunctions, especially (though by no means exclusively!) on what is (and has) gone on within the individual. The psychiatrist examines depression from an angle that places special emphasis to the ‘mental’ (or cognitive) processes as a possible explanation of the cause of the depression.

What is the psychiatrist looking for? I asked my sister-in-law, a senior psychiatrist in South Australia, what it is a psychiatrist deals with. What is ‘mental illness’? She pointed out that a mental disorder (a term she prefers) is ‘a clinical(ly) significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering, death, pain, disability or an important loss of freedom.’⁴

Looking a Bit Further←⤒🔗

Let me attempt to clarify and interact with this description somewhat. In doing so I want to highlight the areas that give rise to concern and criticism.

As a mental disorder, ‘depression’ manifests itself as a ‘behavioural or psychological syndrome’. In other words, it is identified by what a person is doing (or fails to do) and feeling. No obvious organic causes (past or present) have been established. The likelihood is that there may not be. (That is not to say that the psychiatric diagnosis excludes the possibility.) Because there is often no obvious or clear organic cause/explanation the diagnosis is forever open to criticism and abuse. There is no diseased organ offered as proof of the condition. Therefore what do you treat? Are you able to treat anything at all?

Note the use of the word ‘significant’ used in the diagnosing the condition. What is not altogether clear is when ‘significant’ is just that and by what criteria this is measured. It is here that there is lots of room for dispute between psychiatrists themselves. Think for example of what goes on in courtrooms in deciding on whether or not a person is deemed fit to plea. Psychiatrist vs psychiatrist! (See John Grisham’s novel The Testament! 1999 as an example of what can happen in a courtroom.) This, when reported, causes the lay community to view psychiatrists with raised eyebrows. It is unavoidable that a subjective element that has little to do with science will, at some point enter into the picture. After all, it is the psychiatrist who decides on what is ‘significant’ and what is not.⁵

Thirdly, the focus is on what the individual reports. To a large extent the psychiatrist will have no choice but to trust in or somehow assess the reliability of the patient. It is at this level that ‘duping’ becomes a real possibility. When a psychiatrist is duped (and that happens!), you can imagine what this does for the critics.

Fourth, note the potential of the expression ‘an important loss of freedom’. That phrase hides a veritable minefield. Who decides what freedom is? Freedom from what? Who decided what we have a right to be free from? At what point can we speak of it being lost, as opposed to restricted? Is freedom determined scientifically, culturally, along class lines?⁶

You can appreciate therefore that the work of the psychiatrist includes a lot of interpretative judgments, which are more or less subjective. For that reason it is liable to abuse (from all sides) and liable to much criticism. Any of you who have at times read what critics have said will be aware of this. (Especially from a Christian perspective – I think of some big American names like former tele-evangelist Jimmy Swaggart, Dave Hunt, and the most dedicated critics on the Christian block – Martin and Deidre Bobgan.)

Cannot Dismiss It←⤒🔗

But, be warned against dismissing the real and positive contribution that responsible psychiatry is making. Whilst the criticisms mentioned are true, they in fact address what amounts to a straw man. Modern psychiatry, whilst historically rooted in the work of Sigmund Freud, has developed far beyond him. While Freud is perhaps not quite dead (his idea of the ‘unconscious’ and its functions – id, ego and superego – have become staple diet to many introductory psychology classes) he is no longer at the heart of current psychiatric theory and research.⁷‘Mental illness’ diagnosed and treated in purely Freudian terms and using Freudian (talking) therapies is long past.

Whilst Freud is (almost) dead, the language and terminology he introduced is not. Hence we speak of the mind being ill although, strictly speaking, this is a logical impossibility. The ‘mind’ is in and of itself a theoretical construct rather than something physical! There isn’t a thing called the mind that is able to get diseased or sick! Nevertheless, imprecise language notwithstanding, conditions described by Freud (depression, schizophrenia, etc.) are and remain real!

The term ‘mental illness’ (or disorder) is at best a layman’s term and used by professionals because people understand it. However, what a psychiatrist confronted by ‘depression’ is interested in is much more than simply the mind. My sister-in-law points out in her letter that ‘a compelling body of literature shows that there is much physical in mental disorders and much mental in physical disorders.’ Modern researchers know and attempt to study and understand depression accordingly. Modern psychiatry points out that depression involves both mind and body in an interactive way. This has led to increasing research into how the human brain works.

By Way of Example←⤒🔗

In May, 1997 Time magazine published an article entitled ‘How we Get Addicted.’⁸ Intriguing stuff. As a footnote to it there was a piece entitled, ‘Anatomy of Melancholy.’⁹ It reports and discusses the implications of modern research. Readers are informed how ‘scientists take a picture of depression and discover that it actually changes the shape of the brain.’ The portion of the brain being studied is located about 6.3 cm behind the bridge of the nose called the ‘subgenual prefrontal cortex’ – which is known to play ‘an important role in the control of emotions.’ When comparing a population of people in the active throes of depression with a comparable number of normal patients, PET scans showed a subtle but distinct difference: the subgenual prefrontal cortex was almost 8% less active in depressed patients than in the controls. When looking at this part of the brain by means of MRI technology, which makes it possible to examine things even more closely, they discovered, to their surprise, that there was an average of 39% to 48% less brain tissue in the affected region of depressed patients. No, let’s not jump to conclusions – but do let us become a little more cautious in assuming that we understand what is going on in the brain that causes depression. Neither can we necessarily decide whether brain damage as recorded is the cause or effect of depression. However, note well that a depressed person is experiencing more than something going on in his/her mind only! This is the area a psychiatrist will be very interested in take into account.

