Owe Wikström
 – the use of ”God” or ”god”  in psychotherapy – preliminary remarks
The background of this paper consists of many informal discussions I have had during the last two semesters when I have given a number of clinical seminars in psychiatric settings on the role of religion in mental health/illness. For a long time my main interest has been concentrated on the patient´s religiosity. More recently I have become increasingly aware of the role of the therapist´s religiosity and especially how countertransference influences the therapy when the therapist´s r him/herself is a devout Christian yet working in and ”agnostic setting” – such as  a general hospital.
     In this paper I would like to make some clinical remarks as to the ambivalence of Christian therapists who are trained to understand a person´s religiosity in both psychodynamic and theological/pastoral terms. The aim of the paper is to elucidate the internal conflict that may emerge for a Christian therapist. The conflict is as follows: The therapist sees how a patient´s representation of God is linked to intrapsychological emotional forces, conflicts and needs and therefore might intervene by means of a neofreudian/objectrelational theory of religion (God as god);  but at the same time the therapist also would like to be a faithful Christian and therefore – in the psychotherapeutic process – also wants to support the patients experience of God as a living autonomos entity, not reducable to intrapsychic developmental or illusionistic needs (i e God as God).

In order to illustrate my remarks a short case vignette (the version here presented in a shortened version) was constructed and presentented to seven experienced therapists. All working as clinical psychologists in state-run clinics,  not churchoriented institutions. They were also active members of the Swedish natinal church or a free-church.  I asked them in a semi-structured interview what they understood was the best way to work with a pious individual who claimed that one of his main problems was the silence of God.  I thereby stressed my interest in seeing how they  coped – as therapists – with the patient´s experience of the (un-) reality character of God.   Through the method of content analysis  I researched the way the therapists used explicitly religious or faith related terms.
The first part of this article deals with some theoretical objectives of ”theology” and ”psychology”.  The second part breifly describes  a case history where a depressed man´s main problem is the silence of God. In the third part I present and discuss  the questions if,  how  and to what extent the therapists  ”use” their own or the patients faith and belief in a living God as a part of the therapy. Finally I make a few remarks regarding the wider problem of ”use” and ”abuse” of God in psychotherapy.
God as ”God” or God as ”psychological representation”
We all know the basics in early Freudian thinking – God is described as a function of intrapsychological forces and needs – a way to keep a psychological  equilibrium by projecive, compensative and regressive maneuvres.  Later psychoanalytical thinking as well as the theory of sciences has questionend Freud´s unreflected wissenschaftsaberglaube or scientism. There is an implicit evolutionary idea and an absolutistic materialism in his thinking that at a first glance seems to be a result of his investigations. A more adequate description is rather that his view  is an elaborated vorverständnis projected onto the mental arena.  For the clinical psychologist of religion, however,  psychoanalytical thinking and especially the later development of objectrelation theory  (Rizutto 1979,  McDargh 1984,  Jones 1991, Spero 1992, Journal for Psychology and Theology 1994, vol 22, no.4)  have become  necessary tools in order to understand the dynamics of a beliefsystem,  now a little bit less ”loaded” with metaphysical claimings (see expecially Duvall 1994,429). 
The individual does not create his representation of God out of nothing. The specific language as well as the social context are fundamental. The individual´s emotional makeup interacts with culturally-given concepts.  Some religious individuals seem to socialize rather unproblematically  into culturally transmitted traditions where the role of God is represented in myths and rituals.  Other seems to create a private god that sometimes is far removed from the official and institutionalized church´s  version of  god. 
Out of a socialconstructivistic perspective,  social and verbal legitimation are the moments by which the subjective internal world becomes ”objective”(Bruner 1990).  The psychological conditions behind a religious experience therefore can be understood as an interplay between the person´s emotional/cognitive needs and the meta-narratives provided by religious institutions.
But this is exactly where we touch the very center of the internal conflict for a Christian psychologist or a pastor trained in psychodynamic theory. The dilemma can be formulated as a question:  ”In a psychotherapeutic setting, how can the scientific/psychological way of describing the genesis and function of a representation of God ( see above) be combined with a classic intra-religious perspective?   An actor inside a religious structure or church is working in and giving advices out from a theistic world-view –  God is understood and accepted as a living entity, a subject separate from or at least not reducable to a person´s own psychological o social construction.        
