2008-07-21T18:16:00.000-07:00

A Personal Integration of God in Psychiatric Treatment
– Alcoholics Anonymous as a Paradigm

David Mee-Lee, M.D.

Training and Consulting, Davis, California

4228 Boxelder Place,

Davis, CA 95618

(530) 753-4300

Fax: (530) 753-7500

David@dmlmd.com

Co-author: Bruce Anderson, M.D.

President, Adventist Health California Medical Group

St. Helena, California 94574

(707) 963-8802

FAX (707) 963-6328

Box 925, Angwin, CA 94508

(707) 965-2015

banderson@puc.edu

In mental health and addiction treatment there is intense focus on the brain, neural pathways and neurotransmitters and the role they play in how we think, feel and behave. At the same time, there is also an increasing interest in the role of religion and spirituality in behavioral health and medical care (Milstein, 2008, CASA Study, 2001, Shafranske, 2000, Sloan, Bagiella & Powell, 1999). Some are exploring the integration of these two trends in a new discipline, neurotheology, that argues that the structure and function of the human brain predispose us to believe in God (Muller, 2008, Joseph, 2001).

Long before this interest in neurotheology, some psychoanalysts have posited that there are many patients and therapists who already have concepts and experience with God and religion. Ana-Maria Rizzuto, an analyst, in her book “The Birth of the Living God”, draws on clinical experiences with patients as she examined the history of their belief or lack of belief in a God. Rizzuto argues that everyone has a God representation, a “private God.” She sees an individual’s God representation as primary an object representation as father or mother (Rizzuto, 1979, pp. 44, 45, 14).

If Rizzuto is correct, it behooves clinicians to have some conceptual framework about where God fits into psychiatric and addiction treatment. To leave God out of our theory and practice may well be akin to leaving patients’ parents out of our theory and practice. The introduction of God into psychiatric and addiction treatment however, involves the same sensitivity, evaluative and timing skills that accompany the subject of parents in therapy. Just as therapists respect the complexity of feelings, attitudes and individual meaning of parental representations, the same sensitivity is needed concerning God.

In this paper we provide a perspective on how God might be integrated into psychiatric care based on our clinical experience working in addiction treatment programs. Alcoholics Anonymous (AA) is a self-help/mutual help group that was founded in 1935 as a fellowship of people whose primary purpose is to stay sober and help others also suffering from alcoholism. AA grew and blossomed out of the Oxford Group, which was “a non-denominational, theologically conservative, evangelically styled attempt to recapture the impetus and spirit of what its members understood to be primitive Christianity.” (Kurtz, 1979). The Oxford Group’s popularity peaked in the late 1920’s and early 1930’s.

Many addiction treatment programs embrace the Twelve Steps of AA as guiding principles in helping substance-dependent patients. At first glance, the principles and practices in AA would appear to be the farthest from any approaches in mental health or healthcare in general. The success of AA in the treatment of alcoholism has been examined from a systems theory viewpoint by Bateson (1972) and a psychoanalytic one by Mack (Mack, 1981 pp.128-162). We will examine how AA treatment principles may be understood from a theological point of view and attempt to show how these principles may be applied to psychiatric treatment in general.

As Mack says: “Our understanding of the religious aspect of AA may have importance for the mental health field beyond the treatment of alcoholism” (Mack, 1981, p.145). We suggest that the 12 Steps of AA provide a helpful framework for understanding how God and spiritual principles of the Seventh-day Adventist (SDA) Church might assist in patients in psychiatric and addiction treatment. Firstly we will provide an historical context for the SDA church’s worldview and health mission, especially as it relates to alcoholism and chemical dependence.

The SDA Church and its Health and Temperance Mission

Early nineteenth century America was a time and place of great religious diversity. Reform movements flourished in this period, including those devoted to the abolition of slavery, the reform of prisons, the education of the blind and the deaf, the humane treatment of the mentally ill, and the right of free public education (Schwartz & Greenleaf, 2000, p.15, 16). Among other reform movements of the day, health issues also came to the fore because in many ways care of the sick was primitive and prescientific. Medicine relied on methods such as purgation, blistering, and bloodletting; and physicians knew little of the causes of disease or the importance of diet and sanitation. Surgery was dangerous and was done without benefit of anesthesia or asepsis, and mortality rates were very high. The ineffectiveness of medical care along with its attendant risks stimulated increasing interest in health reform, including the improvement of health habits and the use of natural healing methods.

Today concerns about health and temperance are considered an essential part of Adventist belief and practice. Early Adventist preachers opposed the use of alcohol, but the greatest concern of the Millerite preachers of the 1830s and 1840s was not advocating health reform but was preaching the imminent return of Christ to this world. However even then, temperance, especially abstinence from liquor, was an accepted virtue; and use of hard liquor was proscribed. A somewhat different attitude was evident regarding “domestic wine” used for medicinal or sacramental purposes. John Harvey Kellogg remembered that his Adventist parents kept a keg of ale in the basement to be used for a “weak stomach.” (Schwartz & Greenleaf, 2000, p.102).

