The Physician, The Pastor, Psychotherapy, and Counseling
Dr. Adams is Director of Advanced Studies at Westminster Theological Seminary in California. He is also the Dean of the Christian Counseling and Educational Foundation and the author of numerous books on counseling.
This article is taken from a 1988 presentation in Birmingham, Alabama. It is edited for publication, yet retaining an informal style.
For years when I was a pastor, I attended mental health meetings for pastors sponsored by various organizations, at which psychiatrists and psychologists addressed us. The pastors always listened, the psychiatrists always talked. It was never the other way around. It troubled me that the data flow was so one-sided. Therefore, I appreciate the opportunity, as a minister of the Word to come to a gathering of medical personnel to speak to you, rather than merely to be on the other side of the fence. Thank you for the opportunity.
At these conferences for pastors we were told that the pastor is a "gatekeeper." That word that kept coming out all the time. Because the pastor is one of the first to see people with problems (the statistics bear this out), he was taught by the "experts" at these meetings to defer and refer. That is the particular task of the "gatekeeper." His job is to send to the psychiatrist or psychologist people who have anything worse than a psychic scratch. The problem was that, as a pastor, when I followed this advice I found it didn't work! Sending people off to the psychiatrist and psychologist more often than not meant that they came back later on as bad (or worse). So we weren't getting results. It became quite a problem.
I know you physicians have a similar problem. I don't know whether we have any psychiatrists or psychologists here, but most of you are "body" people. You're not working with problems about how to relate to grandmother. You're dealing with body problems. So you have much the same problem that I had as a pastor. You also frequently must send people off to someone else for help. Many of my physician friends have spoken to me about this problem. I've read the literature that says, in some places, up to fifty percent (other literature sixty to seventy percent) of the persons that a physician sees have no organically-based problem and probably shouldn't be there. Their problems are "psychomatic" (or whatever you want to call it). The difficulty is that you've got to do something for those people.
Many physicians, of course, give them some kind of a pill or prescription to make them happier and send them on their way. People aren't happy if you don't do something for them. This is one of the reasons for the enormous amount of overmedication going on. When you send people off to psychiatrists or psychologists you still have the problem. You might take the Weed or Cross approach to Problem-oriented Medicine, but I've been through much of that and it looks so complex that I guess most people wouldn't want to get very heavily tied into it. Also, it is not biblically-oriented, though it attempts to look at the whole person in trying to do the job.
Well, then, you say, "I'll try counseling myself." Some of you have tried counseling people. You are Christians. You know that their real problem is that they need to get certain things squared away with the Lord, with their family members, their boss or others. So, you try doing counseling. That, however, creates a new problem. You have too little time to do an adequate job. It destroys your own family if you stay late night after night, extending your time with such people. Taking extra time, you create new and worse problems than you faced to begin with. You can't do much counseling plus all the body work you must in the ten or fifteen minutes (perhaps a little more for Christian physicians) typically allotted for a patient. Counseling takes time; much more time. L` you give them that kind of time you're going to have to charge exorbitant fees in order to keep your salary level up to where it belongs because you'll see far less people.
So, you are in a dilemma again. You're wrong if you don't and you're wrong if you do. What are you going to do? Well, you refer, reluctantly. If you've read Medical World News, you know that the difficulties with psychiatry and psychology are serious. About ten years ago that periodical first reported an experiment in which a psychiatrist thought he would check out his fellows on their ability to diagnose problems. Into twelve of this nation's leading mental institutions he sent seven persons (I hope the next statement is accurate) as sane as you or I. When they entered they lied only about one thing. They said, "I hallucinated." They didn't act strange in any way, they didn't tell any other lies. Any questions they were asked they tried to answer factually. In these seven instances, how many times do you suspect that they were declared to have serious mental illnesses? Would you believe half? You'd be wrong. Three-fourths? You'd still be wrong. In seven of seven instances these persons were labeled mentally ill. They were called schizophrenic in six cases and manic depressive was the label gummed on the file in the seventh case.
