[This is a follow up course to Orthodox Christian Spirituality and Cognitive Psychotherapy: An Online Course, that appeared in four parts over the years 2012-2013. This second course is specifically oriented to explain Orthodoxy to mental health practitioners,and serve as a useful resource for Orthodox Clergy and laity as well. Ethically, mental health practitioners should incorporate the spiritual values of their patients in the therapeutic process. The course would serve as an introduction of the Eastern Orthodox ethos and cultural traditions to these professionals.
One of the most frequently questions I am asked as Chairman of the Chaplain and Pastoral Counseling Department of the Antiochian Archdiocese is for a referral to an Orthodox mental health practitioner. Sadly Orthodoxy is not a majority spiritual tradition in North America and Orthodox practitioners are few. So careful questioning by potential patients, family and clergy of a potential practitioner regarding the practitioner's understanding and respect for the spiritual values of their patients is very important. This course is meant to aid in this inquiry.
It also should be noted that this course is an updating and reworking of a recently published chapter: Psychotherapy with members of Eastern Orthodox Churches, (Morelli, 2014).]
You doctors, must take good care of your patients in order to avoid unpleasant situations. You should have a practical mind. Generally speaking, every one of us must take advantage of his mind which is a gift from God.
(Saint Paisios of the Holy Mountain)1
The last segment of this online course ended with “the advice of McGoldrick et.al. (1996), that it behooves the clinician to interweave the patient's spiritual value system into treatment.” In this regard a recent review by David Elkind (2015)2 of the Handbook of Psychotherapy and Religious Diversity (2nd ed.) points out: “If it turns out that the [patient’s] religion is to be an important contributor to his or her problem, then the therapist can either refer the [patient] to a more appropriate clinician or seek consultation with a member of the clergy in question.”
Studious immersion in case studies is critical in learning about and understanding psychological processes and the application of psychotherapy to the treatment of individual, family and social disorders. In terms of research it is important to emphasize that case studies are not scientific proof of any theory. At best they serve as groundwork to formulate hypotheses that can be scientifically investigated. (Morelli, 2006b). Hypothesis are assumptions or guesses as to how observations are related to each other to predict observable and measurable outcomes. However case studies or case example also have a didactic function. They can serve to illustrate how treatment can be applied to various disorders. In this regard, it must be further emphasized that it behooves the researcher and clinician to use the best of scientifically evidence based intervention processes in the treatment of any disorder. The case example given below is an outline, a nutshell, of clinical intervention with scientific evidence based psychology treatment, Cognitive-Behavior Therapy (CBT), integrated with Eastern Orthodox spirituality. A contemporary, more detailed of overview of CBT can be found in Beck (2011).
CASE EXAMPLE:
I Case History
Identifying Information: Sophia is a 45-year-old Greek Orthodox Christian female born in Greece. She is married 21 years with two girls ages 20 and 18. She is deeply committed to the Orthodox Church. Her husband and daughters are nominally committed to the Church.
Chief Complaints: She sought counseling for symptoms of anxiety, depression and marital and family conflict over differences in religious commitment.
Psychiatric History: Unremarkable
Personal and Social History: She was born in a small village in Greece. She immigrated to the United States at 10 years of age. She is an only child due to pregnancy and birth complications her mother underwent. She had a very religious upbringing. She reported her parents were very strict. Her mother died when she was 15 years of age. Her father passed away two years later and she lived with her aunt until her marriage.
Medical History: Unremarkable; Mental Status Check: Unremarkable
DSM-IV-TR Diagnoses:
- Axis I: 300.4 Dysthymic Disorder; 300.02 Generalized Anxiety Disorder; V61.20 Parent-Child Relational Problems; V61.1 Partner Relational Problems; V62.89 Religion or Spiritual Problem.
- Axis II: None; Axis III: None
- Axis IV: Psychosocial and environmental factors: Mild (Problems with primary support group-value discord).
- Axis V: Global Assessment of Functioning: 70 (Some Mild Symptoms)
II Case Formulation: Several predominant automatic thoughts accompanied her anxiety and dysphoric emotions. She had a tendency to have demanding expectations. She would complain that her daughters did not do the things she wanted them to do. She had the underlying belief that there is a universal law that children should always do what their mothers ask. If they don't obey, she has the right to get upset. She would also generalize to see things in 'always or never' categories. Her husband had different interests than she did; she would tell herself, he "will never change" and "will always be the same". She would criticize her husband's choices, thereby weakening the marriage even more. She also had Catastrophizing thoughts: the perception that something is worse than it actually is. She erroneously reacted to her daughter's and husband's choices as if they were grave and catastrophic events and she thus reacted with even more anxiety and dejection. She also had erroneous spiritual beliefs incompatible with the mind of Christ and His Church. E.g., she did not understand or apply the principle that God asks and never coerces obedience.
