Integrating religious practices in psychotherapy? A Christian orthodoxic perspective by Frank-Gerald B. Pajonk in Journal of Clinical Case Reports Medical Images and Health Sciences

 Integrating religious practices in psychotherapy? A Christian orthodoxic perspective by Frank-Gerald B. Pajonk in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract 

Mental illnesses are related to the spiritual and religious dimensions of human experience. This has not yet been sufficiently taken into account in diagnostic and therapeutic processes. The aim of this overview is to show, on the basis of the rich tradition of the Christian Orthodox faith, not only that there is a history of Far Eastern provenance with regard to relaxation techniques and mental strategies, but also that the inclusion of spiritual and pastoral elements can help the individual patient to reach “peace of mind” (hesychia). Even severe psychiatric and psychosomatic illnesses, some of which are not always accessible through verbal and cognitive methods alone, can benefit from approaches to soul-spiritual concentration and ritual power such as the “Heart of Jesus Prayer”, because in some disease patterns the “border between me and the world” is obviously connected not only with fears but also with longings. Psychotherapeutic approaches that take into account such existential situations of the human being could therefore be a useful addition to the treatment of affected patients.

Introduction

 In recent years, a growing interest in religiousness and spirituality and their significance for psychological well-being and mental health can be observed in the expanding literature worldwide. As early as 2007 Klein and Albani (2007) published an overview worth reading of findings in relation to religiousness, its possible effects and explanatory approaches, and the practical consequences for psychotherapeutic practice. Interestingly, at that time these authors also criticized the lack of an “empirical examination of religion-adapted forms of treatment”, and called for scientifically-founded investigations “in view of the booming esoteric and (pseudo-)religious treatment market” (Klein & Albani, 2007). Juckel (2018) also emphasizes the importance of conducting more studies in order to show the extent to which such religion-adapted forms of treatment, known in the western medical sense as “complementary methods”, and not only traditional Chinese medicine, yoga and acupuncture, also show significant effect strengths similar to the traditional forms of psychotherapy. Furthermore, it should be proved how far ritualistically standardized procedures from the field of Christian religion, such as the Heart of Jesus Prayer and chanting, but also pastoral conversation and church services, are not at least equal in effectiveness to some long, complex, and cumbersome psychotherapy procedures (Juckel, 2018). It should be mentioned here that both mindfulness-based and relaxationoriented psychotherapeutic procedures have been further developed over the centuries not only in the Far East but in the realm of the Christian Orthodox faith in the Eastern Church; and even today they find an application in the field of Orthodox pastoral care. Moreover, it is worth mentioning that such essential religious–spiritual elements and practices can also now be found in well-established psychotherapy procedures such as MindfulnessBased Cognitive Therapy (MBCT) or Dialectical-Behavioural Therapy (DBT) (Baumann & Pajonk, 2014). In addition, against the background of extensive studies in recent years, it has been noted that an image of God, intense and intrinsic faith, and prayer seem to be favourable in terms of treatment outcomes for diseases across medicine (Schnabel, 2008). One of the few people in the context of the Christian Orthodox faith who has intensively and systematically dealt with this issue and developed the theological foundations of a Christian Orthodox psychotherapy is the Metropolitan of Nafpaktos in Greece, Hierotheos Vlachos. In his books, such as “Ψυχική ασθένεια και υγεία” (Mental suffering and health, 1993/2010) or his 1994/1995 book on orthodox psychotherapy (ορθόδοξη ψυχοθεραπεία, Orthodox psychotherapy), he presents not only orthodox Christian ideas on the concept of the soul and soul suffering, but also religious traditions and methods for soul healing. For example,the concept of hesychia (ἡσυχία = rest, silence) was outlined by him (Briskana-Müller, 2018).