Such serious labels put on people's files follow them throughout the rest of their lives. Yet, in all cases, seven of seven in this instance, the diagnosis was absolutely false. A person can hallucinate for all sorts of reasons as you are well aware: hallucinogenic drugs, sleep loss, etc. Just because a person is hallucinating doesn't say anything about etiology. If a person here in the audience had a red nose I would have no right to accuse him of boozing just because of that. It may be that his wife punched him in it, because he is growing a pimple on it or because he fell asleep under the sun lamp. There are various causes for red noses. The same effect may have various causes. The same is true of hallucinations. Yet in all cases where these persons said, "I hallucinated," they were labeled as having a serious mental illness.
When that experiment hit the fan it splattered all over the medical and psychiatric world and made quite a stir. When it settled down, the fellow who did this went to one of these institutions and said, "I'm going to do it to you again." But he didn't. Then he waited a while and checked the intake records of that institution. He saw that before he said he was going to do it again, virtually nobody was turned away as a malingerer (or fake). However, after he had said this, all sorts of people were being turned away as malingerers. He got them going and coming.
There is a mess out there in psychiatry. Zilboorg, in his two volume history of psychiatry, concluded: "The field is in disarray, just as it was at the beginning." I agree with him that the field is in disarray, but I disagree that it is just as bad as it was at the beginning. If you take as the beginning somewhere around Freud and Charcot, at the beginning of modern psychiatry and psychology, you had only five to twelve different viewpoints, depending on how thinly you slice the psychiatric sausage. Today in America we are told that there are over 230 basically differing viewpoints of counseling psychology and psychotherapy of various sorts. You can't even adequately study them all in a lifetime, to make an evaluation of who is right (if any). Nor can you determine what pieces are right if you are going to eclectically make an amalgam of these viewpoints. Day by day new ones come on the market, and, like breakfast cereals, at each trip to the store you discover new offerings making stupendous claims.
These new systems invariably say, "At last we've found it! All the rest were wrong up until now. You've finally got it!" Thus all your study of Freud and Jung and the others is worthless, because now, at long last, truth appeared. Who knows who's right? You don't even have time to study Jung in a lifetime. Jung is a mystic. Jung is tough. Jung's teaching about the animus and the anima is esoteric. He speaks of a "collective unconscious", mystical "archetypes" that go back to the early days of man's history. Just to begin to understand Jung's viewpoint = let alone evaluate it - is a tremendous task. Then there is Freudianism and all its types: early Freudianism, later Freud, neo-Freudianism which emphasizes the Ego rather than the Id. You find it in all it's strange manifestations, such as in Harris' "I'm O.K., You're O.K.".
There are the "third force" fellows, who have become more dominant than the behaviorists and Freudians. These people have filled our country with humanistic ideas of self-love, self-esteem and self-worth.
Practically every book coming off the press today by Christians purports to see in the Bible teachings of self-worth, self-love and self-esteem. We are told to bolster every human being in order to raise his self-worth. This is something we never saw before, but, rather condemned for many years. But now the church has been brainwashed into believing that this is true. Even our hymns are being changed so that we no longer sing anything about being "worms". And so it goes - just continued change after change. We go from one thing to the next. But there is nothing solid - there is no consensus.
Leading psychologists and psychiatrists first met together about three years ago in Phoenix. Time magazine reported that there was only one conclusion coming out of that meeting that nobody agreed about anything! I was on a jury last year, and we had a psychiatrist testify in the case. It was interesting, when the district attorney asked the forensic psychiatrist, who testifies regularly for $500 per appearance, whether psychiatrists agree on anything? Under oath, he said, "No". That was the honest answer. Only ignorance or arrogance lead anyone in this field to say, "This is right. This is correct." He'd either be ignorant of the varieties of viewpoints and the lack of consensus or he'd be arrogant to say, "I know which one is right.