Let go back to the person in the throes of depression – back to the family doctor’s surgery. The doctor, on determining that there is no obvious organic cause for the depression, knows that she has a choice. He could recommend seeing a psychologist rather than a psychiatrist. What is the difference? Why might the doctor choose one rather than the other?

Distinguishing Conditions←⤒🔗

In the past you would often hear of doctors (and more especially psychiatrists from whom they learned the jargon) distinguish between what they judged a psychotic as opposed to neurotic conditions (psychosis vs neurosis). Broadly speaking, a psychotic condition was regarded as one which is chronic (ie, going on and on and on!), complex and having no obvious or causal explanations. Furthermore, the prognosis was that psychotic depression was a more or less permanent condition. Thus, if deemed a ‘manic’ or bi-polar depressive – a psychotic condition – it is understood to be permanent (albeit episodic).

On the other hand, a neurotic condition was generally regarded as non-permanent, treatable and able to be explained (whatever theory one adopted by way of explanation) in terms of environmental factors and influences. It was suggested that a change in perception, of understanding one’s own history and environment as well as providing the tools to maintain that change would cure, remove or alleviate the condition.

Psychologists with their ‘talking cures’ and hundreds of different therapeutic methods have stepped in alongside of (and often in opposition to) psychiatrists. Therefore, if your doctor thinks that your depression might have something to do with your past history where you learned responses that now discomfort you, he is likely to classify your condition as being a neurosis that you need to be able to explore, come to understand and learn the techniques to deal with, he might well recommend that you see a psychologist.

What about the Spiritual?←⤒🔗

Now suppose that you are a committed Bible-believing Christian, – Reformed to boot! Someone points out to you that doctors deal with the body (things organic) and psychiatrists/psychologists emphasise a second dimension – what goes on in your head – matters of mind as it is shaped by cognitive, historical and environmental factors. You are asked: but what about the spiritual? Aren’t we spiritual beings created by God in his image? Is it not true that we human beings find no rest or peace until we find rest and peace in God? Shouldn’t a spiritual counsellor – from a Christian perspective, a Biblical counsellor (pastor, minister, elder, a sister/brother in the Lord) also be consulted in coming to grips with your depression?

It is at this point that all of kinds difficulties and dilemmas can arise which, rather than alleviate and deal with the problem of depression, in fact introduce new ones. You see, if our concern with and criticism of medical and psychiatric advice in dealing with depression is that it ignores the spiritual (divine) dimension (at least as a means of healing/restoration), the shoe should also be placed on the other foot!

Criticism of psycho-therapy (psychiatric and especially clinical psychology) has, to say the least, been sharp very, very strong, especially within fundamentalist evangelical/charismatic circles and, just as vigorously, within the confessional Reformed (and dare I say it, especially theonomic) camp. And, may I add, with some very powerful and compelling reasons. You see, from Freud onwards, most of psychological theory and practice (with some recent exceptions which adopt a pantheistic – Eastern, New Age form of spirituality) has been at best indifferent to but more likely to be openly anti-Christian.

Many would claim that traditional ‘religion’ is a fundamental cause of much inner conflict human beings experience. They claim that the removal of religious beliefs, prohibitions, superstitions would remove a big if not the major contributing factor to conditions such as depression, guilt, etc.

Secular psychotherapists construct their theories and therapies on the premise that there is no divine help out there or even in here. They proceed on the basis that the only real help available is self-help and that the only real expert in making an individual aware of and teaching him/her how to help self is the trained psychologist. There is, because there has to be, tremendous belief in human ability and the effectiveness of self-help. After all, the only alternative in the absence of divine help is despair.

The impact of humanistic psychology¹⁰ (and Christian psychologists who have attempted to integrate this with the Bible) has led to an age where we have become obsessed with ‘self’. Alongside of that is the belief that all the ills, discomfort, etc., that ‘self’ experiences are due to forces within and without of which self is the victim! No guilt, blame, shame or pangs of conscience should be pinned on the self. ‘Self’ is forever the innocent, undeserving victim. Responsibility and personal blame/ accountability is negated or ignored.

Christian Responses←⤒🔗

In response to these attacks Christians have responded with equal vigour. Many of us ministers have taken up the cry and criticism that first came from Jay Adams (Competent to Counsel 1970) and others such as Thomas Szasz (The Myth of Psychotherapy, 1978) and, in a much more sophisticated and elaborate form, John F MacArthur Jr, Wayne Mack, and the faculty of Masters College faculty, (See Introduction to Biblical Counselling 1994) stating that sin is the problem! In response to psychotherapy, there has arisen the slogan that there is no such thing as mental illness. Others, especially so-called fundamentalist evangelicals and Charismatics have also taken up the cry (and their pens).¹¹ These views were and have tended to remain completely antagonistic towards dismissive of ‘psychology’. The role of the ‘mind’ and, except in obvious instances, organic causes, have been ignored or downplayed. This has helped persuade many Christians – also in our own circles – that psychotherapy is ‘the enemy’.

The result? Many a serious and sincere Christian or Christian family (especially within our own circles) who experiences or are exposed to a severe, chronic form of depression (or something similar) end up in a very difficult position. If a depressed person in our circles turns to one (doctor/psychiatrist for example) there is going to be the extra tension (and even feeling of guilt) in not turning to Biblical counselling – and vice versa. Its as though you cannot have it both ways! This extra tension (and pain) this causes is, as many of you might well know, very real.