A pastor trained in counseling, and working closely with other professionals, has a unique c o n t r i b u t i o n to make in dealing with the de.

pressed.

The Pastor's Role in Counseling the Depressed

PASTOR who really knows his T HE congregation is more frequently baffled, dismayed, and anxious about depresSed men and women than about people with any other problem. A 45year-old man with a jovial, outgoing personality took a challenging new job. In ten weeks, pressured by a boss who expected from him results he could not produce, the man withdrew so deeply into himself he could hardly speak. A 40-year-old woman, known for her friendliness, found herself increasingly overwhelmed by church and community activities. One morning she awakened in such deep depression that 0nly hospitalization and shock therapy could help. Another parishioner became completely withdrawn, immobile, and uncommunicative. Extended and gentle probing by the pastor elicited the feeling that God had abandoned her completely. A recently widowed, 45-year-old woman under psychiatric care, spoke frequently of suicide. One day--when she could not reach her pastor--she blew out her brains with her deceased husband's hunting rifle. The young mother of five children--more or less chronically depressed since childhood --without apparent warning, took an overdose of sleeping tablets and died. Each of these situations, though 38

GEORGE C. BONNELL Pastor of First Presbyterian Church Plainfield, New Jersey dramatic and seemingly exceptional, are not uncommon experiences for the average pastor. What can he do for depressed people? Should he handle the situation himself or make a referral? Suppose the person won't see a psychiatrist ? What are the danger signs in depression? What should the pastor avoid in a counseling situation with a depressed person? How can he cooperate with a psychiatrist in treatment? What happens in the counseling process? These are only a few of the questions raised by any pastor who really takes seriously one of the most difficult and potentially explosive forms of mental illness. I. Origins of Depression and Their Diagnosis

It is not the job of the pastor to diagnose an emotional illness or to speak authoritatively as to its origin. Only qualified professionals can do this, and even they have differences of opinion regarding origin and diagnosis of specific forms of depression. Some forms of depression are psychotic when one's PASTORALPSYCHOLOGY/JANUARY1970

relation to external reality is definitely distorted. Other situations may be anxiety-produced disorders of psychogenic origin. There is also reactive depression where a person does not have the inner resources to cope with some devastating external situation. Sometimes a temporary or more or less permanent chemical imbalance produces depression. Whatever form depression takes, it can have serious consequences for the client. No one really knows whether certain forms of depression are psychogenic, physiogenic, or a combination of both. While today the greatest help comes through therapy, some day scientists may discover that most forms of mental illness result from a chemical imbalance of the body. Freud, in The Question o/ Lay Analysis, declared: In view of the intimate connection between the things that we distinguish as physical and mental, we may look forward to a day when paths of knowledge and, let us hope, of in//uence will be opened up, leading from organic biology and chemistry to the field of neurotic phenomena. That day seems a distant one, and for the present these illnesses are inaccessible to us from the direction of medicine. (Anchor Books, Doubleday & Company Inc., Garden City, N. Y., 1964, p. 72.)

In a letter to his friend, the Reverend Oskar Pfister, Freud wrote: 9 . . the quantities of energy that we mobilize through the analysis are not always

of the order of magnitude of those warring with each other in the neurotic conflict. As a still hazy future possibility we may hope that endocrinology will provide us with the means of influencing this quantitative factor, in which event analysis will retain the merit of having shown the way to this organic therapy9 (Psychoanalysis & Faith, Basic Books Inc., N. Y., 1963, p. 120.) Some people may go on for with no apparent deep emotional lems. Than, over a period of weeks, or months they may find

years probdays, them-

selves deeply depressed. An intensive series of shock treatments coupled with chemotherapy and short-term psychotherapy may bring an individual back to his previous normal state. Others may become depressed, showing obvious psychogenic signs, but will not respond to psychotherapy until the proper drugs take effect. Others, perhaps less depressed, will respond to therapy alone9 The time for use of chemotherapy is fast approaching, In schizophrenia and severe depression the tools of psychotherapy and chemotherapy are often most skillfully combined in the hands of a psychiatrist fully trained in both fields. The number of drugs for treating mental illness seems to increase in geometric progression, and some day perhaps we will discover basic causative factors in the biochemical processes of the human body. In the meantime, it seems a question of which came first9 Emotional states seem to affect body chemistry, and body chemistry affects emotional states. II. Danger Signs in Depression

