Several of Jay Adam’s counselling case studies concern mental health and depression. Let’s have a look at a couple of them.
First of all, we have Violet, a 54 year old lady who is suffering from depression and also has an undisclosed problem which she can tell only to God. Have a look at the questions as well as the case study.
It is worth noting three things here. First of all, that the questions suggest little interest or curiosity in the reported depression. This seems to arise out of an assumption that Violet’s issues all stem from the undisclosed problem. It is of course possible that they do. It may be that Violet lives with her family because she separated from her husband and has never resolved that. It could be that she struggles with same-sex desires or it could be that although she lives with her son and his wife that she has been involved in a long running feud with her daughter in law for many years. It is possible then that her depression is a result of one of those things.
It is equally possible that Violet’s depression and loneliness are completely irrelevant to her secret. Perhaps it was genuinely a throwaway comment intended as light humour. Perhaps there are things that she has learnt are best kept between her and the Lord. It is possible even that she is concerned that there are things she could end up sharing but might have a negative affect on others. For example, it is possible that her concern is for her son and his wife, maybe she worries about how they are coping or maybe they are the ones arguing.
So I would not presume that I necessarily need to know what the specific problem is in order to resolve the problem. Indeed, to avoid some kind of struggle or even game playing I may well be tempted to say “that’s okay Violet, I’m not here to check up on every detail of your life. Shall we talk about how you go about bringing your struggles and cares to the Lord.” This may even give her confidence to begin to disclose or it may be that it helps her find the strength to genuinely take the issue to the Lord in prayer. She may still revisit it at a later date.
I am inclined to lean towards the presumption that if she has begun to mention something via a pre-appointment form that this suggests she is testing the water to see if she has permission to share things with me and so I would find ways to leave the door open for conversation. For example I might mention the wide range of issues that people come and talk to me about being careful to name those seen as the most shameful. I am there indicating that there isn’t anything that will shock me, nothing that cannot be faced in the counselling room and nothing that is going to break my relationship to her as her pastor.
But I also want to give time to talk about a range of issues including her relationships with others, her physical health, experiences in her life and how she is doing spiritually. I will want to talk to her about her expression of bitterness relating to church attendance. I’m not going to presume here that this means she is in sin or that she is automatically in the wrong -though it is completely possible that the resentment does stem from conviction of sin. I also would not presume that the church is at fault. Rather, I would seek to be curious as we look to explore potential causes and consequences together.
One thing I’m particularly interested in is her understanding of justification. There is just the possibility that a block on disclosure is the fear of shame and judgement which arises out of a misunderstanding of the Gospel here. Justification by faith releases us to be truly accountable to others.
Case 11 is about a depressed Christian. The counsellor’s approach is to encourage them to memorise and meditate on Scripture in order to count their blessings.
Adams’ questions on this occasion do give us opportunity to disagree with the methodology and rightly so. It’s worth noting that whilst Adams encourages a directive/ prescriptive approach to counselling where the counsellor instructs the counselee on what they should do, that this is constrained by what Scripture directs. So Adams would argue that in this case, the memorisation of Scripture is a directive command which the Bible doesn’t in fact give. Additionally, the counsellor has jumped in with a solution without even bothering to dig a little deeper into what might be causing depression.
The question of course at this stage is what happens if the counsellor is unable to identify a specific root sin that is causing depression. Does nouthetic counselling allow for the possibility that there isn’t a specific cause? At the same time we need to be ready for the possibility that the cause is the person’s own sin or abuse they have suffered. We will also want to talk about medical causes and about medication.
Our next case study concerns Andy who struggles with weight and self-worth
There is a telling line where he says “I’m ashamed of my past -especially my relation to my parents.” Here is one of those manhole covers but it is not picked up on either in the case study itself or in the discussion questions. To be sure, it does seem that Andy wants to avoid any responsibility in terms of his obesity and there are as Adams identifies chicken and egg questions around this and his self-pity and loneliness. Yet I keep coming back to this point that Andy has begun to open up about this thing called shame and I want to be careful that my suspicion of Freudian obsession with parental issues doesn’t prevent me from opening that manhole cover up.
What we do know is that something is stopping Andy from getting his weight under control and as far as we can tell it isn’t medical. Now, there are two things we would want to talk about in terms of practical causes of obesity. First of all we will want to talk about what Andy eats both in terms of quantity and in terms of types of food. Is his diet healthy? Secondly, we will want to talk about exercise – how much he is doing?
Other approaches to Biblical counselling and coaching provide some helpful tools at this stage by getting the counselee to identify what the actual obstacles are. If Andy’s aim is to be physically healthy, then what is preventing him. We talk in terms of Skills, Knowledge, Motivation and Enemy. Is it that he doesn’t know how to be healthy, or knows but needs training in how to go about it, is it that he lacks motivation or is there something going on in terms of spiritual warfare?
It is possible that he is in a vicious cycle in terms of his depression because he lacks motivation to exercise and at the same time comfort eats on junk food. The vicious cycle will include feelings of guilt after binge eating junk. Breaking the cycle or “frying the egg” involves understanding those motivations including identifying root causes. It may well involve medication and further counselling about those issues. It will involve applying the Gospel to his present situation, his past and his future too, not just some quick fix behavioural responses.
My comments in the last example are crucial for all pastoral cases relating to depression. We need to be aware of the broad range of potential causes including circumstances, being sinned against, carrying guilt and shame, physical causes etc. We need to then be aware of how medication and other, specialised responses may be helpful. We need to remember that our primary responsibility is to apply the Gospel to the situation.