Theoretical foundations

Against the background of the case described in Table 1, the factors of Greek Orthodox psychotherapy that have been identified as effective -namely the Heart of Jesus Prayer, chants, icon veneration, pastoral conversations and services rendered to God (liturgy, odours/incense, mysticism, sacraments), which are all aimed at the religious clarification of one’s relationship with God and thus healing in the sense of peace of mind/soul (hesychia) -will be discussed in more detail below. Thus, Greek Orthodox psychotherapy couldalso be considered as hesychia therapy. However, for a better understanding of the Orthodox psychotherapy developed by Metropolitan Hierotheos, some of the terminology must be explained in more detail. The concept of the soul has been subject to manifold influences and transformations over the millennia, depending on the relevant cultural, social, but also scientific, developments. Based on the teachings and tradition of the Church Father St. Gregory Palamas, it is assumed, in the context of Orthodox psychotherapy, that the soul, as the spiritual element of human existence, has a “trinitarian nature”, in which “nous”, “logos” and “spirit” are united. The nous is to be understood as the centre of human existence, which begets the logos and the spirit in the sense of the spiritual love of man. The soul is closely connected with the body, through which it acts, and it unfolds its energy through thoughts (“logismoi”). What is most essential for orthodox psychotherapy is the “heart”, which is considered as the essence of the soul and the centre of the unity of soul and body. Only when the energy of the soul (nous) returns to the essence of the soul (heart), does man attain unity and communion with the God of the Trinity through the union of these forces, by means of God’s grace (Metrop. Hierotheos Vlachos, 1994/1995). The idea that mental illnesses are related to such a spiritual–religious dimension has been revived by the Orthodox tradition, and should be given more attention today. This is especially the case since mental disorders thematically touch the conditions of existence and the meaningfulness of human life and these should therefore be the content of psychotherapeutic work.In the past and present Christian conception – and this was also the case for Augustine - the soul is part of the “Holy Spirit”, and thus of the transcendental and divine sphere, and it is therefore immortal (Augustinus, 1986). It is part of a spiritual continuum and is only temporarily “chained” to the body. It is part of the transcendental spiritual world before birth and is part of it after death, and during life it is the animating element of life, the breath of life or the principle of life; as a “spiritual soul” it has pure cognitions and is able to comprehend the “intelligible world” (Flasch, 2013). Nevertheless, man and his soul cannot access this sphere during life. He therefore reacts with despair (Kierkegaard, 1997) and his soul is as if torn apart. However, he can understand, through a long path of “crisis” and selfknowledge, how much his way to true knowledge, and with it true love of God, is obstructed by a useless everyday life and hedonistic striving. It is important to realize that despair and brokenness of the soul do not automatically mean diseases of the soul in our contemporary psychiatric sense. Nevertheless, these emotions can also become more intense and eventually lead to disturbances. For Augustine and the later Byzantine Church Fathers, this is about the salvation of the soul, about the metaphysical approach to how I and my soul are anchored in the world, especially in the religious dimension. The soul is sick when it no longer has this anchoring, when man no longer sees and feels it. He then begins to struggle for his soul and to feel his inner emptiness, until his soul finds a cure in the spiritual sense, on what is usually a long path of conversion and reorientation, and again finds the anchorage in the divine sphere (Juckel, 2018). That is, the concept of soul implies a concept of mental illness as a “metaphysical imbalance”. If this is overcome by knowledge and the power of faith, and the soul finds itself strengthened again by constant renewal, for example, in prayer (e.g. in the Heart of Jesus Prayer), then the mental illness can be overcome and “healed”. Only then will all depressive symptoms, such as fears, worries, and feelings of insensibility, despair and hopelessness, disappear with the return of the soul into “its world”, namely the world of pure knowledge, which means, in the tradition of the Church Fathers, with God. In this respect, Christian Orthodox psychotherapy has many fields of application for human life, and some of these go beyond what is usual in professional psychotherapy.

