The Traditional Triage of Mental Disorders

OR, Disease, Disorder, or Demons?

There is a popular idea out there that historic Christianity considered all mental illness a result of diabolic activity. This notion is mistaken. The Orthodox or traditional Christian triage of disorders recognizes a three-fold diagnostic approach.

1. Body (soma) or somatic origin, which manifests biological/physiological disorders;
2. Soul (psyche) or psychological origin, which manifest spiritual/moral disorders;
3. Demons (daimonia), demonic origin, which consists of degrees of interference by malevolent spiritual entities.

The first are the two integrated aspects of human nature; the third is in a category by itself. This triage has been maintained in Eastern Orthodox spirituality since the inception of Christianity and is rooted in biblical religion. Spanning the centuries, pastoral counselors existed in the Church in one form or another, in addition to medical physicians treating illnesses. Sometimes pastoral counseling and medical practice converged in persons whom the Orthodox Church terms Unmercenary Healers. These are enlightened saints who provide spiritual, moral, and physical care to troubled souls without charge.

The Orthodox Christian account of mental-emotional health would not have stood the test of time if the myth that “demons did it” were its sole therapeutic logic. What the Church offers is properly called psychotherapy since the direct sense of the word derived from Greek means ‘treatment of the soul’ (psyche + therapeia), a holistic approach to the human person. In contrast, a pure materialist disease model would be ‘treatment of the brain’ (for mind is excluded from possibility). This is why drug treatment for mental problems is the conventional gold standard of our day. Materialistic naturalism underwrites today’s medical model, which dominates in modern psychiatry.

Orthodox psychotherapy is also in contrast to a purely supernatural approach, which is as imbalanced as purely naturalistic theories. 

Orthodox psychotherapy avoids the false dilemma between natural versus supernatural. It recognizes the correct both-and approach. In clinical terms, this triage also serves as the bedrock for differential diagnoses, i.e. what to rule in and what to rule out. Far from unsophisticated superstition, a careful look reveals that the Church’s spiritual therapeutic tradition recognizes both material (often called natural) and non-material causes. Orthodoxy does so without absolutizing either type of causation in a zero-sum worldview game.

Soma (Body)

Orthodoxy’s traditional triage first rules in or rules out somatic causation. It answers the question, is the cause in a physical body system? If so, medical interventions of the day are prescribed. Substance abuse, neurological problems, paralysis, and other physiological causes have always been viewed as reasons for a disturbance in the somatic category. Material treatments follow material diagnostic conclusions in Eastern Orthodox psychotherapy. This does not rule out intercessory prayer and divine intervention; it simply means physical ailments are sensibly addressed by appropriate medical intervention.

Somatic causes can be of two kinds. First, a medical condition might originate within the body due to a problem of processes or substances, called endogenous illness (endo + genous, “produced within”). This is the first part of somatic causation that must be ruled in or ruled out (differential diagnosis). Aging and congenital conditions, for example, result in endogenous conditions.

Second, and in contrast to endogenous conditions, an exogenous illness is produced from outside the body (exo + genous, “produced outside”), such as an environmental toxin. Get rid of the toxin, resolve the condition—the problem is not within the organism but outside of it. A special case of exogenous causation for the mental-behavioral health field iatrogenic illness, which is a doctor-induced condition (from Greek iatros + genos, “physician-born”). For example, iatrogenic problems commonly come about due to the unrecognized side effects of psychiatric prescription drugs.

Psyche (Soul)

Once the traditional triage rules out somatic causes (e.g. a neurological disorder), the distinction between material and non-material gets fuzzier. It’s no use claiming triage is an enterprise of unqualified certainty or exact diagnostic calculus. Distinguishing the root cause of a mental-emotional problem is complex and delicate if not impossible in some cases. But Orthodox psychotherapy can handle the challenges and ambiguity. In the Orthodox view of human nature, the body and soul (soma and psyche) together compose the human person. The soul is the vitalizing force of the body; the body manifests the soul’s actions and intentions. What affects the body affects the soul and vice versa.