In the theological, ontological a priori there is a latent criticism towards a ”pure” functional perspective where God is (just) a symbolic representation for social, cognitive and emotional forces.  Psychoanalysts, however,  clearly can demonstrate that an individual´s experience of God actually is formed around emotional kernels and that this very inner representation – called God –  is reenforced by cultural and  social contexts. Now, in which way does a devoted Christian that belongs to both symbolic universes/ plausibility structures – the church and the clinic – contain the two separate perspectives and use them in the therapeutic process?
In which way does ”God exist”?
The basic question is thus what one means by ”God exists and acts” and ”God is hiding himself” words in the two traditions: the theology of spirituality and psychodynamic theory.   Generally speaking the psychological theory claims that the concept ”God” is a code or a symbol that refers to a personal psychological reality. Thus, it points to a reality that is at least subjectively true. But the pious  individual and his religious culture attributes this inner object (god) an intentionality of its own (God) that is separated from – or at least fused with – the patient´s psychological composition. The question  whether a God in reality exists or not, appears och disappears as an ontological reality – is not relevant for the psychologist per se.  Psychology as theory can not claim that there is or is not anything beyond that which is experienced. 
Classical theology,  however,  has not been very much interested in the way an individual´s faith is emerging in terms of its social and emotional determinants. The psychological buiding stones of an individual´s representation of or image of God are irrelevant for the theologian. God – says the Christian – reveals him (or her-) self to whomever he wants independent of a person´s  emotional or hidden needs.   Theology is built upon a basic claim, God is not a human creation, he/she has an autonomy of being in spite of the idea that God often is described as ”Semper major”, or hiding in the Cloud of Unknowing.
In a church or in a parish the main goal for believers seems to be to help people to get access an experience of the living character of this very autonomous God. But in  psychotherapeutic work in clinics or private practice it is often said that the objective is not to agree or disagree with the truthclaims of the patient´s theology. The ontological question is, at least in the therapeutic process, intentionally put in brackets. Instead, one explicitly limits the purpose to understand the functions  of the representations of God in terms of mirroring, idealizing – all residues  from early significant others.  One tries to understand the developement and intrapsychological funtion of the claims that the patient attributes to God, how the classical defence mechanisms are intertwined in a persons search for a sense of cognitive coherence. 
In which way does God ”exist”  in a psychological setting? He is living as an experience. But whether there is some ontological reality beyond this or not is a question where the psychologist – in his/her profession – has no mandate to answer. Among therapists dealing with religious issues there are Christians, Jews, Muslims as well as agnostics.
My point, however,  is that this very detached, objective view often is idealized. It is at least problematic coming to the role of God in therapy.  At least the rule of neutrality seems to be challenged to a certain degree when a religious  therapist comes deeply into a process where the question of the silence of God is at stake and that this must be professionally met.
The silence of God – a brief case vignette
A man –  44 years old, active in a church, a teacher, with two children and devorced for seven years – comes for therapy.  He has been in a new marriage for the past  three years. His main problem is a deep feeling of boredom, emptiness and loneliness in spite of a happy marriage, good economy and many friends. After the divorce he had been in short-term psychotherapy.  In the psychotherapeutic process he gradually talks more and more about the absence of God. In the exploration of his family situation it becomes clear that he has had a good relation with his father and  mother says is happy with his new family.
    All his life he has had a very deep and secure trust that God is guiding his life. In his college years he thought about becoming a priest. He is an active religious man, making yearly faith retreats. All his life he has had a deep conviction of the reality and goodness of God. He has had a long – standing  connection to relation to his priest and to a spiritual guide – but they cannot help him now. The main problems are insomnia, anxiety and depression – all related to his loss of faith.