An example of early Adventist attitudes towards the use of alcohol is the experience of Joseph Bates. In 1821, Bates, then a sea captain and later an Adventist preacher, began to worry that he looked forward to his single glass of liquor each evening with greater anticipation than he did to his food. That year he forsook the liquor which he believed had become too important to him, and a year later he also abandoned the use of wine. In 1827 he organized one of the first temperance societies in the nation (Schwartz & Greenleaf, 2000, p.101).

Ellen Gould White was an extraordinarily productive and influential person who had a prophetic role in the founding and growth of the Seventh-day Adventist Church. On June 5, 1863, during family worship at the Hilliard home in Otsego, Michigan, she experienced a forty-five minute vision related to temperance. This “health reform vision” dealt not only with abstinence from liquor but also with moderation in work and eating. It also included the importance of water as a medicine superior to the drugs then in common use and the benefits of a meatless diet (Schwartz & Greenleaf, 2000, p.104).

She later advocated abstinence not only from liquor but also from what she described as “the milder intoxicants,” such as wine, beer, or cider (White, 1905). Three years later, in 1866, the church put the ideas stemming from the Otsego vision into practice with the founding of the Western Health Reform Institute in Battle Creek, Michigan. On October 1, 1876, John Harvey Kellogg, a twenty-four year old physician and protégé of James and Ellen White, reluctantly agreed to become medical director of the Battle Creek institution (Schwartz & Greenleaf, 2000, p.112). Kellogg was a remarkably gifted and energetic young physician, surgeon and entrepreneur. Many health initiatives of the Adventist church resulted from the indefatigable energies of Dr. Kellogg and his collaboration with James and Ellen White. In addition to founding a medical school, the American Medical Missionary College (1895), Kellogg authored dozens of books and publicized health reform by attracting many celebrities and political figures to Battle Creek. In 1878 he co-founded the American Health and Temperance Association and also invented ready-to-eat breakfast foods, peanut butter, and a variety of exercise machines.

This diminutive and charismatic doctor was an innovator in the treatment of alcoholism and discovered the tranquilizing benefits of wet sheet packs in patients with delirium tremens as well as the soporific effects of neutral baths (Schwartz, 1970, p.49-50). The American Health and Temperance Association ended after fifteen years, a casualty of Kellogg’s conflicts with the Adventist church over theological and financial issues. In 1932 the American Health and Temperance Association was reactivated as the American Temperance Society (ATS) and promoted its programs within the Adventist church on a modest scale. A reorganization of the ATS in 1947 was accompanied by the launch of the International Temperance Association headed by the dynamic W.A. Scharffenberg. He established a National Committee for the Prevention of Alcoholism and later persuaded King Saud of Saudi Arabia to be honorary chair of the International Commission for the Prevention of Alcoholism. These efforts culminated in a World Congress of the International Commission which was held in Kabul, Afghanistan in 1972. (Schwartz and Greenleaf, 2000, p.490).

In the 1950s and 1960s local chapters of the American Temperance Society were established in Adventist schools. Another Temperance Department program was the 4 DK Plan (Four Dimensional Key) developed by E.H.J. Steed and Lawrence Senseman, M.D. A four evening presentation was directed to alcoholic individuals and their families, exploring the physical, mental, social, and spiritual dimensions of the patient, followed by eight counseling sessions designed to assist those dependent on alcohol. Modeled on the Five Day Plan to Stop Smoking, this program also featured a minister-physician leadership team (Schwartz and Greenleaf, 2000, p.491).

In recent years Adventist efforts to treat persons suffering from alcoholism and other chemical dependencies have been largely carried out in chemical dependency units of general or psychiatric hospitals. Alcoholics Anonymous and related recovery organizations have furnished a spiritual and philosophical underpinning for the creation of these units. Although AA 12-Step principles are designed to appeal to anyone suffering from addiction, AA’s emphasis on unflinching honesty and its dependence on an undefined Higher Power fit the metaphors of Christianity and readily harmonizes with the Adventist philosophy of wholism.

Pioneered by physician-ethicist Jack Provonsha, founder of the Loma Linda University Center for Christian Bioethics, wholism stresses the unity of mind and body and the interdependence of physical and spiritual wellbeing. It minimizes any distinction between factors which promote physical health and those which promote spiritual growth. The cultivation of physical health becomes a moral imperative providing a religious motive and sanction for health care and a temperate lifestyle (Bull & Lockhart, 2007. p. 313). It provides ethical support for and gives a rationale for lifestyle change and recovery programs that deal with addictions and related disorders. The philosophy of wholeness takes in the whole array of Adventist medical and educational institutions and programs. This belief in restoring the divine in humans by means of healing people physically, mentally, and spiritually is the most convincing philosophical and moral justification for the massive Adventist investment in medical and educational institutions worldwide.

