The Nature of Man and Mental Illness
Dr. White is a 1978 graduate of the University of Michigan Medical School now in the private practice of family medicine in the North Shore of Boston. He also holds a Master of Divinity from Gordon-Conwell Seminary.
Engraved over the entrance of the Harvard school of philosophy are the following words, "What is man that thou are mindful of him?" Rather ironic to find such words over a building people by professors who for the most part distain the Author of the Book in which those words are found. But those words still capture in a lovely way one of the most important philosophical and theological questions of all times, "What is man?" And that question is not only relevant to philosophers and theologians, It is critically important for anyone trying to understand mental health and mental illness.
While the question "What is man?" can be approached in many different ways, this paper will address the question from the perspective of the ongoing theological debate regarding trichotomy, dichotomy and the whole person. For how this debate is finally resolved has enormous implications for treating mental illness.
First we must briefly dispense with two clearly non-Christian anthropologies prevalent in the medical community. Many believe that man is purely a physical being. This material view of the nature of man is popular among premedical students, medical students and physicians. This view sees man as little more than a complex interaction between atoms and molecules, a delicate balance of chemical reactions and electrical activity, an intricate interplay between various cells, tissues and organs. There are, of course, good reasons for the popularity of the material view of man. Premedical requirements emphasize biology, pathology and pharmacology. On clinical rotations the differential diagnosis and management of organic disease is by far the most prominent aspect of clinical training. Even in psychiatry, the disease model of illness is so prominent that we often mislabel temperamental differences as personality disorders or mistake attitudinal and behavioral problems for mental illness. In short, the material view of man is often due to premedical and medical school training bias and is not often the result of serious reflection by those who hold the view.
Another view of the nature of man that is commonly held by non-Christian psychiatrists and psychologists is one that we will call the spiritless view. According to this anthropology, man is thought of as a body and a mind without a spirit. This view of man conceptualizes man as composed of both material and immaterial entities. But the spiritless view rejects a spiritual aspect to the immaterial entity. This view may or may not make a radical distinction between organic and non-organic mental illness. If a radical distinction is made, and it often is, organic mental illness is viewed as treatable by exclusively physical modalities such as drugs and ECT, whereas non-organic mental illnesses are seen as amenable to only counseling and psychotherapy. The spiritless view is not universally held by psychologists. On the one hand, a number of psychiatrists and psychologists are developing a more material view of man. This shift toward the physical parallels the rise of psychopharmacology. On the other hand, there are a number of religious psychiatrists and psychologists who would not deny the reality of the spiritual in man.
Among Christians, a tripartite view of the nature of man (often called trichotomy) was held as early as the second century A.D. by Irenaeus, the Bishop of Lyons. This view holds that man is made up of three distinct metaphysical entities, namely body, soul (or mind), and spirit. However, the trichotomist view originated not in Christianity, but in Greek philosophy. As G.C. Berkouwer points out, trichotomy "finds its origin in the problem of mediating between the two worlds of Greek dualism ... It arises from the need for some intermediary between the two poles of visible and invisible things, for something which should bridge the gulf between the two worlds of body and spirit. This need was met with the 'soul,' which so to speak formed the bond, the juncture, between two things which could actually not be united." This connection to Greek dualism made the trichotomist view unpopular in the early church. There was, however, a revival of this view by a number of biblical scholars and theologians in the nineteenth century and it is held to this day by many Christians, including many Christian psychiatrists and psychologists.
A few who hold the tripartite view of man conceive of the three entities, body, mind, and spirit, as having little or no interrelationship. Thus neurologists and neurosurgeons alone should deal with diseases of the brain, psychiatrists and psychologists alone with diseases of the mind, and ministers and priests with the spirit. However, others who hld the tripartite view see man as a unified person composed of distinct but closely interrelated entities of body, mind, and spirit. Because of the close interrelationship between these entities a spiritual illness may affect the mind or body and vice versa. According to this unified tripartite view, a minister must not neglect the mind and body, nor a psychiatrist the body and spirit, nor a neurologist the mind and spirit. One might, of course, have relatively more or less expertise in the care of the body, mind, and spirit, but no one really interested in the health of the person should be entirely ignorant of any part of man's nature or fail to use that knowledge when appropriate.