 During the first part of therapy the therapist attempts to locate his religious problem in terms of family structure and psychodynamics. But the main problem during the therapy turns  out to be  however more and more concentrated to an existential threat; the silence of God. The patient prays and attents the mass regularily. He reads the mystics especially apophatic theology.  But the reading of St. John of the Cross or the thoughts of the theologia negativa do not help him. What remains is an increasing feeling of existential emptiness or alienation, an experience of having lost life´s basic meaning. He describes his problem as a type of life crise. Above all  he  is disappointed with those  therapists that hide themselves behind  an  objective mask. He wants himself to be taken serious both as a psychological person and as a religious man. He wants his faith in a living God to be taken at face value  and not only deconstructed as an inner object hiding in a safe transitional space.
   His therapist is well trained in objectrelational theory and especially Kohut and Winnicott. The more the therapy continues the more confused the therapist becomes. He sees that he can neither accept the patients Godtalk at face value (God as God) nor deconstruct the patient´s God in terms of intra- or interpersonal hidden dynamics (God as god). He feels himself to be trapped in a cognitive, philosophical and professional dilemma.
My question to the seven therapists responding to this vignette was ”How do you feel about a patient like this and in which way would you ”use” the patient´s own (lack of ) experience of God´s guidance in therapy?
Resonse strategies: 
Three of the therapists (A, D and E) claimed clearly that the faith of the patient should be taken psychologically seriously and be ”understood as an interpretative system and meaning giving behaviour” that hitherto had been giving the patient support. The relation to God might mainly be explored ”in terms of weakening defence mechanisms” and ”lack of mirroring” . To a direct  question at the end of the  interview they said that they preferred to ignore the question of God as God in the therapy. They understood that kind of question as psychologically not relevant. On the contrary they actively tried to not disclose their own belief. Every effort of the patient to talk about his God and draw in the therapist into his theological church-oriented terms was respected but interpreted psychodynamically.  The reason  for this detached position was that only in this position could the transference and countertransference be explored. They worked strictly inside a psychodynamic understanding of a religious problem.
Two of the therapists (B and F) took another position. They also stressed that they actively should accept the patient´s beleif . They talked about their own faith (before the sessions started),  but they did not go into the theological questions in the therapy – the contract was strictly psychological. They claimed that they did not want to strengthen or question the patient´s religious worldview – instead they tried to elaborate the genesis and function of the man´s parental representations. After the therapeutic sessions they prayed for the patients but they never prayed toghether with them. The patient´s were aware of the therapists active christian engagement.  In that way they professionally legitimated the patient´s experience that a real God existed who out of his own will might hide himself in order to – by his ”absence” – negatively demonstrate his ”presence”. These two therapist respected the patient´s worldview  but never used God-as-god as a means for diagnosing or in the working-hrough process. 
And finally, two  of the therapists (C and F) said that in working with religious patients the absence or presence of God must be understood both as a symbolic condensation of  emotional and existential conflicts and possibilites (a psychological interpretation);  and as an act of a living God (a theological legitimation). They switched without hesitating between an intra- and  interpersonal understanding of the content and function of the patient´s losses of faith in God and a more  church-oriented biblical understanding of God as an active interventional person. They also tried to be aware of the ”risks” with this double focus in terms of transference and countertransference,  and focused these themes in their supervision sessions.    In my  remarks later, I will discuss  how these two informants described their way of turning moving the two interpretative frameworks  during the psychotherapy.
Emerging conflicts
The Christian therapists described themselves as working inside two different perspectives, a confessional Christian world-view and a psychological world-view. Thus, they incorporated two partly contradictory interpretative schemes as to the silence of God. One therapist understood the absence of God as a sign or symtom of a psychological problem. He then searched  for reasonable reasons for the depression that is coloring this man´s religious beleif-system; i.e. the divorce, loneliness, guiltfeelings – all these problems are hiding behind what he describes as a religious problem. Instead of working through the loss of trust in terms of unsconcsious conflicts and desires to inner objects, the patient projects his feeling onto a celestial screen and therefore God is expererienced as absent.
But  the other therapist  supported and legitimated the patient´s own religious interpretation and looked actively for cognitive schemas in the Bible or the spiritual traditions of the patient´s church. He thereby tried to understand the man´s experience of God as a real Other, a living entity separate from the patient´s own psychological makeup. Through the therapeutic process the therapist made God´s existence legitime for the patient an existence which sometimes is silent. In struggling with this problem the therapist sometimes  left his detached perspective and acted as a fellow christian, reading the Bible.