Alcoholics Anonymous as a Framework for God in Psychiatric Care
The higher ones’ level of abstract thinking and education, the more likely one is to reject religious doctrine, the church and God. Personal experience and observation suggests this; research and surveys confirm this (Hanser, 1981, Musseu, Conger & Kagan, 1979, Shafranske, 2000, Muffler, Langrod & Larson, 1992); and theorists from Freud to Kohlberg rationalize this ((Hanser, 1981, Musseu, Conger & Kagan, 1979; Freud, 1927).

Since clinicians are well-educated and cognitive1y developed, many reject God. Psychiatrists and psychologists have significantly lower rates of belief in God compared to the general population: 73 percent (psychiatrists) and 72 percent (psychologists) believe in God in contrast to 96 percent of the general public. Only 37 percent of psychiatrists responded affirmatively to a question that “If it were scientifically demonstrated that the use of a spiritual intervention (e.g., prayer) improved patient progress, would you perform that intervention?” (Shafranske, 2000). In addition, spiritual aspects are not fully embraced as part of conventional medical “culture.” (Milstein, 2008)

Against this attitudinal backdrop, it is especially confounding to witness the success of Alcoholics Anonymous (AA) and the 12 Steps, success which cuts across educational, socioeconomic and cognitive levels. Fifty percent of the twelve guiding principles refer to a relationship with God or a power outside ourselves and most refer to morality, right and wrong, spirituality and prayer and meditation. The 12 Steps are described as a “group of principles, spiritual in their nature, which, if practiced as a way of life, can expel the obsession to drink and enable the sufferer to become happily and usefully whole” (AA Twelve Steps and Twelve Traditions, 1952, p.15).

Case Vignette

Robert W. is a 55 year old self-employed businessman who had progressively grown weaker from over fifteen years of chronic alcoholism. Jaundiced, edematous and deteriorated in every aspect of his personal and social life, he had no perception of himself as sick. He had never before agreed to, nor received, primary alcoholism treatment. The only treatment he had received twice was for the secondary complications of his alcoholism. Mr. W’s eight children had been prepared for an intervention session in four preparatory sessions. After only one fifty minute intervention session, Mr. W. agreed to, and followed through with, primary inpatient alcoholism treatment which lasted over one month. The successful outcome of that session was particularly confounding when considering that these same eight children had, without success, been variously urging, pleading, demanding and cajoling their father to obtain treatment for years. His wife had given up bitterly, years before.

What was done in the four preparatory sessions was to review with Mr. W’s children specific descriptions of events, which related to their father’s drinking, e.g. “Last Sunday, you were so drunk that I had to pick you up off the floor and unbutton your coat. I feel so hurt and embarrassed that I can never safely bring home any of my friends when you drink.” When each person had compiled their list of specific events, the intervention session was rehearsed to help the children present the data with an attitude of concern and non-judgment. They were however to be specific, detailed and factual “to demonstrate the legitimacy of the concern being expressed.” (Johnson, 1980, p.56). For example, “Dad, I'm so worried when you go out drinking. In October last year, the car was weaving all over the road and I feared for my life and yours. After you were arrested for driving while intoxicated in January, I got so concerned that I vowed not to ride with you whenever you have been drinking.”

“The goal of the intervention is to have the alcoholic see and accept enough reality so that, however grudgingly, the need for help can be accepted.” (Johnson, 1980, p.57). In essence, the goal of the intervention session was to bring Mr. W. to his first glimpse of Step One: “We admitted we were powerless over alcohol - that our lives had become unmanageable.” Whenever Mr. W. began to waver about his need for treatment, both before and after he was admitted for inpatient treatment, I (DML) would remind him of that one powerful intervention session. In genuine surprise, he had said then: “I didn’t know my drinking was hurting them like that.” We would review in detail again, the events and incidents specifically, to bring him back to Step One. Much of the initial focus in addictions treatment revolves around Step One work, without which Mr. W. would not have experienced and accepted the need for help.

As Mr. W. began to recuperate, emphasis in treatment shifted to helping him see his inability to control his drinking by his own willpower. He had past failed attempts to stop or decrease his drinking; but did achieve a year of sobriety in AA. Such work began the ground work for Step Two: “Came to believe that a Power greater than ourselves could restore us to sanity.”

By meaningful daily attendance at scheduled treatment groups and AA, Mr. W. began work on Step Three: “Made a decision to turn our will and our lives over to the care of God as we understood Him.” AA emphasizes that Step Three is not mystical or esoteric, but very practical. “Every man and woman who has joined AA and intends to stick has, without realizing it, made a beginning on Step Three …. Each of them has decided to turn his or her life over to the care, protection and guidance of AA. Already willingness has been achieved to cast out ones own will and ones own ideas about the alcohol problem in favor of those suggested by AA. Now if this is not turning ones will and life over a new-found Providence, then what is it?” (AA Twelve Steps and Twelve Traditions, 1952, pp.36-37).