The only way in this confusion that anyone could testify that he has the answer and knows he is right is either to be ignorant of the situation or to be arrogant.
Where, then, is the answer to your problem? You physicians
see these people; you have to do something about them. You must work with people
whose lives are full of difficulties and problems. Should you send them off
to the shrinks? Should you try to treat them yourself? Is there hope any where?
But first, on behalf of all concerned ministers who see matters this way, I want to take advantage of this opportunity to ask your forgiveness on behalf of preachers of the gospel who ought to have been working with you and serving you over the years, but who have not done so. The dilemma in which you physicians find yourself, is not of your making. It is not your fault. You're in a dilemma that the church created. Specifically, preachers have brought it about. They are at fault, not you. What has happened is understandable, though not excusable. Pastors used to do counseling. At one time they wrote the books on melancholy (now called depression).
But, in the history of the Church something happened. There came the great liberal onslaught into American Christianity. That movement was so powerful, and had such an impact upon the church, that many things were lost in the battle that ensued. Institutions were taken over by liberals, as were church buildings, denominations, publishing houses, and radio broadcasts. The conservatives who were holding on to the truth became so zealously engaged in the battle with liberalism, while barely hanging on by their fingernails, that they allowed many things to slip by the wayside. And much of what went by the wayside affects our homes and has brought on the chaos that we experience in our communities. The teaching of family responsibility, of husband-wife relationships, as well as parent-child relationships - dropped through the cracks. Everything became a doctrinal issue. The battle had to do with whether the Bible was the Word of God or not. That issue was central and basic and we could never evade that but, on the other hand, many important things disappeared because of the desperation of the circumstances.
One of those things that disappeared was counseling. Pastors stopped doing biblical counseling. At this very time the psychiatrist and the psychologist were coming to the fore. They claimed there was a third category in life beyond the organic category and the spiritual (or moral) category: a non-organic, non-moral category. This they introduced to provide an area in which to work.
This unnatural third category the Bible knows nothing about. The Bible knows about the organic problems people have (sickness, injury, bad health) and the Bible knows about spiritual problems, which have to do with one's relation to God and his neighbor. But it knows nothing about a "mental illness' category, in which a non-organic bug of some sort creates a non-organic problem which has to be treated non-organically under a medical aegis, though there is nothing medical about it. What is peculiarly medical about someone telling how to live with grandmother? This new category forced its way between the two biblical categories that we have always known and believed in. Many pastors were glad to have it so! They were exhausted from the battle with liberalism. They were preaching in storefronts with few resources, trying to make a comeback. They were in bad shape materially and physically and had little time. They were all too glad to have somebody else take over their counseling work. They let it go. Thus, the problem grew and you today are faced with it.
All the while there was a better answer to people's non-organically=based problems. But that answer was buried. The reason there is no consensus today in the field of counseling is because the one Book that could have brought consensus was rejected early on and laughed at by people in the new category. They said, "We can enable people to love, experience joy, peace, and self=control apart from the Bible. But the Bible calls these desirable qualities the "fruit of the Spirit." God has said through His Word, "1 am the one who brings those qualities of life into a person's experience through faith in Jesus Christ as that individual appropriates the Word and as the Spirit of God enables him to fulfill that Word in daily living. l am the one who does that."
They said, in effect, "No, we can do all that without the Word, without the Spirit, without God, without the Church, without any of these things, by means of Freudianism, Rogerianism, Behaviorism, Skinnerianism - or something else. Competitively, these organizations and viewpoints set themselves up over against the Church. Many Christians, now realizing that there was a need to help people in these areas, began to take training. The trouble was that they went for training by these same people who were opposed to God's way, who were in competition with God.
