The Gestalt! Editorial

Jay M. Uomoto, Ph.D., ABMP Shepherd Center Acquired Brain Injury Program Atlanta, Georgia

Jay M. Uomoto, Ph.D., ABMP is Clinical Director and Neuropsychologist of the Acquired Brain Injury Program at Shepherd Center in Atlanta, Georgia. He is also Clinical Assistant Professor of Rehabilitation Medicine at Emory University School of Medicine. His research work has included focusing upon risk factors for dementia in older Japanese Americans, determinants of long term care in that same population, as well as investigating the relationship between mild traumatic brain injury and chronic pain, the efficacy of music therapy in improving sustained engagement in patients with brain injury, and is researching the contributions of religious coping in patients with brain and spinal cord injury. He holds a Diplomate in Medical Psychotherapy and is certified in Health Care Ethics.

Shepherd Center is a 100-bed non-profit specialty hospital located in the south end of the Buckhead district of Atlanta, Georgia. The center provides comprehensive rehabilitation services for persons with acquired brain injury, spinal cord injury, and multiple sclerosis. For more information about Shepherd Center visit the website at www.shepherd.org.

Introduction

In recent times, there has been a renewed interest in the soul as more than a meaningful concept but as an organizing force in the lifeblood of the individual. The concept of the soul is not a stranger either to the field of psychology or the practice of psychotherapy, and its nature has been debated within philosophical circles for centuries. Yet, concern for the soul and its centrality to human suffering and functioning in this world seems to have touched numerous levels of society today including consumers of popular psychology and spirituality to those involved in medicine and biomedical ethics. It seems that the term "soul" is the new catchword for the 1990s. Soul care has now come into vogue as a viable and vital means of healing emotional wounds, bringing a new perspective to human suffering, providing a context within which to understand suffering, and dissipating some of the meaninglessness that comes with human finitude. Indeed, the ancients considered the soul as the center of being-ness of human life, as commented on by Plotinus:

The advent of soul care as a commonly known phrase can largely be attributable to writers such as M. Scott Peck whose book The Road Less Traveled 2 was the catalyst to a host of other titles that sought to find convergence between psychology and spirituality. This was the beginning of rapprochement between psychotherapy and soul care. Thomas Moore followed much later with his seminal work titled Care of the Soul: A Guide for Cultivating Depth and Sacredness in Everyday Life.3 A lesser known be equally powerful treatise on the soul is by Alan Jones in his book titled The Soul's Journey: Exploring the Three Passages of the Spiritual Life with Dante as a Guide.4 In this work, Jones well describes the journey that many must take, literally through their own hell, in order to reach a place of peace, healing and stillness. In essence, suffering is a necessary, even mandatory part of soul care. Jones describes this pain that can be an avenue to growth:

I have, at long last, located an old pain inside me - a pain I seek to understand rather than suppress, a pain that I need, a pain that holds a secret, a pain about love and power, about love and fear. A friend of mine spoke of the pain we feel when we sense that we are growing...It is the pain of life demanding attention. Above all, it is the pain of choice. It is the pain of purgation. (p.109-110).5

Herein is the tension: soul care may focus on, even require suffering as a rite of passage and growth, yet this idea may be antithetical to what may be seen as the primary directive of psychotherapy and of health care in general.

Herein is the tension: soul care may focus on, even require suffering as a rite of passage and growth, yet this idea may be antithetical to what may be seen as the primary directive of psychotherapy and of health care in general. Much of what we understand to be at the core of the helping professions harkens back to the original oaths of medicine, as embodied by the Hippocratic tradition: Benefit the patient and do no harm. In psychotherapy, our patients and clients most often come to us with the intent of alleviating some psychological malady, correcting some interpersonal dysfunction, healing the wounds of trauma, reconciling ailing relationships, lifting mood, reducing anxiety, preventing excess disability, improving functional activities of daily living, removing guilt and shame, and a laundry list of other presenting concerns. The psychotherapist who follows the Hippocratic Oath no differently than a physician is bound to heal and cure their patient's illnesses. Ethicists call this principle beneficence. The relief of suffering is central to this principle. In soul care, the principle of beneficence may take on a different look and demeanor. Beneficence may require allowing one's suffering to continue for the goal of spiritual deepening. It is this tension between beneficence and non-maleficence (i.e., do no harm) within the context of psychotherapy and soul care that is now discussed with the goal of finding a point of convergence between these two forms of addressing the human condition. More concretely, are there irreconcilable differences in the goals of psychotherapy and that of spirituality that places the client or patient in a position of having to choose one over the other? Can one do psychotherapy and not violate a person's desire toward furthering their soul care? Can human suffering be understood simultaneously from the paradigms of psychotherapy and spiritual growth?