In almost every situation of deep depression, referral is strongly advisable. A pastor untrained in depth therapy and unable to read danger signs can do great damage. He may end with a dead parishioner, or one whose depression has progressed so far as to require the most drastic forms of medical and psychiatric treatment 9 Here are a few danger signals to watch for:

1. When the client expresses unusual or bizarre behavior or perception: "I feel that my husband and you (the pastor) are out to get me." "People in the church talk behind my back." "I have an overwhelming urge to run far away from everything." "I won't meet people9 They criticize and make fun of me." 39

" I ' m depressed because I don't dare get angry. If I got angry my anger alone could kill my brother." Bizarre behavior or perception may border on the psychotic. Extra emotional shock may throw the individual completely out of touch with reality. If a person is not borderline psychotic he may still be driven into deeper despair, to suicide, or some form of escape unless help comes soon.

2. When the client goes into such a state o/withdrawal that he finds it difficult to speak or to express his ]eelings. It is often impossible to reach such an individual by psychotherapy alone. A pastor skilled in counseling may he able to lift the depression for a few hours or a few days, hut inevitably the mood returns, often with deepening and more serious consequences. Chemotherapy can generally arrest the downward cycle of depression and despair, while psychotherapy can start the patient back on the road to health again. Unless the downward trend can be arrested by skilled professional treatment, the time of recovery may be greatly extended. 3. When the client speaks seriously oJ suicide. It was once suggested that anyone who talks suicide won't act it. This is not so. Before most attempts at suicide the individual gives some indication of his intention. Whenever a client speaks of suicide it is well to explore the issue more deeply. In all eases of depression the counselor should at least feel out the patient regarding suicide possibility. This can be done through leading comments or questions: "This situation really makes you feel terrible, doesn't it?" "Have you ever had a wish to do something drastic?" "Has harm to yourself or others ever crossed your mind?" Gentle, indirect, leading questions do 40

not put ideas into the client's mind. They simply raise the issue of suicide which can then he brought out into the open if it lurks in a person's mind. Frank discussion will sometimes avert self-destructive behavior. One patient seriously threatened suicide. When she was able to verbalize her reasons for wanting to do so--to "get back at" her husband and psychiatrist--her motivation being ventilated, she went home feeling rather differently than before. If the client wants to "act out" suicidal impulses the red flag is really up. To illustrate: "I feel so miserable I ' m going to put my head in the oven with the gas turned on." ' T m so depressed by my situation and I ' m so angry I'll smash up the car on the next cement abutment on the parkway." "When I leave here I'm taking a bus to New York. I can't stand being around here any more." The latter statement may he a form of escapism other than suicide, but left alone, it is difficult to know what the client will do. In a situation like this, the pastor could ask the man to wait, and then get in touch with the man's wife or some member of the family, warning them of the situation, asking them to notify a psychiatrist, and then driving the client home. Suicide possibilities may become acute when the individual mentions a particular form of self-destruction. When such a situation arises, the person should be closely watched, relatives alerted, and there should be immediate referral to a psychiatrist. I l l . Referral To and C,ooperation W i t h a

Psychiatrist or Therapist Few referrals are easy. The depressive is often a dependent person who clings desperately to the pastor and will PASTORAL PSYCHOLOGY/JANUARY 1970

not let go. However, if he knows that the pastor will continue to see him on a regular basis (i/ the psychiatrist desires) referrals are easier to make. Sometimes the client feels so miserable he gladly surrenders to anyone who promises some form of relief from a dreadful situation. If you are not sure which psychiatrist to call, the head of a neighboring psychiatric clinic or a competent medical doctor can provide the name of someone skilled in dealing with depression. On occasions a pastor may find a parishioner deeply depressed and under treatment by a medical doctor who has prescribed anti-depressant drugs. The pastor may feel--contrary to the doctor's opinion--that psychiatric treatment is immediately imperative. While it is better for a medical doctor to make such a recommendation, the pastor can impress upon close relatives the urgency of the situation and recommend that they call in a psychiatrist for consultation. This is especially urgent when the danger signals of depression manifest themselves. A call ahead by the pastor to the psychiatrist will also help. He will be interested in knowing how long the depression has lasted, what (if anything) triggered it off, significant figures in the family constellation and what, in the pastor's opinion, may have caused the depression. Many psychiatrists prefer to work alone with a patient, without regular pastoral cooperation. The reason is quite simple. When two people counsel the same person they may work at cross-purposes and the client may ventilate significant experiences and emotions to the pastor which would otherwise be exposed to the psychiatrist. It is also easier for a person to relate to one individual in the helping profess i o n s I r a t h e r than two. A client, skilled

in manipulation, may also play one person over against the other. The decision as to whether a depressed patient should be seen by both psychiatrist and pastor should be left entirely ill the hands of the psychiatrist. Some psychiatrists who rely primarily on the use of drug therapy may be happy if a counseling-oriented pastor also sees the client in a .strongly oriented pastoral relationship. IV. What the Pastor Should Avoid in Counseling Depressed People