Praying and prayers

 Meditative practices, such as yoga and Zen meditation, often serve in the emotional or cognitive self-regulation of a person, and usually take place as intrapersonal processes entirely within that person and independently of others, especially once the guidance phase has been completed. Therefore, such techniques can be integrated very well into the wide range of relaxation procedures as selfmanagement activities or as basic fundamental elements of psychotherapeutic procedures. Here, the psychotherapist can have a motivating effect with regard to integration into everyday life (regular performance, especially in the morning, feedback via well-being questionnaires, etc.) or can also provide instruction within the framework of the sessions. The advantage of these non-verbal methods is that they can be used to address other sources of the patient’s experience, especially those of a physical nature, and to include and modify them in the treatment. In the broadest sense, this includes all ergo- and movement-therapeutic offers as well as exercises in the open air. Prayers and prayer chants have a similarly introspective character and can serve to calm and synchronize oneself with a greater whole. In Christianity, prayers, on the one hand, serve to build harmony with oneself and the greater whole (Grün, 2013). Their rhythmic nature – especially musically in chant form – also shows meditative elements connected with mindfulness and relaxation. Christian prayers, on the other hand, and in contrast to the prayers of Far Eastern religions, refer to a personalized God whom one meets personally in prayer and worship (Meyer-Blanck, 2019; Nancy, 2021); this includes silence. Inwardly, a form of conversation and dialogue (Grün, 2015; Alfejev, 2018) develops, from which the praying person returns enriched to his everyday life. This has a rhythmic and thus relaxing effect, and mental events are positively addressed and improved, not only on the physical but also on the spiritual level. In this context, prayers can take different forms (von Sales, 2015). Based on the rich Orthodox experience of the so-called Heart of Jesus Prayer (see below), which, together with appropriate icon veneration and use of Byzantine music, can be arranged in a ritualized manner over appropriate days or weeks for and by the believer (Hutt, 2017), Orthodoxy has a distinctively rich prayer culture. Prayers can serve to anchor the believer in his faith at set times in his daily life or in specific situations throughout the day. These prayers can be individual prayers, but they may also be prescribed prayers from prayer books corresponding to the monotheistic religions, which are suggested by the respective church in the form of devotions, catechisms, and so on, on a daily basis (e.g., Liturgy of the Hours). In the more complex and sometimes more abstract prayers, it is not only about “soothing the soul”, but also the confrontation and relationship with oneself, God and a profound personal or religious–theological issue. Thus, prayers become part of the believer’s everyday life, and, especially in crises, this has a pronounced sustaining function, not only as a spiritual but also as an intellectual resource. The believer experiences the encouragement in prayer more and more like the constant companionship of another, and thus as a strengthening of his everyday life, especially in times of stress. It is not so much a technique asa permanent dialogue with another and higher being, and also an exploration of himself in terms of self-knowledge in relation to a comprehensive worldview.

Heart of Jesus Prayer

 The Heart of Jesus Prayer, with its emotional power, is central in Christian Orthodoxy. The prayer unfolds strong meditative forces, leading to immersion and fusion. The prayer is repetitive and ritualistic, and is followed by the Amen and the the sign of the cross as an expression of Christian faith. The repeated invocation of Jesus in the Heart of Jesus Prayer creates a form of mindful inner emptiness, which establishes a connection with the divine sphere through the increasing absence of any external stimulus. The Heart of Jesus Prayer (also known as the heart prayer or perpetual prayer) is characterized by the fact that the name “Lord Jesus Christ” is continuously invoked (the text of the prayer is, for example, “Lord Jesus Christ. Jesus Christ. Jesus. Christ Jesus” or “Lord Jesus Christ, Son of God, have mercy on me” (Κύριε Ἰησοῦ Χριστέ, υἱὲ τοῦ Θεοῦ, ἐλέησόν με)). This is to comply with Paul’s injunction in the letter to the Thessalonians to “pray without ceasing”. In Orthodoxy, the prayer is accompanied by a prayer chain (komboskoini) consisting of 30, 33, 50, 100 or more knots, which is meant to symbolize the never-ending monastic prayer. The chain serves as an aid to concentration and, for a steady rhythm, is best used in the rhythm of one’s breathing and heartbeat, in complete oneness with oneself, the environment and the divine spirit. Interestingly, reports of current practice speak of positive effects of such meditative practices on mental and physical health: using the Heart of Jesus Prayer has a positive effect on the cardiovascular system, the rhythm of the prayer reduces the breathing rate to about six breaths per minute, and concentration and inner peace, along with mental freshness and creativity, are promoted (Bernardi et al., 2001). The Benedictine Emmanuel Jungclaussen, in his book Instruction in the Prayer of the Heart (Jungclaussen, 2008), presents the function of the Heart of Jesus Prayer as a supportive measure for psychotherapy. It is true that one might think that the Heart of Jesus Prayer is “just” a form of “relaxation technique”, similar to progressive muscle relaxation when used in support of psychotherapy. However, the Heart of Jesus Prayer could enable in particular people of faith, in particular, to experience a much deeper meaning of inner involvement in and through mental illness, and it could possibly also address deeper layers of human meaning in the sense of existential psychotherapy (Yalom, 2010) or Franklian logotherapy (Lukas, 2019).