What happens in this latter case when the therapist on a surface level strenghten and makes it  legitime that the silence of God is a religious problem – yet where a further exploration actually could reveal that the absence of God  indicates an intrapsychological dilemma dressed in theological garments ? A theological interpretation can thus  weaken the patient´s ability to test reality – at least on the psychological level. Verses from the Bible, hymns and narratives from the Christian tradition can reinforce resistance. The theology and ”godtalk”  of the therapist may contribute to a suppression of a conflict and enhance the chance that an immature solution is given to a hidden conflict. 
But the opposite can also be the case. What happens if the therapist ignore the reality character of his patient´s God and deconstructs his loss of faith only  in terms of hidden emotional or developemental residues? Then the therapist does not help the patient to reach a Christian interpretation of his cognitive dilemmma.  The therapist neither helps a patient to a strengthening nor to a questioning of his very religious conviction on a secondary level. 
If one looks further into spiritual theology, the church fathers and mothershas been very well aquainted with conflicts like these. In classical medieval ”pastoral medicine” the spiritual guides were well aware for the need of ”differential diagnoses” between melancholy (understood in terms of biology or psychology) on the one hand and absence of God (in terms of apophatic theology) on the other.
Tentative models
Let me present three very simplified models for handling the conflict observed. Once again, my objective is limited,  i.e.  not whether the therapist should deal with religious material in general,  but to be more exact: if and to what extent a religious therapist ought to help a patient to understand the psychological genesis and function of his representation of God.
The first mode is to legitimate the patient´s own intra religious version. God is a reality that for one or another reason is hiding himself. There are a lot of church-based Christian spiritual traditions especially in the mystical negative theology which understand the longing for God as a sign of the reality of God. He is then described and accepted as an active agent of his own. In my view this is not the (christian) therapist´s task but that of the pastor or the spiritual director.
  A second model is that the psychotherapist actively must avoid intervening in the Christian language-game on the secondary process level and its claimings of theological character. Instead he can de-construct the silence of God in terms of a hidden agenda, use the ”godtalk” as a fertile Rorchah test.   The absence of God might be seen as longing for mirroring, dressed in theological terms. The therapist then does not legitimate the drain of emotional support as a genuine religious experience, but as psychological and functional. 
A third  model is that the therapist is balances between  psychological and theological interpretations. The condition necessary  for working with these ”double perspectives” is that the therapist has intellectually and personally been able to work through how psychoanalytical theory and theological narratives interact and are able to cooperate.  The interviewed therapists, however, claimed that they need more professional thinking and discussions of clinically cases in order to be more aware of basic ontological hidden agendas  ”hiding” both in the theological concepts and psychological theories.
The switching from God as ”god” to God as ”God” was for some therapists made in terms of time.  In the beginning of therapy they made a contract as to where the focus at first should be concentrated, on the psychological content, genesis and dynamics. After that working through-process, they remade the contract in order to more explicitly eluciate the religious problem in terms of cognitive, theological and churchoriented language. Together with the patient one tries to find passages in the Bible or the christian tradition where persons feeling the absence of God are described.
One other type of parallell perspective is not in terms of time but themes.  On the one hand one elaborates the emotional building stones of specific religious experiences, such as prayer, God´s presence, doubt  etc.;   and on the other hand, one tries to confront a patient´s experienced belief in God with classical maps of religious development,  depending upon the religious context of the patient;  St John of the Cross, John Bunyan the Russian Starets tradition etc.   Such a negotiation between a dynamic/psychological interpretation  and a didactic/ kerygmatic  legitimation of the absence of God can actively provide  an integration of the Christian belief-system.  The risk then diminishes that the Christian faith just remains as a cognitive dogmatic system without links to the person´s own inner life or that it is just understood as a defence maneuvre in order to keep psychological equilibrium.  The patient´s need to be taken seriously as believer can in this way be professionally met, as well as the psychologist´s need to question and seek the structures which lie  behind what being  overtly said. 