From a Christian perspective the unified tripartite view of the nature of man has much to commend it in comparison with the material or spiritless view. In the first place, it recognizes a material and an immaterial aspect of man. Secondly, it does not neglect the spiritual in man. Thirdly, the unified tripartite view recognizes the unity of the person. All three of these features of the tripartite view are consistent with the biblical view of man as depicted in the creation account. For in Genesis 2:7 we read that "the Lord God formed man from the dust of the ground and breathed into his nostrils the breath of life, and man became a living being." Here we see that man has a material aspect of his being which originates in the dust of the earth. Man like the animals is an earthly being (vs. 19). But man also has an immaterial aspect which originates more directly from the breath or Spirit of God. Man is not only an earthly being. He is also a spiritual being. Man is "formed from dust but endowed with the nesama (breath-spirit)," says Henri Blocher.
The distinction between the material and immaterial aspects of man, between body and spirit, is found not only in biblical teaching on the original creation of man but also in biblical teaching on death. For example, our Lord made clear this distinction when he said, "Do not be afraid of those who kill the body but cannot kill the soul." (Matthew 10:28, see also James 2:26). But while recognizing this distinction, Scripture also clearly teaches that during life on earth man is a unity of body and spirit. Biblical authors simply do not conceive of man in this life as a body without a spirit or vice versa. He is, in the Hebrew, a nephesh - a person (again see Genesis 2:7). He is not partly a body and partly a spirit as though the two existed side by side with little or no interrelationship. Rather he is a person - a thoroughly integrated body - spirit. Karl Barth put it well when he described the human person as both "bodily soul" and "besouled body."
Despite its favorable features, even a unified tripartite view purified from contamination by Greek dualistic philosophy is problematic. It is true that various biblical terms are used to describe the different aspects of man's nature, including the words which in many English versions of the Bible are translated body, soul (or mind), and spirit. For the most part, however, soul and spirit are synonyms in Scripture. John Murray has shown, for example, that devotion to God, as well as joy and sorrow, are attributed to both the spirit and the soul in Scripture. With such insights and with adequate refutation of such cruces interpretum for the trichotomist's position as Hebrews 4:12 and 1 Thessalonians 5:23, Murray is justified in concluding his essay on trichotomy by saying, "The evidence does not support the tripartite construction."
Now the fact that the Bible does not recognize a tripartite view does not immediately allow us to reject that view. There are, after all, many ideas which God did not deem significant enough to warrant special revelation in Scripture. In other words, it is possible that God chose to reveal to us that there are at least two entities in man, namely the body and the spirit, and further chose to allow us to discover a third entity, i.e., the mind, through general revelation. This argument, however, is not convincing since Scripture, from beginning to end, is concerned with the nature, as well as the destiny, of man. If Scripture did in fact describe and differentiate two entities and omitted such descriptions and differentiations of the third would be a significant omission. but his is not the only reason I find the tripartite view problematic. If there is a distinction between the mind and the spirit, what is it? I have great difficulty conceptualizing the difference. For example, is memory of the mind or spirit? The mind most would say. But I have wonderful memories of things I have read about God and joyful experiences in his Spirit. So what, then, is memory, of the mind or spirit? Or, what about the will? By faith an act of the will enabled me (as a secondary cause of course) to become recipient of God's saving grace. But my will also enables me to make rather mundane choices like whether or not I'll snooze for five more minutes after the alarm clock rings in the morning. So then what is my will a function of -- the spirit or the mind? And when I die will my mind be ushered into the presence of God or just my spirit? If just my spirit, what is a spirit without a mind? I have trouble enough trying to conceive of a spirit without a body.