Other spiritual practices

There is little doubt that the combination of prayer and music, often in hour-long chants such as in church services in praise of a Higher Being, is capable of producing a special deep intimacy and peace of mind. This is also true of other religions, because this connection between rhythm, music and spirituality can also be found in, for example, Islam and Judaism. In Orthodoxy, the sensory experience is enhanced by the visualization of the saint(s) in the immediate veneration of icons (Alfejev, 2018), but also by olfactory rituals such as the burning of incense, which establishes the reference to Jesus’ birth and thus the entrance of the divine into the world. Daily pastoral care, as presented by Hutt (2017) for example, is organized on the basis of monastic life in precise suggestions for the organization of days and weeks by means of prayers, icon veneration, and chanting. Through this and additional pastoral and spiritual discussions, the soul is calmed and grounded in God, and, strengthened in the sense of having greater resilience, can cope better with the stresses of everyday life. Programmes of this kind for the religious clarification of one’s relationship with God and for finding the salvation of the soul also have a long tradition in, for example, Catholicism in the form of the Jesuit Retreats (von Loyola, 2016) or Benedictine monasticism, which also provide for a precise daily course of spiritual exercises, times for relaxation, prayers (with an indication of one’s own hurts and illnesses), behavioural instructions and time spent with biblical passages, but also for the contemplation of holy images, which then unfold a healing power (Frick, 2005).

Paths to peace of mind (hesychia) 

In addition to the spirit, Greek Orthodoxy, as already shown above, focuses very strongly on the heart. Healing of the heart and healing of the spirit, or healing of the thoughts and thus of the soul, are very closely connected. In this context, certain mental–emotional states such as “provocation”, “bondage” or “aggression” contribute to the suffering of the soul, whose purification (“catharsis”) and then healing through “pastoral care” is among the most important tasks (Vlachos, 1995). Vlachos (1995) further states: "What is healed in the first and most important place is the heart of man, which is the center of his whole being. In other words, it is not only the treatment of the visible signs of the diseases, but the healing of the inner self – the heart. As long as man is ill, his nous is dispersed into the world by means of the senses. He identifies himself with the mind (intellect), and therefore he must return to dwell in the heart – and this is the work of Orthodox spirituality. The Orthodox Church is called a hospital for this very reason, a clinic of the soul. However, the Orthodox Church not only emphasizes the need for healing; it also outlines the means by which it is obtained. Since man’s nous and heart are impure, he must successfully pass through the three stages of growth in the spiritual life: Purification of the heart, enlightenment of the nous, and theosis. Orthodoxy is not like philosophy. It is more closely related to the applied sciences, mainly medicine. (.....) Orthodox spirituality is Christocentric because the hypostatic unity of the divine and human natures was accomplished in Christ, indivisible, inseparable and without mixture or transformation. Therefore, Christ is the only remedy of man’s diseases. Since Christ cannot be considered independently of the other Persons of the Holy Trinity and of the Church, which is His Body, at its core Orthodox spirituality is simultaneously Trinitarian and ecclesiastical". In the context of Orthodox psychotherapy, another factor, namely self-knowledge in the sense of “repentance” and “confession”, plays a major role. The main therapeutic principle is that people should free themselves from any inner turmoil and tension. In this regard, the Heart of Jesus Prayer described above serves primarily to help us achieve mental relaxation and tranquillity. It is only when we lose all impatience and tension that we regain trust in God and can then again come closer to ourselves and also to God. In Orthodox psychotherapy, everything culminates in the process of hesychia, which means mindful meditation, the emptying of all thoughts and impulses of the mind, and the coming to rest of the soul. The purpose of hesychia is to calm the body and soul. This includes the central instructions from the New Testament: self-control, love, attention and spiritual competence. In this form of inner gathering and coming to rest, it is important that the mind is calm and the heart is open and ready to experience the divine impulse. The moment a person is open like a "vessel", the divine grace can enter him. The person in the state of prayer thinks about absolutely nothing, but concentrates his mind (nous) on the words of the prayer. The state of complete peace of mind is sought, and this is considered a prerequisite for experiencing a special divine grace: thus, prayers can perceive the uncreated Tabor Light in a vision in which God himself is present and visible. In practice, the following aspects have been shown to be good for the process of immersion and prayer: breathing evenly, not letting the eyes roam, and listening again and again to the heart while rhythmically praying “Jesus Christ have mercy on me”. It is important to take the mind away from the heart again and again, so that the heart remains pure and open. The praying person can lie stretched out to relax, or can “sit on a pillar”. The important thing is to be completely in prayer, controlling the body in such a way that the person praying may seek and find God in his own heart. Even if his shoulders hurt and his head begins to hang, the praying person has to concentrate completely in and on the inside, and through that all disadvantages and strains are cancelled.

