Mental Illness and Psychiatric Treatment

A Guide for Pastoral Counselors

Gregory Collins, Rev Thomas Culbertson, Harold G Koenig

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135186005
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Take your rightful place on the holistic health care team, with the goal of restoring vitality of body, mind, and spirit to people suffering from emotional illness! This book is designed to bring essential knowledge and skills to the religious professional who seeks to provide special ministry to the emotionally troubled. It provides a basic understanding of psychiatric illnesses, theory, and treatment modalities that is certain to enlarge the perspective of the pastoral worker. In addition to an essential overview of psychiatry in general, Mental Illness and Psychiatric Treatment: A Guide for Pastoral Counselors will help you to better serve people suffering from depression, anxiety disorders, chemical dependency, reality impairment, or personality disorders. The book's format is designed specifically to help pastors grasp the principles of intervention in each of these disorders. Each of its five concise clinical chapters follows a four-part format that covers the duties and responsibilities of the clergyman as part of the holistic health care team, consisting of:

• recognizing the disorder
• assessing its severity
• intervening in a crisis
• counseling in the recovery phase

In their experience, the authors have observed that severe emotional or psychiatric illnesses often involve spiritual sickness as well. Spiritual sickness is a complex concept that may take many forms depending on the type of emotional illness it accompanies. Mental Illness and Psychiatric Treatment: A Guide for Pastoral Counselors shows you what spiritual symptoms to look for when assessing someone in your care. For example, did you know that:

• severe depressive illness could include the loss of faith, abandonment of hope, loss of a right relationship with God, or even self-hatred, guilt, despair, and self-annihilation
• a psychotic reaction marked by loss of contact with reality might involve abnormal self-importance, grandiosity, fear, or stubbornly mistaken perceptions of reality
• a problem with alcoholism might involve immoral behavior, irresponsible conduct, denial of the loss of control over liquor consumption, or abject guilt, shame, and self-hatred
• personality disorders may bring on profound disturbances in social relationships, self-centered anger, impulsiveness, dishonesty, impurity, or distrust of others
• people with anxiety disorders can lose their trust in God, develop obsessive fears and tensions, and become unable to turn things over to God's divine care

In Mental Illness and Psychiatric Treatment: A Guide for Pastoral Counselors, you'll find the information you need to make effective judgments and assessments about the people seeking your help. The book provides you with fascinating case studies that highlight symptoms and illness patterns as well as treatment options and techniques for coordinating pastoral counseling with the mental health team. You'll learn to recognize the spiritual symptoms of disease—negative, inappropriate, of self-defeating attitudes or behaviors—and to deal specifically with these manifestations of illness through pastoral intervention and counseling.

Chapter 1

An Overview of Psychiatry

To be part of the holistic health care team, the pastor must have a working knowledge of how the other team members function. That is, she or he must be familiar with basic psychiatric terminology and have some understanding of the many therapeutic modalities employed by the practicing psychiatrist. Meeting the need for a comprehensive overview of psychiatry, however, is a difficult undertaking, one that itself would require a very large book. Psychiatric illnesses are too numerous to be cataloged here, and diagnostic symptoms are extremely variable. No two patients are exactly alike in their presentation of signs and symptoms. Also, modern psychiatry combines a good deal of art and science in ways that are difficult to describe, quantify, or validate. In no other specialities of medicine are there so many theoretical diversities and so many schools of treatment. One reasonable approach to understanding this complex subject is through history. Although the following material is far from a complete historical review, it should provide a basic understanding of some psychiatric fundamentals. These fundamentals provide the theoretical basis for the study and practice of modern psychiatry. Many of these concepts or ideas have become so popularized that educated lay-people will understand them immediately. The interested pastor should study these fundamental principles and have a ready, if basic, understanding of them. They do provide at least one framework with which to view and understand our human nature, with its vulnerability to mental illness.

History of Psychiatry

There can be little question that modern psychiatry began with the contributions of Sigmund Freud. Indeed, prior to Freud, there was scarcely a science of psychiatry at all and virtually no understanding of normal mental processes, much less of mental disorders. Freud’s observations and subsequent writings drastically revolutionized our understanding of how the mind works in health and in sickness. He and his colleagues were largely responsible for the first successful “talking cures,” and his writings on mental processes have popularized psychoanalytic concepts to such a remarkable extent that they are indeed almost household words.