Before turning to the bipartite view, let us examine the monadic view which Henri Blocher says "was fashionable among theologians" earlier this century. This "whole person" movement was so concerned with emphasizing the "psychosomatic unity" of man that it rejected every form of anthropological duality. Man, according to the monadic view, is a monad -- an indivisible and impenetrable uniform substance. The Hebrew mind, they said, did not conceive of man as a duality but only as a unity. This view, however, was based on a hermeneutic that was fundamentally flawed. For it was based on a persumed understanding of the function of "the Hebrew mind" which has been shown by linguistic analysis to be pure speculation. Further, Robert Gundry in his scholarly work SOMA in Biblical Theology, shows that the OT evidence raised to support the monadic view is open to a better interpretation, i.e., "because of their interpretation the soul is the animation of the body and the body is the incarnation of the soul .. a psychophysical unity - but a unity not a monad." Gundry goes on to show that the somewhat equivocal evidence for anthropological duality (within unity) in the OT becomes unequivocal in the NT, as well as in NT Judaism. A small sample of some of the biblical citations Gundry draws on to support duality includes Genesis 2:7, Ecclesiastes 12:7, Isaiah 10:18, Matthew 10:28, II Corinthians 4:16, and James 2:26. He is especially convincing when he argues that "body" (soma) in Pauline theology has a strictly physical meaning. Since "spirit" (pneuma) has a clearly non-physical meaning, we must accept that Paul conceived of man as an anthropological duality, as well as a unity.
In summary, then, I reject the tripartite and monadic view of man's nature and hold to the bipartite view (often called dichotomy). According to this view, man is made up of two distinct metaphysical entities, body and spirit, the material and the immaterial. But I do not hold to a bipartite view of man which fails to fully recognize the close interrelationship and interpenetration between body and spirit. Rather, a unity of duality would best characterize my view. It should be noted, however, that the recognition of only two metaphysical entities does necessarily entail a rejection of a variety of different aspects of the immaterial in man. Indeed, Scripture affirms the variety with such diverse terms as spirit, soul, mind, heart, bowels, and kidneys.
Having arrived at a unified bipartite view of man's nature, what then is mental illness? Mental illness, in my judgement, would include some illnesses which are primarily bodily or material dysfunctions, like many severe depressions, and some illnesses which are primarily spiritual or immaterial dysfunctions, like at least some anxiety disorders. That many severe depressions are primarily bodily dysfunctions is evident by their prompt response to appropriate psychopharmacologic and electrophysiological treatments, i.e., antidepressants and electroconvulsive therapy. Anyone who regularly treats severely depressed patients, as I do, cannot help but be impressed by the dramatic improvement that these physical modalities have on his patients. And a recent well-designed study has confirmed these anecdotal impressions. While counseling may slowly help a severely depressed patient recover, antidepressants work much more quickly and save many depressed patients untold agony. Of course, counseling is necessary to aid the patient's recovery and to help prevent future episodes of depression. Many mild anxiety reactions, on the other hand, respond promptly to appropriate counseling alone.
I remember, for example, one time when I became acutely anxious after purchasing a camera which was beyond my means financially. Conditioned by the poverty I had witnessed in Africa as the son of a missionary, my conscience would simply give me no rest. Fortunately, I went to a wise counselor, my mother, who advised me to return the camera. For while everything is permissible, not everything is beneficial (I Corinthians 10:23). On returning the camera, my anxiety immediately disappeared. You see the most effective way to treat a guilty conscience is to repent. In my case, the primary dysfunction was spiritual, i.e., sin. For had I listened to my wisely tutored conscience, I would have never purchased the camera.