The Twelve Steps - A Theological View

Thus far, we have referred to the first three steps. At this point, we examine these steps, as illustrated by Mr. W’s treatment, from the viewpoint of theology. We examine AA principles from an Adventist theological perspective with whose theology and heritage we are most familiar. However, the spiritual and theological principles likely cut across all faiths. While the terms may vary, the essence remains the same.

Step One

Step One says: “We admitted we were powerless over alcohol - that our lives had become unmanageable.” Theologically, we see this powerlessness and unmanageability described thus: “No one has ever really followed God’s paths or even truly wanted too Everyone has turned away; all have gone wrong. No one anywhere has kept on doing what is right; no one” (Romans 3:11, 12, Living Bible) “When I want to do good, I don’t and when I try not to do wrong, I do it anyway. Now if I am doing what I don’t want to, it is plain where the trouble is: sin still has me in its evil grasp. (Romans 7: 19, 20, Living Bible).

Step One then, may be viewed as bringing patients to an awareness of sin and their powerlessness over it. Since the word “sin” can have negative connotations, further explanation is warranted. Karl Menninger, in his book “Whatever Became of Sin?” explains what he means by sin. “I mean any kind of wrong doing that we used to call sin. I have in mind behavior that violates the moral code or the individual conscience or both; behavior which pains or harms or destroys my neighbor - or me, myself. You know what wrong doing is and if a better word than sin is available, use it” (Menninger, 1973, p. 17). Menninger further defines sin: “Sin is transgression of the law of God; disobedience of the divine will; moral failure. Sin is failure to realize in conduct and character the moral ideal, at least as fully as possible under existing circumstances; failure to do as one ought towards ones fellow man (Webster)” (Menninger, 1973, pp. 18, 19).

Viewing Step One as an awareness of sin does not add depression and gloom, but hope for change. “The assumption that there is sin in it somewhere implies both a possibility and an obligation for intervention. Presumably something is possible which can be reparative, corrective, meliorative and that something involves me and mercy. Hence sin is the only hopeful view....When no one is responsible, no one is guilty, no moral questions are asked, when there is, in short, just nothing to do, we sink to despairing helplessness. We wait from day to day for improvement, expectantly, but not hopefully.” (Menninger, 1973, p. 188)

Mr. W’s family had sunk into despairing helplessness, waiting day to day for improvement, but becoming more and more hopeless and frustrated. Hope returned when they saw that there might be a different way to help their father see what he was doing to himself and others. Such awareness provided the possibility and obligation for intervention and a reparative, corrective recovery program. Mr. W’s surprised and painful awareness of how his drinking had inflicted such harm and pain on his family led him to the first step, and acceptance of hopeful treatment. As AA summarizes it: “the admission of powerlessness is the first step in liberation.” (AA Twelve Steps and Twelve Traditions, 1952, p.5).

Step Two
Step Two says: “Came to believe that a Power greater than ourselves could restore us to sanity.” If Step One can be understood theologically as bringing people to an awareness of sin, then Step Two may be viewed theologically as the solution to sin - salvation. Alcoholics, Seventh-day Adventists and the Jews Paul was addressing in the book of Romans, have great difficulty with Step Two. Alcoholics may admit they have a problem, but then keep trying to control their drinking by their own will power. They share “the widely internalized belief that it is a shameful and embarrassing failure to admit that this function (controlling their drinking) is no longer within the governing capabilities of the self.” (Mack, 1981 p.134).

Seventh-day Adventists may admit they are sinners, but like the Jews Paul was addressing, have too often kept trying to save themselves by emphasizing all kinds of good works. Some Seventh-day Adventists have found it a shameful and an embarrassing failure to admit that salvation (solving the sin problem) is no longer within the governing capabilities of the self. “Now do you see it? No one can ever be made right in God’s sight by doing what the law commands. For the more we know of God’s laws the clearer it becomes that we aren’t obeying them. Now God says he will accept and acquit us if we trust Jesus Christ to take away our sins.” (Romans 3:20, 22 , Living Bible)

Step Two emphasizes that through humility and an open mind, alcoholics can be led to faith. Every AA meeting is an assurance that God will restore them to sanity if they rightly relate themselves to Him (AA Twelve Steps and Twelve Traditions, 1952, p.34.) For Mr. W, the first step was to present him with the reality of his actions in the intervention session (his “sins”). Step Two was to help him see he could not stop drinking by himself (accept “salvation”).

Step Three

Step Three says: “Made a decision to turn our will and our lives over to the care of God as we understood Him.” Having established Step One, the problem and Step Two, the solution, AA then begins to address the practical day to day application of the solution. “Like all the remaining steps, Step Three calls for affirmative action, for it is only by action that we can cut away the self-will which has always blocked the entry of God - or, if you like, a Higher Power in our lives. Faith, to be sure, is necessary, but faith alone can avail nothing. We can have faith, yet keep God out of our lives.” (AA Twelve Steps and Twelve Traditions, 1952, p.35.)