Psychotherapy As Soul Care

One solution to the tension defined above would be to somehow meld psychotherapy and soul care and treat them as one activity. Psychotherapy as a stirring of the soul, and the consequent insights and changes brought about by therapy, could be understood as caring for the soul.

Psychotherapy as a stirring of the soul, and the consequent insights and changes brought about by therapy, could be understood as caring for the soul.

Jung was adept at recognizing the soul as something to be addressed and sought as a part of analysis and psychotherapy. He was fascile in moving between conceptualizing the significance of dream analysis to contemplating upon the spiritual problems of man.6 In practice, the soul is accounted for within psychologic interventions and one does not worry whether or not one has actually spoken a word about God, spirit, or soul. Yet, even Jung raises the tension between psychotherapy and soul care at the point of considering the relative roles of physician and clergyman on issues of the suffering soul:

It is in reality the priest or the clergyman, rather than the doctor, who should be most concerned with the problem of spiritual suffering. But in most cases the sufferer consults the doctor in the first place, because he supposes himself to be physically ill, and because certain neurotic symptoms can be at least alleviated by drugs...We can hardly expect the doctor to have anything to say about the ultimate questions of the soul. It is the clergyman, not the doctor, that the sufferer should expect such help.7 (p. 227)

Thus, there are limits to the degree to which the psychotherapist may approach and properly address larger or deeper issues of the soul. Psychotherapy is not seen as a substitute for soul care, but that it can enhance one's own wrestling with soul care issues. Jung might say, however, a boundary exists between the two at the juncture of such issues as good, evil, ultimate meaning, faith, and grace imparted by God. Should a person's psychological disturbance be rooted in spiritual pathfinding, that is the point that psychotherapy is distinguished from soul care.

Psychotherapy Versus Soul Care

One can view psychotherapy as always orthogonal to the work of soul care. They address two different domains or levels of human functioning. This would imply that human maladies can be categorized as being appropriate or inappropriate grist for the psychological mill. Maladaptation in interpersonal functioning, anxiety disorders or family disintegration may be seen as appropriate categories of concern for psychotherapy whereas spiritual ennui or complacency and stagnancy in faith development may simply be the purvey of a soul caregiver - be it a priest, clergyman, or shaman. Unfortunately, this does not provide resolve for how human suffering can be understood. One would be forced to label a particular episode of suffering or type of suffering as either psychological or spiritual in origin. This runs the risk of seeking to divide the world into those traditional categories of sacred and secular; that which is spiritual versus that which is, in essence, "just" psychologic or psychic. Moreover, this type of conceptualization may only create deadlock when the client presents in the psychotherapist's office with the question of whether or not the malady should be relieved and psychologically remedied, or brought to greater acuity and clarity so as to better be able to apprehend the suffering and to mine its spiritual value.

Psychotherapy as a Road Toward Soul Care/Soul Care as a Road Toward Effective Psychotherapy

Another way to view the tension may be to place in temporal sequence the activities of psychotherapy and soul care. In the first scenario, psychotherapy may pave the way toward deeping one's engagement in caring for the soul. For example, removing a layer of anxiety may prove to be essential in order for a client to have the introspective stamina to engage in contemplating matters of the soul. Cognitive-behavior modification could function in this case as a varnish remover that uncovers the antique wood of the soul underneath layers of psychological stain.

Is it beneficial to the patient to have as the first goal of psychotherapy the relief of suffering?