Conclusions 

The association or integration of religious practices such as prayer into psychotherapeutic practice has no tradition to date and is also viewed rather sceptically (Utsch, 2018). Moreover, empirical studies have been scarce (Montag et al., 2020). Ebrahimi et al. (2014) conducted group therapy for depressed patients with suicidal ideation. In the arm of the study that deepened additional spiritual aspects such as prayer, reading the Quran, practising patience and trust in God, and talking about forgiveness, grace, repentance, and other religious practices, the therapeutic outcome was significantly stronger. There is still a call to ask more about religious background and spiritual practices in the context of psychotherapy and, if necessary, to counsel the patient in this regard. However, the extent to which the therapist is open to this, addresses it or even encourages it also depends on his spiritual attitude (Poole & Cook, 2011). Including prayers in therapy is still considered rather problematic, since it presumably affects the boundary between therapist and patient and thus the dynamic events of the therapeutic process (Pfeifer, 2018). In this context, psychotherapy could also be spiritually helpful in a whole other sense, starting on the other side. Those who do not accept a higher being, could also learn, in a psychotherapy of objective meaninglessness (Kanitscheider, 2008), the integration of exercises on what it means as a human being to be only nature, to endure this world purely, and to form, with modesty and serenity, one’s life in the here and now. To “prescribe” religious activities such as praying and intercession to improve or heal a condition, as has been attempted in some studies, leads to the trivialization of religion as a mere “self-management technique” (Frick, 2005), which would also explain the heterogeneity of the results of such studies (Roberts et al., 2007; Bredle et al., 2011). Any such study would have to be embedded in a larger context of spiritual attitudes and practices within a holistic approach of “spiritual care” (Nauer, 2014). Yoga or other secular techniques to gain “mysticism without religion” (Wetz, 2015) would miss the specific essence of a connectedness with the big and the whole, which is only possible through religious experience with an Absolute and Other (Rahner, 1960). Suffering, including psychological suffering, represents a borderline experience of man in which he comes up against the limits of finitude (Frick, 2005; Juckel & Mavrogiorgou, 2018). Only a real spiritual approach to this leads to peace of mind, the hesychia. Many people, and thus many patients, are religiously bound or influenced. In mental crises and in psychiatric illnesses, this dimension is far too little explored and used therapeutically, in connection with pastoral care or spiritual practice, for example (Juckel et al., 2018). With the approaches of Orthodox psychotherapy, especially through the use of the Heart of Jesus Prayer and the goal of hesychia, the existence and importance of a ChristianEuropean tradition has been pointed out. Our case from Table 1 exemplifies the interrelationship between psychiatric–psychotherapeutic action and religious themes and practices. A stronger “both/and”, instead of an “either/ or”, especially in supposedly godless times (the “longing for the completely different” remains (Horkheimer, 1985)), and a mutual reference to each other in order to make better use of the respective strengths of each affected person, could also represent interesting therapeutic approaches in the future. Thus, in his wonderful book on melancholy (Guardini, 1949), to which he assigned a more existential dimension than a purely psychological function, the Catholic theologian and philosopher Guardini wrote: “Melancholy is something too painful, and it reaches too deeply into the roots of our human existence, for us to leave it to the psychiatrists”. Only in a religious understanding in relation to an Absolute would a real dealing of man with his psyche, and precisely also with his melancholy, succeed, because suffering is to be understood as a part of life, as is taught by the books of Job and Ecclesiastes. The idea that mental illnesses, which touch the conditions of existence and the meaningfulness of human life, represent something spiritually and religiously higher and should therefore be explicit topics in psychotherapeutic work, is being reawakened by the Orthodox tradition, which looks back strongly to the basic ideas of Augustine, and should be given more attention today. It would also be conceivable that severe psychiatric illnesses, especially those that are not always accessible just verbally and cognitively, could also benefit from such approaches of soul-spiritual concentration and ritual power (Vlachos, 2010; Fukui et al., 2012). Moreover, in many clinical cases, fundamental existential questions and feelings of the human being are touched during the crisis that is experienced. Here, psychotherapeutic approaches that take religious dimensions into account could possibly even be more effective.

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