III Treatment Plan: Initial intervention focused on ensuring a trusting, caring, therapeutic and spiritual relationship. She was comfortable to know her feelings and thoughts were listened to and understood. The principles of cognitive-behavioral therapy were reviewed in sessions and in bibliotherapy assignments. David Burns' (1980) book, Feeling Good, was used. Standard tools of examining and restructuring automatic thoughts and consequent emotions were aimed at attenuating her anxiety and dysphoric symptoms. Behavioral practice (role playing) both in the office and as "homework assignments" was integral to the treatment. The depth of her religious commitment allowed for a significant spiritual component to her treatment. Her demanding expectations led her to impose her personal set of rules on her family, often coercively. She assumed that the inviolability of physical laws (gravity, for example) applies to moral laws and social norms as well. This was rooted in her faulty understanding of human nature and God. God gave mankind free will. Obedience, while a requirement, always remains a choice and cannot be coerced. A person cannot violate the law of gravity, for example, but remains free to disobey God's commandments (as well as social rules and norms). Disobedience to the moral law of God certainly causes different degrees of consequences, some major like the loss of eternal life, and others more minor. Nevertheless, God does not force obedience.; it can be offered only in freedom. So the understanding and practice of Orthodox spirituality was integrated into her treatment.
Clinical Outcome: Sophia's anxiety and depression symptoms significantly decreased over the course of a year. The relationship with her husband and daughters also was much improved; she was no longer distressed over choices they would make that differed from hers. For example, not only was she less controlling but participated more in her husband's hobbies.
Clinical Postscript: Some years after termination of therapy I was contacted that Sophia had terminal brain cancer. She was admitted into a leading cancer hospital. Her initial presenting problems and treatment focus involved on her anxiety, dysphoria and family problems. Because she was a deeply religious woman, I made clinical-pastoral visits (as a priest-psychologist) to her during and up to her death in the hospital. The nature of her new 'treatment' shifted from family issues to the acceptance of her impending death. Because of her deep commitment to Orthodox Christian teaching, the concept of her spirituality was integrated into exploring and addressing the "meaning of her life." It comforted to her to know that she had brought Christ to her family, and that He would continue to care for them spiritually after she would be dwelling with Jesus after her physical death. By addressing her cultural value of being a devout Orthodox Christian and integrating this into her therapy, she became fulfilled spiritually and could die in peace.
ENDNOTES
1 Former Elder, now Saint Paisios of the Holy Mountain was officially canonized a saint by Patriarch Bartholomew of Constantinople and the Holy Synod on 13 January 2015. (www.omhksea.org/2015/01/ecumenical-patriarchate-officially-entered-elder-paisios-among-the-list-of-saints/) Among the Orthodox, the pathway to sainthood is usually started by the popular acclamation that someone is worthy (Axios!) of sainthood. This was the certainly the case of saintly Elder Paisios. His Feast Day will be on 12 July. My readers may want to pray the Apolytikion and Kontakion of the new saint:
Apolytikion in Tone 1
The offspring of Farasa, and the adornment of Athos, and the imitator of the former righteous, equal in honor, O Paisios let us honor O faithful, the vessel full of graces, who hastens speedily to those who cry out: glory to Him Who gave you strength, glory to Him Who crowned you, glory to Him Who grants through you healings for all.
Kontakion in Plagal Tone 4
The most-famed ascetic of the Holy Mountain, and the newly-enlightened light of the Church, let us praise him with hymns with all our heart, for he leads the faithful towards a perfect life, filling them with rivers of gifts, therefore we cry out: Hail, O Father Paisios.
2 Elkind, D. (2014) PsycCRITIQUES .Vol. 59, No. 45, Article 4
REFERENCES
(These references are for the entire course, only a portion are for Part 6)
Abramson, L. Y., Seligman, M. E. P., & Teasdale, J. (1978). Learned helplessness in humans: Critique and reformulation. Journal of Abnormal Psychology, 87, 49-74.
Alfeyev, Bishop Hilarion, (2002). The Mystery of Faith. London, England: Darton, Longman and Todd.