Sigmund Freud was born to a Jewish family in 1856 in what is now the Czech Republic. At an early age, Freud moved with his family to Vienna, where he lived until 1938, when the Nazis took over Austria and he was forced to flee to England. As a student, Freud was strongly influenced by the scientific thinkers of the day, and he cultivated qualities of scientific discipline and intellectual integrity. Freud’s early medical training demonstrated his marked interest in brain function and psychology, and he postulated a physical relationship between psychological phenomena and physical events in the brain cells. Early in his career, Freud began to study neurology. In 1885 he was the recipient of a traveling grant to study for nineteen weeks in Paris at the Salpetriere Hospital under the great French neurologist Charcot. Freud was impressed with Charcot’s work with hysteria, an illness characterized by weakness, paralysis, or sensory losses such as blindness, deafness, or numbness, all without demonstrable neurologic pathology. Freud became convinced that hysterics were suffering from real illness and were not malingering or faking, as was the widespread belief of the day. Charcot, through the use of hypnosis, was able to precipitate hysterical paralyses, seizures, and other typical symptoms, and Freud began to believe that such illnesses were, in fact, psychological. Freud subsequently studied hypnosis in France and was deeply impressed with the results that French physicians were able to obtain. He was also fascinated by previously hidden mental processes that could be examined under hypnosis. He returned to Vienna in 1886 with the intention of practicing neurology. He did so and published several highly regarded papers on neurological subjects. By 1887, Freud had become interested in the various psychological phenomena that he was seeing as part of his practice, and he became friends with Josef Breuer, another Viennese physician.

Breuer and Freud eventually published “Studies on Hysteria,” which was largely inspired by Breuer’s work with “Anna O,” a twenty-one-year-old girl. Anna, an intelligent girl who had been deeply devoted to her father, for two years suffered a debilitating illness with symptoms of severe paralysis and numbness in both legs, disturbance of eye movements, impairment of vision, difficulty in maintaining head position, nervous cough, nausea when eating, and intense thirst yet loss of power to swallow liquids. Her ability to speak diminished until she could neither speak nor understand German, her native language. She frequently had states of “absence” or delirium during which her entire personality altered. Anna’s illness first began while she was caring for her beloved father during his eventually fatal illness. She was forced to abandon this task because of her own illness. Sympathetic observation soon enabled Breuer to note that she usually mumbled some words during her absence states. Breuer put her into a hypnotic trance and repeated these words to her, and she was eventually able to reexperience the thoughts that were characteristic of the absences. These thoughts were like reveries or daydreams, which usually began with a girl beside her father’s sickbed. Whenever she revealed a number of these fantasies, she would return to her normal mental state for a few hours; then she would lapse again into another absence, removed again by telling the new fantasies. Clearly, the mental alteration in the absence state was derived from the disturbances accompanying these intensely emotional fantasies.

Subsequently in hypnosis she revealed that her avoidance of drinking from a glass came about after witnessing a dog, which she despised, drinking out of a glass. The dog belonged to her English governess, whom she greatly disliked. After this revelation her symptom disappeared permanently. No one had ever before cured a hysterical symptom through such a “talking cure.” Breuer and Freud realized that Anna’s symptoms were remnants of earlier, highly emotionally charged experiences determined by memories and feelings from past events.

In another session, she recalled being by her father’s sickbed and falling into a reverie. She imagined a snake in the room trying to bite her father and tried to frighten it off by waving her arms, but she found that they could not move. This intensely emotional feeling of paralysis initiated her long-term active paralysis and numbness. When this scene was relived in hypnosis, the paralysis ended, the patient was cured, and the treatment was complete.

Freud concluded from the case of Anna and others that such patients suffer from reminiscences and that their symptoms are memory symbols of earlier traumatic events. In addition, according to Freud, mental suppression of such traumatic events means that these emotions are pent up and retained. These imprisoned emotions are then changed (“invented”) into abnormal physical symptoms and behaviors, giving rise to the multiple symptoms in the illness of “hysteria” (named for the “wandering uterus” thought by the ancient Greeks to cause such multiple symptoms). Breuer and Freud chose the term hysterical conversion neurosis for this displacement process. These patients were entirely unaware of the symbolic connection of their symptoms to the traumatic events. Freud postulated that these memories and their attendant emotions exist out of awareness in the unconscious mind in the illness of “neurosis.”

Freud eventually found that he could not hypnotize all his patients, and he began to make the “talking cure” independent of hypnosis. The abandonment of hypnosis presented a formidable difficulty, since the object of treatment was to discover something that neither the doctor nor the patient knew. These memories were imprisoned in the unconscious by a force that Freud felt had to be overcome to bring these repressed thoughts to awareness. To accomplish this, mental resistances had to be overcome along the way.

Freud and his colleagues began to develop other techniques to uncover unconscious conflicts and wishes and to make them available to the patient. He recognized that often the symptoms themselves were indirect, symbolic expressions of the conflict, and that the conflicted emotional reaction was often displaced from the unconscious problem to the symptom. Similarly, he found that the mechanism of repression out of conscious awareness was only partially successful, so that remnants of the underlying problem often surfaced to find expression in indirect yet decipherable ways. Because of the incomplete nature of repression, Freud believed that the individual’s mental productions and ideas must reflect the unconscious conflict, and he focused on particular mechanisms to uncover it.