Theologically, being aware of sin and the powerlessness to save ourselves (Step One) led us to faith in God for salvation (Step Two). Then begins the practical day to day application of salvation. The parallel to AA is clear in this quote: “What’s the use of saying that you have faith and are Christians if you aren’t proving it by helping others? Will that kind of faith save anyone?... It isn’t enough just to have faith…. Faith that doesn’t show itself by good works is no faith at all - it is dead and useless.” (James 2: 14-17, Living Bible)

In the treatment of people with alcoholism, the progression from Step One through to Step Three is a difficult one. It presents the paradox of personal powerlessness versus personal responsibility. This is a struggle not only for alcohol-dependent people, but also for health professionals, Seventh-day Adventists and the Jews Paul was addressing in Romans.

The alcoholic understandably questions: “If you tell me my life is unmanageable and I’m powerless to do anything about it then what am I supposed to do? I’ve got plenty of will power to stop drinking. I think I can kick the habit this time.” Likewise clinicians express concerns that if patients are told that their life is unmanageable and they are powerless to do anything about it, then this will only foster passivity and irresponsibility. Patients may blame their substance use on their disease and think they do not have to take personal responsibility. Some Seventh-day Adventists and the Jews in Romans question, “Well then, if we are saved by faith (powerless) does this mean that we no longer need obey God’s laws? (responsibility)” (Romans 3:31, Living Bible)

Step Three and the remainder of the Twelve Steps shed light on the process by which this paradox is resolved. AA does not say that sustained and personal responsibility is not required to stay sober. It talks more of the misdirection of that effort. “Our whole trouble has been the misuse of will power. We had tried to bombard problems with it instead of attempting to bring it into agreement with God’s intention for us” (AA Twelve Steps and Twelve Traditions, 1952, p.42.) Mr. W. had tried all kinds of efforts to stop drinking on his own - gardening; burying himself in work; and taking disulfiram (Antabuse). He found himself defeated and frustrated because he had not first integrated Step One and Step Two before the affirmative action of Step Three.

Seventh-day Adventists have correctly emphasized the need for personal exertion and responsibility. However, like alcoholics, they have often misdirected that obedience. Bombarding our shortcomings with a barrage of “works”, we have failed to see the destructive, personally erosive effects of skipping Steps One and Two - the “faith” part. The productive sequence of faith and works is this: “Only when we trust Jesus (faith) can we truly obey him (works)” (Romans 3:31, Living Bible). Or as AA says: “It is when we try to make our will conform with God’s that we begin to use it (our will power) rightly” (AA Twelve Steps and Twelve Traditions, 1952, p.42.)

It may be clear by now, that what we are proposing is that Steps One and Two of AA may be conceptualized as justification by faith; and Steps Three through Twelve as sanctification. Even a cursory reading of the remaining steps will demonstrate this, but another quote under Step Six will illustrate further: “If we ask, God will certainly forgive our derelictions. But in no case does He render us white as snow and keep us that way without our cooperation. That is something we are supposed to be willing to work towards ourselves. He asks only that we try as best we know how to make progress in the building of character. So Step Six – “were entirely ready to have God remove all these defects of character” - is AA’s way of stating the best possible attitude one can take in order to make a beginning on this lifetime job.” (AA Twelve Steps and Twelve Traditions, 1952, p.66.) Clinically, it is a fascinating experience to observe the change in patients’ personal and interpersonal life as they progress in AA through the steps.

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God in Psychiatric Treatment

Arguably, controversies in the SDA church concerning righteousness by faith have some of their psychological roots in confusion over the role of personal responsibility. Many of the debates and theoretical battles on psychiatric treatment also focus around the issue of personal responsibility. Debate over nature or nurture; genetics or psychodynamics; neurotransmitters or maladaptive behavior patterns; systems theory or intrapsychic theories - all have implications for the role of personal responsibility.

It is in the relationship of 12-Step principles to personal responsibility that AA has much to teach Seventh-day Adventists and mental health professionals. AA teaches us about where God fits into treatment in the way it resolves the paradox of personal powerlessness versus personal responsibility. We will now propose some concepts about how God might fit into psychiatric treatment, using AA as a paradigm. It is our hope that God in psychiatric treatment will take on a broader and more sophisticated significance than the simplistic, often destructive interpretation of attributing mental illness to the workings of the Devil. God in psychiatric treatment means much more than simply handing a patient some religious material; or even simply praying with a patient.

Just as it seems AA would have little to offer mental health treatment in general, it would seem even less likely that there would be any comparison between psychoanalysis and AA. Yet, here is a personal clinical vignette. It is a case I (DML) know very well: David ML is a thirty-two year old married psychiatrist who would begin the psychoanalytic hour feeling that he clearly had no contribution or responsibility in the latest argument with his wife. He was convinced that it was all her problem and what needed to happen was for her to understand him better or change her neurotic ways. The patient would settle back on the analyst’s couch, waiting to have his astute evaluation of the impasse vindicated by the psychoanalyst.