Alfeyev, Archbishop Hilarion. (2009). Christ the Conqueror of Hell: The descent into Hades from an Orthodox perspective. Crestwood, NY: St. Vladimir's Seminary Press.
Athanasius, St. (1975). On the Incarnation of Our Lord. Crestwood, NY: St. Vladimir's Seminary Press.
Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall.
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of Depression. NY: Guilford Press.
Beck, A.T. (1988). Love is Never Enough: how couples can overcome misunderstandings, resolve conflicts and solve relationship problems through cognitive therapy. NY: Harper-Collins
Beck, A.T. (1999). Prisoners of Hate: The cognitive basis of anger, hostility and violence. New York: HarperCollins.
Beck, J.S. (1995). Cognitive Therapy: Basics and Beyond. NY: The Guilford Press.
Beck, J.S. (2011). Cognitive Therapy: Basics and Beyond. (2nd ed.). NY: The Guilford Press.
Breck, J. (2001). Scripture in Tradition: The bible and its interpretation in the Orthodox Church. Crestwood, NY: St. Vladimir's Seminary Press
Burns, D. (1980). Feeling Good. New York: William Morrow.
Demakis J. (2004). Historical precedents for synergia: Combining Medicine, diakonia and sacrament in byzantine times. In S. Muse (Ed.), Raising Lazarus: Integral healing in Orthodox Christianity. Brookline, MA: Holy Cross Orthodox Press.
Ellis, A. (1962). Reason and Emotion in Psychotherapy. Secaucus NJ: Lyle Stuart.
Ellis, A. & Harper, R. (1975). A Guide to Rational Living. NY: Wilshire
Enright, R.D. (2012). The Forgiving Life: A Pathway to Overcoming Resentment and Creating a legacy of love. Washington, DC: American Psychological Association
Erwin, E. (1980). Psychoanalysis: How firm is the evidence? Nous, 14, 443-456
Exline, J.J., Baumeister, R.F. Zell, A.L., Kraft, A.J., & Witvliet, C.V.O., (2008) Not so innocent: Does seeing one's own capability for wrongdoing predict forgiveness. Journal of Personality and Social Psychology, 94, 495-515.
French, R. A. (1991)(trans). The Way of a Pilgrim; and The Pilgrim Continues His Way. San Francisco, CA: Harper
Galanter, E. (1962). Contemporary psychophysics. In Brown, R. (Ed.), New Directions in Psychology. NY: Holt, Rinehart & Winston.
Gassin, E.A. (2001). Interpersonal forgiveness from an Eastern Orthodox perspective. Journal of Psychology and Theology, 29, 187-200.
Hausherr, I. (1990). Spiritual Direction in the Early Christian East. Kalamazoo, MI: Cistercian Publications.
Howe, R. (2005) The Disease Manager's Handbook. Sudbury MA: Jones and Bartlett Publishers.
Hronas, G. (1999). The Holy Unmercenary Doctors: The Saints Anargyroi, physicians and healers of the Orthodox Church. Minneapolis, MN: Light and Life.
Izard, C. (1993). Four systems for emotion activation: cognitive and noncognitive processes. American Psychologist. 100, 1, 68-90.
Izard, C. E. (2001). Emotional intelligence or adaptive emotions? Emotion, 1, 249-257.
Izard, C.E. (2002). Translating emotion theory and research into preventative interventions. Psychological Bulletin, 128, 796-824.
Kadloubovsky, E., & Palmer, G.E.H. (1954). Early Fathers from the Philokalia. London: Faber and Faber.
Kahneman, D. (1973). Attention and Effort. Englewood Cliffs, NJ: Prentice Hall.
Krindatch, A. (2011),(Ed.). Atlas of American Orthodox Christian Churches. Brookline, MA: Holy Cross Press
Langes, M. (Ed.) (1977). The Evergetinos. Athens, Greece: Monastery of the Transfiguration.
Lazarus, R.S. (1991) Emotion and Adaptation. NY: Oxford University Press
Loftus, E. F. (1980). Memory, Surprising New Insights Into How We Remember and Why We Forget. Reading, MA: Addison-Wesley
Marmor, J. (1962). Psychoanalytic Therapy as an Educational Process: Common Denominators in the Therapeutic Approaches of Different Psychoanalytic Schools. In Masserman, J.H. (Ed.). Science and psychoanalysis. (Vol. 5). Psychoanalytic education. Pp. 286-299. New York: Grune & Stratton.