But there are many mental illnesses which do not fit into neat categories. For example, what about a mild to moderate depression in the context of a strained marriage. Is the dysfunction primarily of the body or the spirit? Or, how about an anxiety disorder in which the anxiety escallates to the point where the person is functionally incapacitated? A panic disorder, for example, which is characterized by episodes of the sudden onset of overwhelming anxiety, often responds promptly to small doses of antidepressants without the use of tranquilizers. While counseling is often helpful in uncovering and resolving underlying unnecessarily conflict, the panic episodes themselves respond much more quickly to psychopharmacologic maneuvers than to counseling. Before we go on I should try to clarify in an overly simplified way an important difference between antidepressants and tranquilizers. While tranquilizers make virtually all people feel more calm (even those who do not consider themselves to be anxious), antidepressants only make truly depressed people feel and function better. In other words, antidepressants seem to target a specific neurochemical imbalance, while tranquilizers have a more generalized and global effect. This is not to say that tranquilizers have no place in our psychopharmacologic armamentarium. However, to illustrate the physical aspects of some mental illnesses, antidepressants are more useful than tranquilizers.
How, then, do we explain the overlapping dysfunctions of body and spirit? Man, as we have seen, is a unity of duality. Man is spirit united to body with an integration of both entities. Thus a spiritual dysfunction may cause a bodily dysfunction, and vice versa. Indeed, given the unity of man it would be highly unlikely to find any mental dysfunction in which both the material and the immaterial in man were not affected even if the dysfunction originated in one entity or the other. Take again the case of my "photosensitivity." While sin leading to a guilt-ridden conscience (spirit) was clearly the cause of my anxiety, the mediation of that anxiety was neurochemical (body). And what if my anxiety escallated to the point where I was incapable of even deciding whether my counselor's advice to return the camera was good advice. The neurochemical component of the dysfunction might have become the primary dysfunction, even though it was not the cause of the dysfunction. In that case a brief course of a mild tranquilizer might have calmed me down to the point where I could make a rational decision. You see the entity (spirit or body) in which the primary manifestation of a mental dysfunction presents itself is not always the primary cause of the dysfunction. Interestingly, there are biblical examples of disorders in one entity leading to dysfunction in the other. Job's body, for example, was afflicted from head to toe with painful sores (Job 2:7), and this physical illness almost certainly contributed to his depressed spirit which had "no peace, no quietness ... no rest, but only turmoil" (Job 3:26). And Elijah's depressed spirit (1 Kings 19:3 - 4) seemed to respond, at least partially, to sleep and, especially, food and drink (1 Kings 19:5 - 9).
But some mental illnesses are hard to understand even on the basis of a cause originating in one entity leading to an effect in the other. Could there be another way to understand at least some overlapping mental illnesses? It seems to me that the union of the material and the immaterial in a person could result in some mental dysfunctions which are unique to man as a unity. This is a difficult concept, so let me illustrate with an analogy. If water and oil are mixed together they separate one from the other and each retains its own characteristics with no new characteristics resulting from their mixture. However, if salt is mixed with water, the mixture still has some characteristics of both salt, namely a salty taste, and wter, namely water's fluidity. But the mixture of the two also produces some unique features, like a lower freezing point. I would suggest, then, that in man as a unity there are some characteristics of his being which are clearly material, others immaterial and some which are unique to man's unity of body and spirit. Thus some mental illnesses are primarily spiritual in origin, others primarily bodily, and some are unique to man as a unity. Could schizophrenia be due to mental dysfunction unique to man as a unity? Schizophrenia does not seem to fit well into the earlier mentioned categories; and most psychiatrists believe that both organic and nonorganic factors contribute to the disorder. What about many existential crises? Solomon's existential concerns seem to have been partly due to the "burden" of God having "set eternity in the hearts of men" without giving them the ability to "fathom what God has done from beginning to end" (Ecclesiastes 3:10-11). And problems related to the eternal, immaterial spirit of a man being confined to a temporal, material body have troubled philosophers down through the ages.