1. Do not deal with unconscious materials. The interpretation of a particularly frightening dream or the sudden exposure of strong feelings of resentment can sweep away a person's defenses and plunge him into suicidal panic. One cause of much depression is unrecognized and unresolved anger. As a child the client may not have been permitted to express negative emotions to his parents. Up to the present he may only be aware of feelings of affection for them. To suddenly confront the individual with unmanageable emotions may be too much for his weak ego structure. 2. Do not paint bright colors where there are none to paint. An emotionally ill person can smell a "phony" a mile away. A pat on the back, a cheery expression of optimism, or an irrelevantly bright remark may only drive the person into deeper depression. It is best to support the strong part of the person against the unhealthy part, not by spiritual pep talks, but by appropriate expressions of satisfaction wherever the individual shows strength and health. 3. Do not over-interpret. Let the client free-associate. Let him talk about what he wants. So long as this is carried through, the person's defenses will not be removed, and the individual---at

41

his own pace--is able to face his feelings with minimum anxiety. 4. Do not lapse into the mood o / t h e eounselee. This does not mean always using a cheery, Pollyanna tone of voice. It means that the eounselor is in tune with reality and that through him the depressed person is helped to feel that perhaps things are not quite as bad as he makes them out to be. 5. Do not exceed your limits as a counselor. A depressed person--often in desperation--will cling to anyone who will lend an ear. He will often give strong credence t o what the counselor says or does. It is easy in such situations (feeling you have things well under control) to push too hard, and to have the situation blow up in your face. 6. Do not press the client. In situations where an individual has withdrawn from Iife out of anxiety, it is easy to see areas in which he must face reality. It is too easy, out of lack of genuine empathy, to push too hard. Let him set the pace! Don't become impatient! If the counselor pressures the client this may only intensify his perfectionism and arrest any progress toward satisfactory resolution of emotional problems. V. The Process of Therapy

In any creative counseling situation a great deal goes on that may not be apparent except to one who is trained in the field. An awareness of the process of therapy helps toward creative involvement between counseIor and client. The following areas of involvement are closely interrelated. 1. Trans/erence. Very often a depressed person will develop the same feelings toward his pastor that he had toward his parents or others who were the first authority figures in his life. 42

Transference feelings can be used to cement a relationship of trust and dependence out of which the client develops a better understanding of himself. From time to time it may be necessary for the pastor to help him understand the feelings which may baffle and shame him. Often, depressed women become as deeply dependent on the pastor as they were on their fathers, experiencing also from time to time some of the angry, demanding and possessive emotions they had felt toward their fathers. The pastor then becomes a father-figure to the client, who as an infant may not have received enough attention, feeding, and support. Even in infancy the world may have appeared to he an untrustworthy place in which to live. As transference feelings are expressed to him the pastor may then help the client understand something of the nature and origin of these emotions. Strong negative transference feelings (anger transferred from early authority figures to the pastor) should be discouraged by prompt interpretation and subtle discouragement of their expression, whenever possible. A pastor, because of his diversified role (he sees the client in other situations) and lack of training in depth therapy should not deal extensively with these feelings. Depressed people are lonely, solitary human beings who desperately need to know that someone cares. Even in later years, if a relationship of basic trust which was never experienced before is developed with someone who cares, the client can come to know that the world is, after aI1, not as untrustworthy a place as he first imagined. No amount of assurance will always suffice, for he desires constant attention. Just to know that someone cares, that someone is ready to listen, is enough sometimes to enable one to verbalize his despair rather than to act it out in destructive PASTORAL

PSYCHOLOGY/JANUARY ]970

forms of withdrawal and suicide. In situations of depression, as in most other counseling, it is not information or even insight that counts most. An accepting, honest, person-to-person relationship enables the client to see himself as he is, to feel his real emotions, and to work his way through to a more spontaneous relationship with all the realities of life.