Consider all of this in an ancient, clinical case study. Saint John Chrysostom (5th c.) once wrote to a despondent man named Stagirius. He suffered from suicidal ideations and was apparently possessed by a demon. As an enlightened therapist, however, St. John counseled the following:

These baneful thoughts do not only come from the demon; your own melancholy is also very much to blame. Yes indeed, this dark sadness even more than the evil spirit provokes these thoughts, and perhaps they are the only cause. It is certain that some individuals, quite apart from any demonic obsession, suffer this mania for suicide after excessive suffering. 

Quoted from Larchet, Mental Disorders and Spiritual Healing, p. 98. The Three Books to Stagirius have not been fully translated into English.

St. John does not automatically attribute suicide to a demonic cause—even in a known case of likley possession! St. John explain further:

Our joys and sadness come not so much from the nature of things as from our own dispositions. If they are wisely directed, we will always have a great store of contentment in our hearts. Bodily illnesses have as their cause some interior disorder rather than inclement weather or any other external influence, but this is even more so for maladies of the soul. For if those of the body are the lot of our nature, those of the soul belong only to our will.

Ibid.

First, notice the two-part triage of body and soul. Second, notice that St. John involves the disordering of biological systems as a cause and not fanciful or superstitious exterior causes, like a change in weather. He then uses this as an analogy for psychological problems: they arise from a disorder of our will. This means we have control over our inner states. We cannot blame changes in our inner disposition on lack of control, as if blaming changes in weather. As the master pastoral physician, St. John wants his patient Stagirius to take responsibility for his life. So, what else might we glean from this case?

After presumably ruling out medical causes such as substance abuse (e.g. alcohol), St. John brings up other possible, interlocking causes. Suicide, he observes, arises from a person’s dark inner struggles, a psychological condition. The psychological condition, in turn, can be related to environmental factors (but not the weather!). Excessive suffering, after all, happens within a social and cultural context, i.e. a person’s environment and family system. In Stagirius’ case, he became a monastic without a clear call or blessing. His problems erupted in the context of monastic community. Furthermore, St. John recognizes the role of strong emotions, patterns of thought and behavior, which we might term a cognitive-behavioral approach.

He also teaches that the demons cannot do anything without the consent or will of the human person. Stagirius is letting himself be vulnerable to demonic influence. Demons sow seeds in the soil of our hearts, which we till ourselves. They cannot force depression or despair.

The type of therapy needed follows from the diagnosis. In Stagirius’ case, therapy consists of cognitive and moral elements. For example, in this short passage, we see the saint reframing the man’s situation. The saint replaces the emasculating belief that the demon is causing suicidal thoughts with the new frame that Stagirius’ own passions or thoughts are doing this. Stagirius is now positioned for empowerment to make life-changing decisions for his own well-being, such as repentance of sin and/or addressing self-defeating habits.

Divine grace is also assumed in the background, which makes possible any and all healing of the human person. Without healing grace from the Father through the Son in the Holy Spirit, health—the right-ordering of disordered nature—is impossible. I have not gone into any detail, but in this case Stagirius consulted many holy people and holy places, and what is even clearer from the brief passage, he placed himself under the spiritual guidance of an ordained and knowledgeable shepherd of Christ, St. John. He is therefore undergoing therapy within the purview of the Church. Orthodox psychotherapy is part and parcel of the life of Christ in the Church.

As shown in the little case study of poor Stagirius, the traditional triage of the Orthodox Church has a lot of practical, clinical value. Much of it is familiar to our own time. The modern West is rediscovering what the ancient East never lost. The “demons did it” stereotype instead shows a lack of understanding of Orthodoxy and historic Christianity. Let us realize that time-tested, traditional Christian spirituality is by no means an outdated relic of primitive therapy. What is more, the robust anthropology of Orthodoxy houses critical knowledge of the human person and the human condition. 

BIBLIOGRAPHY

Henry Wace & William Percy, A Dictionary of Early Christian Biographies. Stagirus. Hendrickson Publishers, 1999.

Jean-Claude Larchet, Mental Disorders and Spiritual Healing: Teachings from the Early Christian East. Angelico Press / Sophia Prennis, 2011.