In the light of this discussion two propositions of Jay Adams' early teaching on nouthetic counseling must be challenged. The first proposition is that all mental illness, apart from a few organic malfunctions, are really disguised spiritual illnesses resulting from the sinful behavior of the sufferer. The overlapping nature of many mental illnesses (even Adams considers schizophrenia to be "a gray area") makes this assessment simplistic. But worse, this proposition illegitimately injures people who are already hurting. Adams even discourages the use of the term "mental illness" because it declares "a host of people 'sick' who are not." My experience, however, has taught me that many are truly mentally ill. To mislabel their illness as a self-inflicted "spiritual" problem adds to the already great suffering of many. I am not talking about straight-forward cases of sin leading to mental dysfunction as in the case of the camera which we discussed earlier. Rather, I am talking about more complicated cases where the nouthetic counselor seeks a devil behind every bush because he believes that the vast majority of mental illnesses are really spiritual illnesses in disguise and are the direct result of the counselee's sinful behavior. Only as a last resort will he send his counselee for professional help, and then only to a physician who is to look for those rare organic malfunctions. As case from my practice may illustrate the point.
I was sent a patient by a conscientious elder of a fine evangelical church who had been trained as a nouthetic counselor. After months of unsuccessful counseling the woman was sent to me. Within fifteen minutes I knew that the patient was suffering from an agitated depression with an associated panic disorder. This nouthetic counselor had rightly searched for and found some attitudes and behaviors in the patient's past and present which needed changing and set about trying to help her change them. He became convinced, however, that most of the patient's problems began as defenseive responses to being sexually molested by her natural father as a young girl. Since according to the presuppositions of nouthetic counseling, most mental illnesses are really spiritual illnesses in disguise and are the direct result of the counselee's sinful behavior, it naturally followed that the patient needed to repent of her sinful defensive reponses. But what, may I ask, is morally culpable behavior requiring confession of sin in a young child who is sexually violated by her own father? 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 father needed to repent of his sinful incestuous behavior, not the patient! Through the only defensive responses she had available to her at her vulnerable age, she was trying to preserve her sense of self and the world from intolerable confusion and utter chaos. To suggest that this patient confess her sinful defensive responses reveals an unbalanced hamartiology - a hamartiology that overemphasizes sinful agency and minimizes victimization by sin. If, in fact, mental illness is really spiritual illness whose root cause is the sufferer's sin, then this counselor's approach is commendable. But I believe (and hope to demonstrate in a future paper) that mental illness often results from being a victim of sin - sin resulting indirectly from the general effects of the Fall and more directly from the particular sinful behavior of others. Fortunately, with a course of antidepressants this patient promptly improved and has not relapsed.
A second proposition of Adams that must be challenged is his rejection of psychiatry as a valid profession. While I sympathize with his distrust of Freudian psychology, he has thrown the baby out with the bath water. Mental illnesses are incredibly complex. Classifying mental dysfunctions as primarily spiritual or bodily or as overlapping is not an easy task. Investigating mental dysfunctions which are unique to man as a unity are particularly challenging. So is determining cause and effect especially when the primary manifestation is not found in the causal entity (spirit or body). And discovering appropriate therapy for many of these illnesses, whether the therapy be found in Galatians or in a textbook on psychopharmacology, requires an expertise that many laypersons who think they are comptent to counsel simply do not have. Christian psychiatrists, on the other hand, can (and should) as a part of their vocational calling devote much more time to both serious study of medicine, psychology and Scripture, particularly Scripture as it bears on their profession. As a result, they would advance our understanding of many mental illnesses and would be of invaluable assistance to those of us who are trying to help people suffering from mental illness, whether we be a nouthetic counselor or a family physician with a Bible.
There is, however, no neutral "mind" which psychiatrists and psychologists can safely address while ignoring God's Word. The two aspects of man's being recognized by Scripture are spirit (the immaterial) and body (the material). The "mind" is simply an improper conceptualization. The fact that people consciously ignore God's Word does not, however, prevent them from contributing to our understanding of mental illness. For through common grace, they may contribute (indeed have contributed) valuable insights. And while we might expect more fruit from their labors when they study the body, there is no a priori reason why they should not contribute to our understanding of the spirit and the interrelationship and interaction of the body and spirit. As Christians, however, we will need to be even more cautious of pagan "scientific" findings regarding the immaterial than we already are of the material. For if Scripture has much to reveal to us about the visible world (and it has), it has even more to reveal of the invisible.