After hypnosis, the technique of free association was adopted, wherein the patient would say anything and everything that entered his or her mind, being careful not to censor anything, no matter how irrelevant it might seem. These spontaneous verbal productions are then “psychoanalyzed” so that the analyst is able to discern the relationship of the symptoms to the underlying problem or unconscious conflict. Another technique used in psychoanalysis is the interpretation of dreams. Freud recognized that dreams, far from being irrational, unexplainable phenomena, often contain the keys to understanding unconscious mental conflicts and wishes. These unconscious thoughts are defensively acted upon and shaped in characteristic ways to produce what the person remembers as his or her dream. Defense mechanisms commonly seen in dream alteration are symbolization, condensation, and displacement. The actual underlying wish or conflict is indirectly or symbolically represented, or the wish is displaced, i.e., fulfilled or represented in another manner. Condensation is most readily observed in time relationships: childhood events or characters are juxtaposed with later life events or persons.

Clearly, this description is not meant to be anything more than a brief synopsis of dream interpretation in the psychoanalytic sense. For those readers who might be interested in more detail, we suggest Freud’s classic book The Interpretation of Dreams (1953).

Still another “road to the unconscious” is seen in various bungled acts or mistakes. Freud perceived that common mistakes may have psychological determinants. He especially noted temporary forgetfulness, “slips of the tongue,” mistakes in reading and writing, loss or breakage of objects, and other “mishaps.” All these events may be provoked by hidden desires, wishes, fears, or other emotions and thus lend themselves to psychoanalytic interpretation.

All of these Freudian concepts have achieved widespread acceptance, or at least popularity, since the time of their introduction. Other Freudian theories, while widely known and studied, are more controversial in terms of their validity or applicability to clinical situations. Among these are Freud’s theories of early sexuality. Simply stated, Freud noted that human beings are creatures with a sexual instinct, or libido, and that this instinct finds expression normally in all ages of human development, not just after puberty. Freud believed that these sexual drives are focused and channeled differently at various ages, and that neurotic conflicts seen in adulthood often have their roots in problems in early sexual development. Thus, in early infancy, the baby is seen investing the sexual instinct in an oral way through sucking and biting. Too much or too little gratification for these activities is hypothesized to create “oral-dependent” or “oral-aggressive” personality types with resultant neurotic conflicts. Soon the infant passes to a more assertive stage and becomes emotionally interested in bowel training activities. Thus, sexual instincts are channeled into “anal-retentive” and “anal-aggressive” modes of behavior, for example, resisting or giving in to parental demands.

The next stage is discovering one’s own genitals, with resulting exploration, touching, or masturbating. This so-called phallic stage occurs around ages four to five and seems more relevant to boys than girls. Indeed, the female counterpart, the stage of “penis envy” when little girls discover the absence of external sex organs, has been roundly criticized as blatantly sexist.

It is at ages four to five that so-called oedipal conflicts arise, that is, preference by the child for the parent of the opposite sex. This stage may be mild, with only a few fantasies, or it may be quite severe, with aggression and temper tantrums directed toward the parent of the same sex. Freud believed that this oedipal conflict was the basic complex behind virtually every neurosis. In the grade school years, these sexual impulses are quieted, and mental forces such as shame, morality, and disgust are imposed to keep these instincts in restraint. The child is in the latency phase of sexual development, which ends with the dawn of puberty and the focusing of sexual interest on the love object with the goal of reproductive sexuality in the phase of genital primacy.

In this normal process, the natural progression can be inhibited or delayed, or the individual can become fixated at an immature level. Under stress, regression can move the person backward developmentally to a more immature stage.

In 1911, Freud described two basic principles that guide mental processes. Both of these principles, the pleasure principle and the reality principle, are needed to maintain a state of equilibrium in the personality. The pleasure principle refers to the need to avoid pain and seek pleasure through activities which provide immediate gratification directly or which relieve tension. Eventually, the constant pursuit of pleasure and tension relief must give way to dominance by the reality principle, which embodies the demands of external reality. This principle requires delay of immediate pleasure or gratification so that pleasure can be achieved in the long run. The reality principle, or the delay of immediate gratification, was seen by Freud as a learned or socially conditioned function, and as a feature of emotional maturity and health.