2. Counter.trans/erence.

Counseling is a two-way street. Before he becomes deeply involved with anyone, the pastor h a d better be aware of his own feelings, He can over-encourage the dependence of an already depressed, dependent person in order to promote his own feeling of omnipotence. He can encourage anger in the patient to exploit his own resentment against parent figures. He can misinterpret feelings of transference as romantic feminine advances and be frightened out of a relationship that might have benefited the counselee. He can if he himself is also d e p e n d e n t - share his own feelings of frustration and anger, thus m a k i n g the therapeutic relationship impossible and downright explosive. This is why pastors who engage in any kind of counseling should themselves know what it is like to sit where the client sits. Pastors who have experienced individual or g r o u p therapy are far better equipped to do effective counseling. Those who have not undergone therapy, no matter how proficient they m a y be, could be m o r e effective if they themselves h a d experienced what the client himself is going thraugh.

3. Feeling o~ anger. Depression often results from anger turned inward. A careful probing of the client's past generally reveals that he was taught as a child to hide negative feelings in order to be accepted a n d loved b y his parents. Expressions of anger m a y have been regarded as sinful, so by sheer force of

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43

habit the eounselee may have repressed his real feelings in order to get parental approval. Pastor: "Were you ever angry with your parents?" Client: "Of course not. I wouldn't think of such a thing. It makes me feel guilty just to think of it." Pastor: "Were you aware of your anger toward me when you came in today?" Client: "No. You are the last person in the world I could be angry toward." Sometimes a person may mention a dream or nightmare which explodes with unexpressed hatred. Client: "I had a most horrible nightmare in which I told my father just what I thought of him. He became very angry and abusive, telling me that I was an ungrateful child." Pastor: "How did you feel at the end of the dream?" Client: "I felt horrible and I wanted to take it all back. I spent the whole next day feeling alternate emotions of hatred and remorse." These dreams furnish the counselor with further evidence of the volcano which lurks beneath the surface. He will be very careful regarding any interpretation. Interpretation can bring to the surface of a person's life such explosive emotions of guilt, hate, and fear as to sweep away all defenses. In the process of counseling the individual becomes progressively aware of his anger, its original source as directed against parental figures, and its current expression.

4. Feelings o] per/ectionism. "I can't stand not being perfect." . . . "Every time I make a mistake I become very angry." . . . "I'm afraid people will see the kind of horrible person I really am deep down inside." . . . "There is such a gap between the person I am and the .44

person I want to be that I can never fill it up." Once again~ seeds of perfectionism, planted by parents or parent figures and nourished through the years, can create Ihe most devastating Feelings of depression and self-hatred. Patients with strong feelings of perfectionism often go through cycles of depression and anger. Perhaps onefourth of the anger wbieh boils beneath the surface explodes in a temper outburst while the rest continues to bubble within. The person feels terribly guilty for what he has said or done, represses the emotion, and plunges into depression. Very often the contrast between perfectionistic expectations regarding oneself and the actual reality become so extreme as to leave a person feeling utterly desolate: "I'm nothing . . . I can't do anything r i g h t . . . I'm no good at all . . . . " Perfectionism can also creep over into the realm of religion: Client: "I've got to be 100% perfect. I know God expects that of me." Pastor: "Does he expect that of anyone else?" Client: "No, but he does of me." Pastor: "Do you mean to say that of the three billion people in the world today God expects only Charles Brown to be perfect but no one else?" Client: (With a slow smile) "Yes." The client was beginning at this point to recognize the absurdity of his overexpectations. Over a period of time he may be brought to recognize the crippling effect of his perfectionism and its source in relation to childhood authority figures. In an atmosphere of acceptance and permissiveness, he may gradually develop more moderate expectations of himself.

5. One's religious outlook. Strong feelings of guilt, deeply charged emotions of anger, or a solid streak of perPASTORALPSYCHOLOCY/JANUARY1970

fectionism inevitably affect a person's religion. (a.) The concept of God: In a group of twenty-seven people in a class on "Christian F a i t h and Mental Health" I discovered that approximately twenty had or still entertained the idea of God as a man with a long white beard, sitting on a golden throne, writing in a book everything they did that was bad. Some depressed people develop such a fear of God they are afraid to read the Bible. They develop terrifying fantasies regarding death and final judgment. The whole structure of their theology is based upon fear. Pastor: " W h y do you feel depressed?" Client: " M y mother said~ 'You'll get p a i d back for what you are doing to me.' " Pastor: " W h a t did you do to your mother ? " Client: " I talked back to her." Pastor: "Who's going to pay you back?" Client: "God." Pastor: "Really? When you think about God, what comes to your m i n d ? " Client: "A man . . . very big . . . a white robe . . . a throne . . . watching over the whole world . . . He sees who is good a n d bad . . . He plans something like the flood or another disa s t e r . . . My mother's uncle talked about the book of Revelation. He was a minister. I was frightened to death of him. All m y relatives were so strict, so religious . . . I was scared of them. Two of the children never married. There was no fun in the family." Pastor: " W h a t kind of God would you like to believe i n ? " Client: "A God who loves me as his own little child. Who accepts me in spite of my sinfulness and failure 9 Inside of me right now are two kinds of G o d - their kind and the kind I want to know.