Many of you may not realize that psychotherapy has set itself up in competition to God. Whatever you call it, that is all I can call it. If I set up a store on one corner and I sell auto tires and three other people set up tire shops on the other three corners, I call that competition. We're claiming our product can do the same thing. We're trying to get the same people for the same purpose. Here is God saying, "I can give you love, joy, peace, self-control, etc., through my Spirit by my Word." Here are other people saying, "No we can enable you to experience love, joy, peace, self-control, without the Word." That is competition. They have set up shop over against God saying, "We can do a better job, in a different way." I don't know how you can integrate those two things. Surely, there is no way they can be integrated. If the Old Testament teaches us anything at all, it is that God doesn't bless His competition! I don't believe you can have it both ways. You're must choose between them.
So there it laid buried in the Word of God - the idea that there were answers, qualities of life, that God promises to people who love and serve Him obediently through Christ. Christians went off to study with all kinds of pagans. Then they tried to integrate these competitive viewpoints with Christian beliefs. They then proclaimed themselves as "Christian psychologists, Christian psychiatrists, Christian counselors". What they did was hold their Christianity, which in most cases they genuinely believed, in one hand, and their therapeutic methods in other hand. The right hand didn't know what the left hand was doing. The two were never really brought together. They didn't think presuppositionally, they didn't see contradictions, they didn't recognize the competitive nature of the situation. They said on the one hand, "I go to church, I am a Christian and I try to live that way in my community." On the other hand they said (in effect), "This is my job and I will give them Freud and Rogers, with a little prayer and Bible sprinkled on top.
They thought integration could take place very simply because these people had PhD's in psychology and a Sunday School degree in Bible. When you put a Sunday School degree together with a PhD, which one do you think is going to take over? Obviously, the Bible is likely to be bent to fit the degree. Many of our seminaries, lax as they are in other ways, always seem to be interested in accreditation. So they brought in psychiatrists and psychologists to boost accreditation rather than theologically and exegetically trained people who knew the Word in depth to teach pastoral counseling. What did they teach? "Ministers, you're gatekeepers. You must learn to refer and defer to the Christian psychiatrists." That is, self-styled "professionals" who have hung up their shingles outside of and in competition to the Church. Thus, even in Bible-believing circles, the Bible was laid aside in favor of psychotherapy, which is not firmly entrenched inside the Church. The competitive camel has come under the tent - its nose, its body, its hooves, its tail.
But, long overdue, something else has been happening in the last 20 years. The new breed of ecclesiastical cat I mentioned has begun to flex his muscles. He says, "No, we must not turn to pagans out there to find the answers to people's problems. And we must stop bringing pagan ideas into the church. We must turn to God and determine what He has said must be done. We must develop a methodology that is not borrowed from the pagans but which grows out of biblical presuppositions about what is wrong with human beings and what the Bible says must be done about these problems. The methodology must be appropriate to basic biblical presuppositions at every point." These ecclesiastical cats are multiplying and becoming available in more and more areas today. They are persons who want to cooperate with the Christian physician.
Last Monday I was talking to a group of pastors, men who are concerned about these matters. In the question and answer period one of them said, "How do you find a Christian physician who will work with you? How do you find a physician who, when you send him someone for a medical workup, won't shoot him off to a shrink but will send them back to you so that you can counsel him?" I get this question all the time from the other side of the fence. Here are people who are longing to work with you.
They care about people and are more and more equipped to deal with people who have non-organically generated problems.
There are all sorts of training institutions in this country, now well over 30, that regularly turn out pastors trained to do truly biblical counseling in a sophisticated way. There is a national organization. There are programs of continuing education for pastors who organically were trained in wrong ways. There are video and audio courses and books galore. This has all mushroomed in the last 15 years. More and more of these pastors are ready to work with Christian physicians in a significant alliance.
These counselors recognize what James 5 is all about. James wrote, "Call for the elders of the Church if you are sick." The passage goes on to talk about what they do when they get there. These elders don't just pray. James continues,
"Let them pray for him, rubbing him with oil in the name of the Lord, and the believing prayer will deliver the one who is sick. The Lord will raise him up and if he has committed sins he will be forgiven. "
The verb that I translated "rubbing him with oil" is rather significant. The King James and some other translations render it "anointing him with oil" as though it were a ceremonial event.