It was always surprising to find myself walking out of that analytic session fully aware of what I was doing to my wife and my part in the impasse. Despite this painful fresh awareness of my “addiction” (pathological patterns leading to personal and interpersonal negative effects), I was strangely accepting of that and realized I was powerless to change it by power of positive thinking or any other psychic manipulation. Feeling hopeful and optimistic that things could improve, I would often pick up the phone, make amends for my “neurotic” ways and resolve to make it better between us.

In that fifty minutes, my analyst had brought me through Steps One to Three and probably up to Step Ten. With a tone of concern and non-judgment, he would intervene in my harangue of projected blame with specific, piercing interpretations of my behavior and ideas. Designed to help me see reality (or at least his perception of it), the interpretations served to bring me to an awareness that, in a way, my life had become unmanageable and that I was “doing it again.” At that point, feeling embarrassed and remorseful for having been obstinate and self-righteous, I would remind myself that I am who I am; and that my feelings and the past could not be instantaneously changed by legislating an immediate improvement in my attitudes or patterns - indeed that I was powerless over my past and who I am. (Step One – “We admitted we were powerless over alcohol – that our lives had become unmanageable.”)

The natural next step was then to turn to my analyst, believing he could “restore me to sanity.” (Step Two – “Came to believe that a Power greater than ourselves could restore us to sanity”). I would determine to continue analysis believing that things could improve. The affirmative action of Step Three or the “works” I needed to do consisted of lying on the analyst’s couch and rambling about all manner of free associations. From one view, this is a ridiculous, expensive obsession. From another, this is a restorative healing investment. But no matter what your view, it certainly parallels the kind of commitment Step Three in AA demands: “Made a decision to turn our will and our lives over to the care of God as we understood Him.”

Although my analyst rarely told me specifically what to do, his searching interpretations of my behavior left no doubt as to what needed to change (Step Four –“Made a searching and fearless moral inventory of ourselves”). Accepting his interpretations and insights led me to make amends and pick up the phone (Step Nine – “Made direct amends to such people wherever possible, except when to do so would injure them or others.”).

Here is a second clinical vignette:

Mary P. is a 31 year old married factory worker who has been in psychiatric treatment of one kind or another on and off for ten years. She has been variously diagnosed schizophrenic, histrionic personality, borderline personality and a variety of other affective, and anxiety disorders. About two years ago, she joined a charismatic group of the Catholic Church and found great comfort and support there. Now that the Bible and God are meaningful to her, we talked very directly about scripture and God. She has already firmly assented to Steps One through Three. Indeed she at times she would accuse me of a lack of faith when I express skepticism about the healing services she witnessed. In our sessions together, we frequently dealt with her anger and rage for not getting the understanding and support from her husband she feels she deserved. Much of my work with her was to help her take some responsibility in changing her situation with her husband.

On the surface of it, the session sounds like a Bible study as I quoted her Ephesians 4:26: “If you are angry, don’t sin by nursing your grudge. Don’t let the sun go down with you still angry - get over it quickly.” (Living Bible). We talked about how being angry is not a sin, but nursing the grudge is and she began to look at what she might do to get over it quickly such as talking to her husband and expressing her anger. Other times, we would talk about how her husband may not be able to change or how he may be hurt. Pointing out that she may need to understand and accept him, we would discuss examples where Jesus accepted people for who they were, even though He was hurt when his disciples couldn’t stay awake just before his crucifixion; or when Peter denied Him.

Making Sense of the Clinical Vignettes

What do these two clinical vignettes illustrate about how God may fit into psychiatric treatment? In the first example there was no mention made of God; while in the second vignette, God and the Bible are referred to extensively. We will first discuss how God fits into psychiatric treatment even without direct reference to Him; and then discuss how He fits into psychiatric treatment with direct reference to Him.

In the first example, the therapist made the patient aware of his harmful, hurtful behavior; his powerlessness to change it alone; and how to take hopeful affirmative action to improve things - all without invoking God by either the patient or the therapist. Indeed if the insight had been achieved by referring to sins, evil and the injunction to follow God’s ways of acceptance and love with my wife, I might have experienced my analyst as unempathic to my pain and unaccepting of who I am. This may well have resulted in more resentment and alienation both with him and my wife.

The sequence of Step One, Two and Three and so on was followed in that analytic session. Or viewed theologically, justification was followed by sanctification all without direct reference to God. Bringing patients through the progression from Step One to Step Three firmly asserts God’s presence and principles in psychiatric treatment even if God is not directly referred to.

The generalized point is this: If a patient has negative connotations or associations about God it is likely to be more destructive to invoke God's name and methods directly in psychiatric treatment. This does not prevent God’s presence in treatment. If the therapist believes in the positive benefits of concepts of sin, powerlessness, personal responsibility, justification, sanctification and God etc., that framework and knowledge can guide treatment. Such principles can help evaluate psychiatric theories and methodologies by raising such questions as: How does the theory deal with the issue of personal responsibility and personal powerlessness? How does the methodology provide hope? How is the process and sequence of behavior and attitude change explained? What is the role of the therapist in the school of thought?