The reverse scenario of soul care preceding psychological relief entails the necessity of prolonging suffering, or at least not reflexively attempting to eliminate discomfort, in order to embrace the spiritual and soul caring qualities that suffering may bring. Yalom8 reviews Tolstoy's The Death of Ivan Illyich to illustrate the legacy of suffering and dying as a way to acutely appreciate, and then apprehend, life in all of its nuances. In this story, Ivan Illyich suffers from a horrible stomach pain that eventually is diagnosed as a terminal condition. He realizes, according to Yalom, that "he is dying badly because he has lived his life badly" (p.33).9 This deep insight allows him to live his remaining life with integrity. Without this suffering, Ivan Illyich may never have had the opportunity to experience that personal growth - such growth being conceptualized as soul cure by some. Illyich's pain never dissipated; yet, the reframing of his life proved sufficient for satisfying his soul that the physical pain was superfluous. Illyich's struggles to find meaning and purpose to his suffering constituted his form of spiritual sojourning.

Much publicity has come to some of the newer psychotropic mood drugs. The much heralded selective seratonin reuptake inhibitors (SSRIs) have proven themselves quite effective in alleviating depressive symptomatology. Therapeutic benefit from this class of medications occurs more rapidly, with less sedating side effects and with less weight gain propensities. The various debates on Prozac, for example, underscore some of the tension that surrounds the success of this drug. Is it an artificial means of altering personality? Does one's essential personhood change as a result of Prozac? In connection with the present discussion, the question arises as follows: Because drugs such as Prozac are so effective, are we in danger of cutting off the process of soul care too soon by its use to relieve suffering? The patient who arrives in the office of a psychiatrist may request assistance for their psychologic suffering, but with a stroke of the pen on the prescription pad, and the snapping off of the paper that is traded in for a dose of relief, is that patient prevented from engaging in a struggle for soul care? It is not much of a stretch to consider the psychotherapy candidate that may present to the therapist in similar fashion upon an intake interview. Is it beneficial to the patient to have as the first goal of psychotherapy the relief of suffering? Is it harmful (non-maleficence) to deny that patient access to a "dark night of the soul" experience, and hence a missed opportunity for a deepening of one's spirituality? At what clinical cutoff point is the so called "bottom line" beyond which one would not allow soul care to occur in favor of psychotherapeutic intervention in the context of an office visit?

Rapprochement

There will likely always exist a tension between psychotherapy and soul care. Each represents a circle, and they overlap with any person that presents for a first session in the psychologist's or health care professional's office.Sometimes these circles

In practice, the tension between psychotherapy and soul care will necessitate that the psychotherapist be well informed and sensitive to matters of the soul.

or realms of inquiry, do not overlap and the content of each can remain orthogonal to each other. In that case, what one does in psychotherapy does not effect what happens at the level of the soul. There are likely to be occasions when the patient presents with concerns that are so intricately intertwined with spiritual and religious overtones, that what one does in the psychotherapy session will most naturally impact upon that patient's personal spiritual well-being. In other situations, the therapist may be required to prioritize, not only from the standpoint of good clinically savvy, but also on the grounds of clinical ethics, whether or not to address the emotional issues first, that is, before attempting to raise concerns about a suffering soul. There are obviously going to be no set rules.

In practice, the tension between psychotherapy and soul care will necessitate that the psychotherapist be well informed and sensitive to matters of the soul. This is no different than needing to know how to consider multicultural issues in treatment, or understand developmental and aging issues while delivering treatment services. It may also require the psychotherapist to have on their own list of consultants such individuals as ministers, priests, chaplains, and other such individuals who tend to specialize in soul care and cure. Rapprochement may therefore involve an interdisciplinary approach and dialogue. Psychotherapists, psychiatrists, priests, pastors, rabbis, other clergyman and religious practitioners may need to open more extensive discussion to better understand the relative contributions of each of these traditions to the clinical situation.

References

1. Plotinus. Cited in Cousineau, P. (ed.) (1994). Soul: An archaeology. San Francisco: Harper San Francisco.
2. Peck, M.S. (1978). The road less traveled: A new psychology of love, traditional values and spiritual growth. New York: Simon and Shuster.
3. Moore, T. (1992). Care of the soul: A guide for cultivating depth and sacredness in everyday life. New York: Harper Collins Publishers.
4. Jones, A. (1995). The soul's journey: Exploring the three passages of the spiritual life with Dante as a Guide. San Francisco: Harper San Francisco.
5. Ibid.
6. Jung, C. G. (1933). Modern man in search of a soul. San Diego: Harcourt Brace Jovanovich.
7. Ibid, p. 227.
8. Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books.
9. Ibid, p. 33.