There are two New Testament words for anointing. One of them refers to ceremonial anointing chrio, the term from which the word Christos (or Christ, the "Anointed One") comes. That word speaks of the Spirit coming upon people as a chrisma (Cf. I John). But that is not the word used in James 5. It is aleipho, and is distinct from it. It is a word which, for example, Hippocrates used to speak of how people were helped physically by doctors in his day. Greek physicians mix ed herbs and various medical potions with oils and wine. The person was rubbed with these, medically. That is what this verse is talking about. It is talking about rubbing or smearing. It is not talking about ceremonial anointing at all.
James, therefore, is saying that the elders are to do two things. First, they were to administer medicine: rub him with it. Of course, doctors weren't available on every street corner in those days. He calls the elders. Anyone administered medicine. The elders were to pray but also to use the best medicine of their day. Secondly, they were to pray for his healing. Exercises by people who carry a little bottle of oil around and make ceremonial noises are out of the spirit of this passage. If the person is ill because of some sin, he is to confess it and it will be forgiven. So the elders were to recognize the dual responsibility of dealing with people who have both organic and non-organically caused problems. They ministered medically and spiritually.
There are, finally today, men who want to work with physicians as a team, fulfilling both aspects of James 5. But in what circumstances might you want to work with such men and refer patients to them? One instance is when medicine won't work or shouldn't be given. A brief check by you of some of the attitudes of some of those people, and the nature of their life problems, might indicate that the source of the difficulty is something you ought not to be handling. To prescribe tranquilizers as so often is done to deal with marriage problems, etc., is the wrong solution and bad practice. That is not the way to deal with marriage or many other problems. Tranquilizers don't resolve such problems. They only make people incapable of dealing adequately with problems as they remove initiative to deal with them.
Complaintive, self-pitying persons may be those you should think about referring. They need someone who will face them with their responsibilities before God and their neighbors. Depressed and suicidal persons need to be dealt with by someone who is going to take the time.
Anti-depressants are not the answer to depression, but help in getting one's life squared away so that he or she (more frequently she) meets responsibilities. Such people must be taught now to discipline their lives so as not to follow their feelings but their responsibilities before God and their neighbor.
At our counseling training center (we have 5 of them now, some operating for over 17 years) we have had hundreds of depressed people helped quickly and lastingly by the application of biblical principles. In four to six weeks we have these people not only out of the depression (that usually take a week or two) but functioning as they ought to, so as to stay in that condition. Concerned homosexuals and lesbians can benefit from biblical counseling. You have no pills for those problems, but there are people who can deal with them. In I Cor. 6:9, Paul states "Such were some of you." There are ways of dealing with such people but they take some time. Often a counselee has to be convinced that there is hope for him to change because he has bought a lot of propaganda that says he is genetically askew. Pastors, trained, biblically know how to counter such ideas. Also consider referring to these pastors persons acting in a bizarre manner who are not on drugs and who show no other indications of an organic difficulty. Bitter, resentful people or fearful, anxious and worried persons can benefit from biblical, pastoral counseling.
Moreover, consider referring husbands and wives troubled about their families, their marriage, or divorces. Also, people undergoing tragedies and griefs. You can't be the support they need during such times adequately, though you may give them a word of encouragement and pray with them. You have so much else to do, so if you try to do counseling in addition to medical work, you and your own family will soon need counseling. I find this to be a problem with many Christian physicians. They neglect their own families because they care so much about their patients and they spend more time with them than they really should. But then nothing gets done properly. They spread themselves too thin. I even find physicians wanting to get into the ministry to do counseling more effectively.
In general, I'd say anyone who needs to deal with values, attitudes, or behavior change is one who should be referred to a biblical counselor. Today, more and more, you can find such counselors in or near your community. It is worth a trip. We have known people to come 150 miles or more for biblical counsel. To find the person who knows how to deal with a problem in the right way will solve many difficulties.