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My God is not the right kind. He's not strict enough." This client, for the first time, is taking a new look at her religion. P e r h a p s - - j u s t p e r h a p s - - s h e doesn't need to feel so perfectionistic. F r e u d was right when he said that m a n y people think of God as a father image projected out on the c a n o p y of the universe. It is the responsibility of the pastor, gently and firmly, to use his role as an authority figure in counseling and to help the client correct his distorted concept of God. (b.) The conscience and a sense of guilt: Since our s u p e r e g o - - t h e unconscious and partly conscious p o r t i o n of our c o n s c i e n c e - - i s largely the p r o d u c t of moral values taught when we were pre-school children, it is not s u r p r i s i n g that most depressed people have an overwhelming sense of guilt. " I look upon my conscience as a small voice inside that tells me where I am wrong." 9 . . "I feel, somehow, I ' v e c o m m i t t e d the u n p a r d o n a b l e sin---but I d o n ' t know what it is." . . . " T h e r e is a r i g h t a n d a wrong in every m o r a l issue. T h e r e are no greys." In order to contain their strong, unexpressed feelings of anger, m a n y peo45

ple have to sit on their emotions. They develop an overwhelming, all-controlling superego which crushes feelings of rebellion. When these emotions rush to the surface the individual is swept by a sense of guilt which in itself acts as a repressing mechanism. Somehow the individual must be helped, slowly and sometimes painfully, to express these negative feelings in constructive and creative ways so as not to destroy the fabric of his life.

6. In all depression there is a ]eeling o/something taken away. One depressed person felt that God had forsaken him. However, he came to feel that somehow the pastor could mediate God to him when he felt forsaken. This could only be done because his pastor was familiar with how his problems affected his relationship to God. Another client felt constantly under divine judgment, isolated by the wrath of God. This involved gentle probing into his strong sense of perfectionism. A third who lost his j o b - - f e h that his whole purpose in life was taken away because his self-esteem and his work were very closely interrelated. In almost every situation where a person is depressed, the counselor must try to find out what the person feels has been taken away. Over a period of time the client will learn for himself what causes this feeling of "taken awayness" so that he can deal more directly with the dynamics of the situation. 7. Work with the ]amily. "If Tom only had enough faith he wouldn't feel so depressed." . . . "I am ashamed of my husband because he is mentally ill." "He's an intelligent person. He knows his work. Why should he feel so overwhelmed?" . . . "If a man is really 'saved' he will never become depressed." While the psychiatrist works with the 9

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individual, the pastor deals with the client in context with his family9 It is amazing to discover the ignorance, superstition, and prejudice that still prevail in peoples' attitudes to mental illness. Medieval churchmen used demonology to explain diverse forms of mental and physical illness. Even today, some people regard the mentally ill in the same superstitious manner that medievalists considered them to be "possessed." A vague feeling that the sick person is "different," that the illness might creep out and infect them, that "all you have to do is try a little harder," leaves us with the impression that moralistic people today have their own unverbalized expression of demonology with regard to the mentally ill. Just as churchmen once thought heretical the idea that mental aberrations were the result of natural processes, so many today regard as heresy the idea that even if someone is really "converted" (whatever that means) he still may become mentally ill. Many a guilt-ridden neurotic is driven to despair by well-meaning relatives and friends who have no clearer ideas regarding mental illness than the medieval monk who believed in demon possession. An individual does not become ill by himself but (in part) as a result of his relationship with those about him. The feelings he had toward parents and siblings are later transferred to his contemporaries. Relatives also need to have interpreted to them the process of the counseling experience so that many misunderstandings regarding psychotherapy can be corrected. However, if any confidences are to be revealed, the client must first give permission to the counselor9 The only exception is when the person's life is in danger because of suicidal impulses, bizarre behavior, severe withdrawal, or some other "red flag" signal. PASTORAL PSYCHOLOGY/JANUARY]970