Our understanding of the nature of man has, as we have seen, many implications for our understanding of mental illness. We have argued from a biblical perspective for a unified bipartite view of man's nature. Though we have only scratched the surface, we have seen how the unified bipartite view leads us to accept some ways of conceptualizing and treating mental illness while rejecting others. Hopefully these insights will help us better understand and care for the mentally ill.
1. Adams, Jay, A Theology of Christian Counseling - More ThanRedemption, 1979, p. 110. Adams has recognized the importance of this debate for counseling
2. Hoekema, Anthony, Created in God's Image, 1986, p. 205.
3. Berkouwer, G.C. Man: The Image of God, 1962 (reprinted 1981), pp. 208 - 209
4. Hoekema, Anthony, op. cit., p. 205.
5. Blocher, Henri, In the Beginning, 1984, pp. 186 - 187.
6. Barth, Karl, Church Dogmatics, 1960, III, 2, p. 350. The present author, however, does not accept the technical meaning that Barth gives to these phrases. For Barth clearly holds to a monadic view of man's nature.
7. Murray, John, "Trichotomy," Collected Writings of John Murray, published post mortem in 1977, 2, p. 32. Hebrews 4:12 speaks of "the word of God" as "sharper than a double-edged sword" which "penetrates even to dividing soul and spirit, joint and marrow." Murray exegetically demonstrates that the idea behind the word "divide" (merismos in Greek) never means "distinguishing or separating two things" in the NT. Rather the thought is "cleaving within." Murray says, "joints and marrow represent the most occult parts of our physical frame, soul and spirit our inmost spiritual being." The "The Word penetrates to the inmost parts of our being and like a sharp sword can rend them asunder." (pp. 31 - 31). 1 Thessalonians 5:23 speaks of the "whole spirit, soul and body" being kept blameless. Murray points out that in Scripture an accumulation of terms (like heart, soul, mind and strength in Mark 12:30) expresses completeness and "is not intended to provide us with a definition of the components of human nature." (p. 31)
8. Blocher, Henri, op cit., p. 88.
9. Barr, James, The Semantics of Biblical Language, 1961, (reprinted 1983), see especially chapters 2 and 3.
10. Gundry, Robert, SOMA in Biblical Theology, 1976, (reprinted in 1987), p. 121.
11. Kaplan, Harold, et al., Comprehensive Textbook of Psychiatry, 1989, Vol. 1, pp. 943 - 944. In a recent NIMH multisite collaborative study, 250 outpatients with major depression were placed in one of four treatment groups: one control group on a pill-placebo, one group on a standard antidepressant drug (imipramine) and two groups on psychotherapeutic regimens. After those with the severest symptoms were treated three and a half weeks, 10% of the control group had recovered, 35 - 45 % of the two psychotherapy groups had recovered and 75% of the antidepressant drug group had recovered.
12. Adams, Jay, Competent to Counsel, 1970. While Adams does have a short section in his book entitled "Not all Sickness Related to Particular Sins" (pp. 108 - 109), one cannot read this book without being convinced that Adams believes that the vast majority of mental illnesses are the direct result of sinful behavior. I cannot recall one contemporary example in _Competent to Counsel_ where a person's mental illness (excluding medical problems like "brain damage" and "toxic problems") was not demonstrated to be the direct result of sinful behavior.
13. Ibid, pp. xiv and 12.
14. Ibid., I base my assessment that Adams has rejected psychiatry as a valid profession on the following: (1) his conviction that "qualified Christian counselors" are "more competent [to counsel] than psychiatrist" (p. 18), (2) his calling psychiatry a "cult" (p. 110), (3) his discouraging Christian counselors from referring to psychiatrists of even "difficult cases and special problems" (pp. 268 - 269), and (4) the recurring derogatory remarks he makes regarding psychiatry in reference to psychotherapy (e.g., p. 139), institutional care (e.g., 183), psychotherapeutic agents (e.g., p. 142) and electroconvulsive therapy (e.g., p. 122).
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