McGoldrick, M., Giordano, J. & Garcia-Preto, N. (Eds.). (2005). Ethnicity & Family Therapy. (3rd ed.). NY: Guilford Press.
McGuckin, J. A. (2004). The Westminster Handbook to Patristic Theology. Louisville, KT: Westminster John Knox Press.
Morelli, G. (2004) Sex is Holy: The responsibility of Christian parenting. The Word. 48. 6, 7-8.
Morelli, G. (2006a, March 6). Asceticism and Psychology in the Modern World. http://www.orthodoxytoday....
Morelli, G. (2006b, May 08). Orthodoxy and the Science of Psychology. Available: http://www.orthodoxytoday....
Morelli, G. (2006c, July 29). Dealing with Brokenness in the World. Available: www.orthodoxytoday.org/OT....).
Morelli, G. (2006d, December 21). The Ethos of Orthodox Christian Healing. Available: http://www.orthodoxytoday....
Morelli, G. (2009, September 26). Secularism and the Mind of Christ and the Church: Some Psycho-Spiritual Reflections. Available: http://www.orthodoxytoday....
Morelli, G. (2014). Psychotherapy with members of Eastern Orthodox Churches. In P. Scott Richards & Allen E. Bergin (Eds.) Handbook of Psychotherapy and Religious Diversity (2nd ed. pp. 77-102). Washington DC: American Psychological Association.
Novaco, R.W. (1975). Anger Control: The Development of an Experimental Treatment. Lexington, KY: Lexington.
Novaco, R.W. (1977). Stress inoculation: A cognitive therapy for anger. Journal of Consulting and Clinical Psychology, 45. 600-608.
Palmer, G.E.H.; Sherrard, P.; and Ware, K. (Trans.) (1971, 1981, 1988, 1990). Philokalia, I IV. London: Faber and Faber.
Posner, M.I., & Snyder, C.R.R. (1975). Attention and Cognitive Control. In Solso, R.L. (Ed.), Information Processing and Cognition: The Loyola Symposium. Hillsdale, NJ: Erlbaum.
Powers C., Nam, R.K., Rowatt, W.C. & Hill, P.C. (2007). Association between humility, spiritual transcendence, and forgiveness. Research in the Social Scientific Study of Religion, 18, 75-94.
Rathus, S. A. (1973). A 30-item schedule for assessing assertive behavior. Behavior Therapy, 4, 398-406
Sakharov, Archimandrite Sophrony, (1999). St Silouan the Athonite. Crestwood, New York: St. Vladimir's Seminary Press.
Shiffren, R.H. (1988). Attention. In Atkinson, R.C., Herrnstein, R.J., Lindzey, G., & Luce, R.D. (Eds.), Stevens' Handbook of Experimental Psychology. (Vol.2). NY: Wiley.
Spiegler, M.D. & Guevremont, D.C. (2010). Contemporary Behavior Therapy. Belmont, CA: Wadsworth.
Staniloae, D. (2003). Orthodox Spirituality: A Practical Guide for the Faithful and a Definitive Manual for the Scholar. South Canaan, PA: St. Tikhon's Seminary Press.
Tavris, C. (1984), Anger: The misunderstood emotion. NY: Simon & Schuster
Vlachos, Archimandrite Hierotheos (1993). The Illness and Cure of the Soul in the Orthodox Tradition. (Translated by Effie Mavromichali). Levadia, Greece: Birth of the Theotokos Monastery.
Vlachos, Archimandrite Hierotheos (1994a). Orthodox Psychotherapy: The Science of the Fathers. (Translated by Esther Williams) Levadia, Greece: Birth of the Theotokos Monastery.
Vlachos, Archimandrite Hierotheos (1994b). Orthodox Spirituality: A Brief Introduction. (Translated by Effie Mavromichali). Levadia, Greece: Birth of the Theotokos Monastery.
Ware, Bishop Kallistos (1979). The Orthodox Way. Crestwood, NY: St. Vladimir's Seminary Press.
Ware, Bishop Kallistos (1963). The Orthodox Church. London: Penguin Books.
Weiner, B. (Ed.). (1974). Achievement Motivation and Attribution Theory. Morristown: General Learning Press.
Wheeler, E. P. (ed., trans.) (1977). Dorotheos of Gaza: Discourses and Sayings. Kalamazoo, MI: Cistercian Publications