The terms id, ego, and superego were also coined by Freud to describe particular modes of functioning in the human mind. These terms are not associated with particular brain structures, but with mental functions. Freud conceptualized the id as the repository of instinctual strivings. Sexual, aggressive, and even death instincts were theorized as id-related mental processes. The id is governed by the pleasure principle, which is charged with seeking gratification for its various instinctual cravings.

The superego, according to Freud, comes into being during the transition beyond the oedipal complex. Over the years, superego has come to be almost synonymous with the voice of conscience, the repository of learned social, moral, and religious values inculcated by society. These superego prohibitions put limits on the constant striving impulses of the id and provide reasonable self-control and appropriate socialization for the individual.

The ego consists of mental functions concerned with data processing, memory, calculation, and defense mechanisms. The ego maintains the relationship of the organism to the external world and provides a sense of reality. Ego regulates and modulates instinctual drives by constant application of the reality principle. Ego functions also include characteristic defense mechanisms which control anxiety, preserve self-esteem, and mobilize the energies of the organism toward the satisfaction of various needs. For a thorough discussion of the ego defense mechanisms, we refer the reader to The Ego and Mechanisms of Defense by Freud’s daughter, Anna Freud (1966). Among the more commonly seen defense mechanisms are the following:

• Repression remains the core of most of the defense functions of the ego; it serves to banish from consciousness unpleasant thoughts, ideas, wishes, or attitudes that might be inconsistent with one’s ideals or self-concept.
• Rationalization consists of making excuses or alibis for instinctual or pleasure-seeking behavior. For example, a compulsive drinker may rationalize his or her excessive alcohol consumption on the basis of the need to relax, unwind, or deal with a tension-producing job or other problem.
• Denial is often blatant in psychiatric disturbances. A person may refuse to see the extent of her or his problems or may deny the long-term consequences of her or his acts. Another form of denial is unwillingness to concede the need for help. For example, a compulsive gambler may deny that she or he has a serious problem and refuse a referral to Gamblers Anonymous.
• Projection is often seen in paranoid disturbances in which the patient’s own unconscious motivation may be “projected” and attributed to others. For example, accusations of infidelity by one’s spouse may be a projected jealousy or wish. (“She must be cheating on me. I would if I could.”) More commonly seen is projection of blame. It serves defensively to exonerate the person from self-blame or social disapproval. “He made me do it” or “It’s his fault, not mine” are commonly occurring human responses indicating a degree of projection of blame.
• Sublimation is one of the healthier defense mechanisms. It allows the ego to channel instinctually determined energies into socially adaptive and constructive outlets, for example, becoming a soldier in order to sublimate powerful aggressive urges in a socially appropriate way.
• Compensation is another healthy defense mechanism that allows an individual to maintain self-esteem in the face of certain shortcomings by investing energies in another, gratification-producing area. The painfully shy, socially introverted young boy who becomes an outstanding scholar and earns a good deal of self-respect and social approval is a good example of compensation.

As a final contribution, Freud noted the phenomenon of transference, in which the patient displays seemingly inappropriate emotions toward the doctor or therapist; such emotions are said to be neurotically (and unconsciously) transferred from their earlier objects and now find expression in the doctor-patient relationship. Analysis of the patient’s transference reactions is often a keystone of psychoanalytic work. The therapist will usually go to great lengths to avoid influencing the transference; often the therapist presents a rather bland facade to the patient or even sits out of the patient’s view, saying little. Such techniques are stressful yet still commonly used in psychoanalysis. The patient responds to the bland therapist’s facade by inserting his or her own transference reactions, revealing hidden thoughts and emotions.

This process of overcoming resistance and uncovering the unconscious wishes or conflicts of the patient is the essential basis of psychoanalysis. Viewed in a psychoanalytic light, the repressed wish or forbidden conflict is reexamined and placed in a newer, more mature, detached perspective. The repressed conflict is understood as normal and is reconciled with the person’s forbidding conscience (superego), or it is redirected into other channels to serve the person in better ways (sublimation). Conscious thought and mature adult choices now prevail where only unconscious emotion and unexplained symptoms formerly dominated.

Modern Psychiatric Treatment

We hasten to add that the terms psychoanalysis, psychiatry, and psychotherapy are not all synonymous, yet they are often confused by the public. We have spoken now at length about theories underlying psychoanalysis, yet this is just one theory and branch of psychiatric practice. Most psychiatrists are not ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• Preface and Acknowledgments
• Introduction: The Function of Pastoral Care in a Holistic Health Approach
• Chapter 1. An Overview of Psychiatry
• Chapter 2. The Depressed Person
• Chapter 3. The Anxious Person
• Chapter 4. The Chemically Dependent Person
• Chapter 5. The Person Experiencing Loss of Contact with Reality
• Chapter 6. The Person with a Personality Disorder
• Epilogue
• References and Suggested Readings
• Index