Besides helping evaluate various schools of thought, the guiding principles also help in specific treatment with patients whether in outpatient psychotherapy or inpatient acute care. In listening to the patient, such questions arise: What are they doing to harm themselves and others? How can I help them see that reality and accept that their lives are unmanageable? How can I help them see that they are powerless and give up their old ways of repetitively and counterproductively dealing with the problem? How can I help them to look beyond their own efforts and establish hope? Yet, how can I help them accept responsibility to change what they can and accept the things they cannot change? If I am successful in all of this, I believe God and His methods have been at work, even if I have never mentioned His name.

Now for the second vignette when God was referred to extensively. All of the “God treatment principles” naturally apply here also, but this example illustrates how it may be far more efficient and effective to talk about God and scripture directly. If the patient has positive concepts of, and meaningful experience with God, to not use the language and experience of that patient robs them of valuable treatment interventions and interpretations. When Mary P. would find herself harboring resentment, it was productive and reassuring to her to remember her own acceptance by God. Noting the Bible’s attitude about anger, she realized her need to resolve differences quickly. This facilitated positive action more effectively than simply telling her about anger without appeal to a higher authority. Her ability to identify with Jesus’ hurt and acceptance of others facilitated her empathy and acceptance of her husband more effectively than hours of couples therapy focused on establishing empathic contact.

In the treatment of psychiatric disorders, the paradox of personal powerlessness versus personal responsibility is always an issue. For example, if you believe the schizophrenic has a brain disorder and is therefore powerless, he is still personally responsible for accepting treatment and taking medication. Or if you believe the “neurotic” is shaped by past experiences, and is therefore powerless over his past, he is still responsible for whether he continues his self-defeating ways.

In the matter of personal responsibility, the sequencing of the 12 Steps of AA from unmanageability to making amends and helping others resolves the paradox of powerlessness versus personal responsibility; of faith versus works; of God versus human effort - in short, how God might fit into psychiatric treatment.

Discussion and Conclusion
While it may be interesting to see parallels, between AA, psychoanalysis, justification and sanctification, etc., why bother framing things in terms of sin, God and religion? Why not just use the treatment principles without involving God and religion either with patients or in the thinking of the therapist? Part of the answer draws on the observation that psychoanalysis and long term psychotherapy; addictions treatment and Christianity, contain more coherent, complementary, and consistent principles than might be apparent at first glance. Apparently incompatible approaches to behavior change enhance each other to produce a synthesis far more rewarding and integrated for both the patient and therapist. To examine how God might fit into psychiatric treatment promises to enhance treatment, not regress it.

Or if Rizzuto is correct, God in psychiatric treatment is not a technique or “icing on the cake”, but a major part of treatment to be addressed with the same respect and skill that accompanies work on other primary objects. John Mack provides a part of the answer to the question of why involve God. “Throughout the history of civilization, human beings have had great difficulty managing their childish desires, their self-oriented drives and grandiose wishes, their narcissism, without reference to a greater power in the universe, someone or something they call God….From a historical perspective, no reference to moral values...that is not perceived as deriving from a force in the universe greater than man himself has generally proved powerful enough to prevail in the face of man’s egoistic desires.” (Mack, 1981, p.144)

A final part of the answer comes from Bean and Zinberg who suggest that involving “higher authority” in treatment has implications for meaning to life. They also point out that much of AA’s success has to do with “higher authority” and reliance on a moral code. “The reliance on a moral code is far too little understood by most of the ‘self-help’ organizations that have attempted to copy one or another aspect of AA.” (Bean & Zinberg, 1981, p.31). Does God fit into psychiatric treatment? The answer is a frustrating yes and no. “Yes”, we propose, always, if you are talking about how to understand people’s problems and how to help them change. But “no”, if you are talking about the automatic or superficial invocation of God’s name; and direct references to Him in treatment with all patients. This process demands a sophisticated understanding of how God historically insinuated Himself into people’s lives; a sensitive ability to listen and evaluate a patient’s private God and spiritual orientation; and a skillful sense of the timing of references to God.

References

Bateson, G (1972). The Cybernetics of ‘Self’: A Theory of Alcoholism in Steps to an Ecology of Mind. Ballentine Books, pp 309-337.

Bean, M & Zinberg, N. (1981). (Eds.) Dynamic Approaches To The Understanding and Treatment of Alcoholism. The Free Press, division of Macmillan Publishing Co, Inc., NY.

CASA Study: So Help Me God: Substance Abuse, Religion and Spirituality. The National Center in Addiction and Substance Abuse at Columbia University, New York, NY. www.casacolumbia.org. Accessed July 11, 2008.

Freud, S. (1927). The Future if an Illusion. Summarized in Abstracts of Sigmund Freud (Ed.) Carrie Lee Rothgelp, Jason Aronson Inc., 1973, p.238.

Hanser, J. (1981). Adolescents and Religion. ADOLESCENCE, XVI(62). Libra Publishers Inc, NY.