I'm suggesting that these pastors are out there, available and ready; more and more they are on the scene. There are gaps--in Utah, Idaho, some parts of Texas and the far west. But there is a network you can utilize through our national organization called the National Association of Nouthetic Counselors. The word "nouthetic" is simply a New Testament Greek word that means to counsel people. It means "to counsel." There are three elements in the word which was brought over directly from Greek since no English word approximates it. The three elements in it are change, effected by confrontation, out of concern. The word also has a warm familial matrix, in which deep family-like concern is exhibited.
The Bible doesn't deal so directly with medicine as it does with lifestyle. Medicine is mentioned, and it is commended. The physician is not looked down upon in the Bible so long as he does not get in the way of God.
The Bible, of course, forbids trusting physicians instead of God. Also, physicians involved in some kind of incantation or pagan cultic practices are looked down upon. But the Bible deals less directly with medicine than with lifestyle. There is some direct data on medicine. Those data ought to be known by every physician. Many physicians aren't aware of what the Bible has to say about medicine. An example is the James 5 passage discussed earlier which may not have been well-focused in some of your minds. There are other passages in Proverbs and elsewhere that have direct bearing on medicine. Probably, if you were closer to some theologians concerned about this matter they could help you to get some of those data on the table where you could work with them.
The Bible also gives us definite principles and presuppositions related to ethics in medicine, which is the topic of this conference. If you want to find presuppositions for ethics in medicine or anything, you must go to the Scriptures. In extant ethical textbooks there is total confusion as each person is left to decide what he is going to do. You see norms derived from some sort of natural theology which is, supposedly, universally agreed upon. The confusion in the field of ethics is simply horrendous. Until you realize that God is the one Who, in His Word, sets the norms, Who gives us the principles and practices, Who tells us what the human being ought to look like, you're stuck. However, few physicians have a good biblical training in their background. That is understandable. So you need to get together with some people who have that training if you want to make ethical decisions which are biblical and pleasing to God. You must know biblical principles. This means sitting down with theologians. You need to talk with them about passages. You need to consult reliable exegetes who will answer your questions about given passages, what they really mean, rather than the way well-meaning, but uninformed Sunday School teachers may have interpreted them.
For example, take the Proverbs passage which says, "As a man thinks in his heart, so is he." How often have I heard in a Sunday School class or elsewhere, "Here is an important philosophical principle for us to follow in life." Well, it isn't anything of the sort. This is one of the few Proverbs that has a little bit of context. It is talking about going to eat with a man who serves you a meal. He asks you, "Would you like a second pork chop?" But the whole time he is .thinking in his mind, "I hope he doesn't take it, that pig. I want it for supper tomorrow night." What the passage says is that what he may be thinking in his heart is what you really need to take into consideration; not what he says. It has nothing to do with a philosophy of life. It is more nearly a philosophy of eating.
It is necessary, also, for the theologian and Christian physician to work together to determine what the biblical data are and how they apply to medical practice. On the one side you have people who can produce something in the way of organic data and on the other hand you have those who can produce exegetical data. We need to bring those together. Too often we have people with organic data who don't know the biblical side well enough and vice versa. What we need is a fruitful union if we really want to get some ethics moving here. Such an alliance would help both the pastor and physician. I'd like to see over a period of years opportunities for solid Christian physicians, theologians and exegetes to meet together to iron out some of these things. We get too many books in which either one or the other tries to do the job without recognizing the data in the other field.
Casuistry will be the outcome. Casuistry is a good
thing which has a bad name. It only has a bad name because of the way it was
carried on in medieval days. It simply means the application of biblical principles
to life situations. That is what we have got to get down to - understanding
what the Scriptures say, what the circumstances are, to bring these together
in a way that grows out of our biblical presuppositions according to our biblical
principles and practices. I am calling today for a fruitful relationship between
theologians and physicians. May God grant us a day to come in which we will
see that. It is my hope and prayer.
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