A psychological way of understanding religion (God as god)  is necessary for every (religious) psyhotherapist. By means of it he can critically elaborate the intra-  and interpersonal function of his patient´s representation of God. A future need for therapists is the crosscultural training  for supervision strategies that are especially formed to handle the balance between two meaningsystems;: theology and  psychology. In the future it seems meaningful to elaborate the particular research arena we might  label ”Transcultural Clinical psychology of Religion”.
Use and abuse – concluding remarks.
I started with the question of how to ”use” religious terms in a therapeutic process. I will end with a few remarks related to the Uppsala 1993 preliminary discussion on abuses or use of religion in therapy.
To speak of something in terms of its ”use” and especially its ”abuse” has both normative and practical implications. This becomes especially evident if one turns the sentence ”uses and abuses of religion (i.e. God) in psychotherapy” around:  the ”uses and abuses of psychotherapy in religion”. In both cases religion/psychotherapy is seen as a vehicle of something outside itself. As to the first,  religion is a ”means” or and ”end” in a therapeutic process. The baseline is here mental health according to one or another definition. As to the the second, a psychotherapeutic method and relation – both psychodynamic and cognitive approach –  can be used or misused to deepen or weaken the religiosity of the individual. But the baseline is then related to whatever one means  by religious, whole or mature. So, regardless of our position we will end up with more or less normative –  or perhaps  theological – questions.
My main argument is that neither theology nor psychology can be seen in purely functional terms. Psychoanalytically oriented therapy has as its main goal insight; to help someone get in touch with his/her unconscious motives and to bring them into awareness. As a side-effect the person´s  autonomy heightens and sometimes the capacity to surrender to a faith or to leave a too regressive belief system.
In other situations an individual chooses to take an opinion that (from an unreflected psychological perspective) seems more or less neurotic/immature, but in her own religions framework is perfectly logical. Is her religious conviction then an abuse or use, and out from whos  baseline? Religion is (from an intrareligious perspective) not mainly a meaning-giving pattern, a comforting or a social framework,  a psychodynamic force to enhance identity etc. It is understood per se, not through its psychological effects but from its own inherited merits.   So instead of discussing religion  terms of ”use” or ”abuse”, I have tried to take another standpoint and to look ”inside” the Christian therapist who keeps together two different language-games through which one speaks of  God, the ontological/theological on the one hand and the functional/psychological on the other, the ontological as a religious person and the functional as a psychological professional.
Browning,D.S. (1987). Religious thoughts and the modern psychologies. A critical conversation in the theoogy of culture. Philadelphia:Fortress Press
Finn.M & Gartner,J  (Eds.) (1992)  Object relations theory and religion: Clinical applications New York:Preger Press
Duvall, N.S.(1994) Religious representations. Review of Finn, M & Gartner, J  Eds., 1992) Object relations theory and religion: Clinical applications New York:Preger Press. In: Journal for Theology and Psychology, 22, 4  429-432.
Jones, J.(1991) Contemporary Psychoanalyses and Religion. New Haven and London: Yale University Press.
Macquarrie. J.(1982) In search of humanity. A theological and philosophical approach. London: SCM Press.
Narramore, B (1994). Dealing with religious resistance in psychotherapy.  Journal of Psychology and Theology, 22,249-258.
Rizutto, A.M. (1979)  The Birth of the living God. Chicago:
University of Chicago Press.
Spero,M, (1990). Parallel dimensions of expereince in psychoanalytical psychotherapy of the religious patients.  American Journal of Psychotherapy,35,565-575.
Spero, M (1992) Religious objects as Psychological structures. A critical integration of Object Relationstheory, psychotheraoy and judaism. Chicago:University of Chicago Press.
 Wallace, E.R.(1988) What is ”truth”? Some philosophical contributions to psychiatric issues. American Journal of Psychiatry, 145, 137-147.
Wikström, O (1996), God as an ’acting agent’ in psychotherapy? in Demarinis,V &Wikström,O Ed. Clinical Psychology of Religion. Emerging cultural and multicultural questions from European and North American Voices. Stockholm Forskningsrådsnämnden. 96:4.