Johnson, V. (1980). I’ll Quit Tomorrow. Harper and Row Publishers, San Francisco, CA.

Joseph, R. (2001). The limbic system and the soul: evolution and the neuroanatomy of religious experience. Zygon, 36:105-136.

Kurtz, E. (1979). Not-God: A History of Alcoholics Anonymous. Hazelden, Center City, MN.

Mack, JE. (1981). Alcoholism, A.A., and the Governance of the Self. In MH Bean, & NE Zinberg (Eds.) Dynamic Approaches To The Understanding and Treatment of Alcoholism. The Free Press, division of Macmillan Publishing Co, Inc., NY.

Menninger, K. (1973). Whatever Became of Sin? Hawthorn Books, Inc. NY.

Milstein, JM (2008). Introducing Spirituality in Medical Care – Transition From Hopelessness to Wholeness. JAMA, 299(20), 2440-2441.

Muffler, J, Langrod, JG & Larson, D. (1992). “There is a balm in Gilead”: Religion and substance abuse treatment. In JH. Lowinson, P Ruiz, RB Millman & JG Langrod (Eds.) Substance abuse: A comprehensive textbook. (2^nd ed., pp.584-595). Baltimore, MD: Williams & Wilkins.

Muller, RJ. (2008). Neurotheology: Are We Hardwired for God? Psychiatric Times, XXV(6), 24-25.

Musseu, PH, Conger, JJ, Kagan, J. (1979). Child Development and Personality. 5^th Edition. Harper and Row, NY.

Rizzuto, Ana-Maria. (1979). The Birth of The Living God - A Psychoanalytic Study. The University of Chicago Press, Chicago.

Schwartz, R. (1970) John Harvey Kellogg. Nashville, TN: Southern Publishing Association.

Schwartz, R., & Greenleaf, F. (2000) Light Bearers. Nampa, ID: Pacific Press Publishing Association.

Shafranske, E. (2000). Religious involvement and professional practices of psychiatrists and other mental health professionals. Psychiatric Annals, 30(8), 525-532.

Sloan, HP, Bagiella, E & Powell, T (1999). Religion, spirituality and medicine. Lancet, 353(9153), 664-667.

Twelve Steps and Twelve Traditions, (1952). Alcoholics Anonymous World Services, Inc., NY.

White, EG. (1905). The Ministry of Healing. Mountain View, CA.

Table 1 ... Note ...... for the sake of this blog site, David's three table comparison was given as three single longitudinal tables. If you are are printing this paper off, it is suggested that you manually cut and paste the three columns together to make
David's three table comparison ......

12-Steps of AA as a Paradigm for God in Psychiatric Care

12 Steps of Alcoholics Anonymous

1. We admitted we were powerless over alcohol – that our

lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could

restore us to sanity.

3. Made a decision to turn our will and lives over

to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves

5. Admitted to God, to ourselves, and to another human being

the exact nature of our wrongs

6. Were entirely ready to have God remove all these defects of character

7. Humbly asked Him to remove our shortcomings

8. Made a list of all persons we had harmed, and became willing to make

amends to them all.

9. Made direct amends to such people wherever possible, except when

to do so would injure them or others

10. Continued to take a personal inventory and when we were wrong,

promptly admitted it

11 . Sought through prayer and meditation to improve our conscious

contact with God as we understood Him,

praying only for knowledge of His will for us and the power to carry that out

12. Having had a spiritual awakening as the result of these Steps,

we tried to carry this message to alcoholics and to practice these principles in all our affairs

Seventh-day Adventist Theological View

1. Justification by faith – sinner who cannot

save self by justification through works

2. Justification by faith – salvation, saved and accepted

just the way we are (just as if we had not sinned)

3. Sanctification – choosing God, giving our heart to God

4. Sanctification - faith with works

5. Sanctification – confession, honesty

6. Sanctification – transformation

7. Sanctification - forgiveness

8. Sanctification - reconciliation

9. Sanctification - reconciliation

10. Sanctification – daily devotions

11. Sanctification – daily devotions

12. Sanctification – witnessing; message to all the world

God in Psychiatric Care (Explicitly or implicitly)

1. Awareness of repetitive ineffective thought and behavior
patterns leads to self acceptance; the possibility

for intervention; and hope for change

2. Recognition that current coping knowledge and

skills not effective. Faith that therapy can bring recovery and improve life

3. Acceptance of need for help and committing to treatment process

4. Responsibility to open honest exploration in treatment

5. Ongoing opening up and acceptance of ineffective patterns

6. Therapeutic alliance and readiness to change

7. Ongoing process to change ineffective patterns

8. Responsibility to repair past and present relationships

9. Responsibility to improve relationships,

including acceptance and relationship with “self”

10. Maintain personal awareness and responsibility for integrity

11. Maintain recovery strengths, resources and supports

to grow mentally, socially and spiritually

12. Service to others, community and “giving back”.

Self help and mutual help recovery groups

APersonalIntegrationofGod