Rethinking integration: a prodding case in Brazil.

Garzon, Fernando

I like integration--as long as I can apply the concept clinically on my own terms. These include having resources available that modern science affords: Psychiatric consultations, medical evaluations, and quality inpatient services. Such go hand-in-hand with my Christian cognitive behavioral integration approach. I see all of these together as gifts from God to help people. Multicultural cases, however, can challenge my typical integration approaches and standard clinical practices. This especially occurs when I am outside my familiar U.S. practice setting, as was the case with Lucia, a 32-year-old woman I met while attending a week-long emotional healing conference in Sao Paulo, Brazil, conducted by Neil Anderson (Freedom in Christ Ministries). Dr. Anderson gave me permission to accompany him on this trip in order to participate in the conference and make qualitative research observations.

Before introducing Lucia, it's appropriate to take a look first at the conference itself. Briefly, Dr. Anderson's conference revolved around two of his written works, Victory Over the Darkness (1990a, revised 2000a) and The Bondage Breaker (1990b, revised 2000b). These works focus on God's acceptance and the role of the world, flesh, and the devil (I Jn 2:16; Gal. 5:19-21; Eph. 6:12) in cultivating secular values instead of Christian values. Anderson espouses the development of a positive self-identity through understanding Christ's love for us, and encourages the utilization of sacred text passages to cognitively restructure maladaptive self-perceptions. Teaching sessions and worship sessions alternated throughout the conference. Participants included three hundred ministers and their spouses, primarily indigenous to Brazil. Individual "discipleship counseling" appointments were available to those needing more intensive ministry (Anderson, 2003). These appointments generally lasted 4-8 hours and utilized Anderson's structured Steps to Freedom in Christ approach (Steps or Steps to Freedom) found in the above works. The Steps have some features similar to the historical prayer of examen (cf., Foster, 1992, pp. 27-36). They involve confession, renunciation, prayers of repentance, and the utilization of sacred text passages from the Bible to affirm God's forgiveness and love. Further description will be found in Lucia's intervention details below. Of course, Lucia is a pseudonym, and the identifying demographic information has been altered to protect her confidentiality.

The Client

Lucia was a 32-year-old married enculturated Brazilian woman with 2 male children (7 and 9 years old). Since she did not speak English, a translator with a bicultural Brazilian/United States background assisted her treatment. As is common in developing countries, the translator had little formal psychological training. I spent about 45 minutes orienting him to the psychological interview process to make the session more productive. Clearly, much more training time and a female translator would have been optimal; however, Lucia's crisis condition precluded postponing the session for further preparation.

Lucia described Major Depression and panic attack symptoms. These lasted over the last 2 years, worsening during the last 6 months to the point of mood congruent auditory hallucinations. The voices focused on condemnatory and worthlessness themes and she described them as now occurring constantly. It should be noted that the translation process may have impacted the accurate assessment of the extent of these auditory hallucinations. However, Lucia displayed no looseness of associations, disorganized speech or bizarre behaviors suggestive of Schizophrenia. Agoraphobic symptoms also had emerged in the last six months.

Lucia's history provided clinical clues to her condition. She was raised and currently lives in the same small subtropical town as her relatives, about 10 hours from Sao Paulo. Her parents were still alive and married, and she described their socio-economic status as poor to lower middle class. While she was growing up, she perceived her father as harsh and critical but non-abusive, and her mother as consoling.

Over the last two years, Lucia felt increasingly neglected by her husband. She reported him spending less time with her and felt he was more focused on his small but growing lumber business than on the family. Arguments erupted. No resolutions ensued. Lucia's hopelessness grew.

From the beginning of their marriage, the couple had been actively involved in a small conservative evangelical church. Lucia became a born again Christian when she was a teenager, and met her husband in church. During the first eight years, Lucia believed her marriage was fine. The last two years of fighting though have taken their toll. To cope, Lucia spent time with her cousins, read her Bible, and attended more to her children. Yet the arguments and her husband's withdrawal continued. She wondered what was happening. As is common in her culture, she began questioning whether someone had put a curse on her. Lucia believed a neighbor with whom she had been having several disputes may have been responsible. In my assessment of this belief, the boundary between cultural conceptualization and delusional thinking became clearer as she acknowledged that someone else could have put a curse on her or her dilemma could have been coming from another source.

Not knowing how to utilize her Christian faith to address this fear of a curse, Lucia decided to visit a Macumba practitioner six months prior to the conference. Macumba practitioners in Brazil are similar to black magic witch doctors in other cultures. While Lucia's decision may seem surprising to many western Christians, syncretistic coping patterns occur in many cultures when the formalized religious system (such as Roman Catholicism or Evangelical Christianity, for example) does not appear to have a remedy for a culturally defined problem (Hiebert, Shaw, & Tienou, 1999).

In a midnight ceremony, the Macumba practitioner spread fecal material over Lucia's body, placed her in a partially dug grave, and poured a solution on her that had been made from native Brazilian plants. After an incantation, he lifted her out of the grave and told her the curse would be completely broken off if she returned for the second part of the ceremony the next week and gave him the equivalent of $500.

The ceremony itself greatly frightened Lucia. Her anxiety and panic attacks increased. Indeed, she began feeling very guilty for pursuing black magic as a potential solution to her dilemma. She reported that shortly after the ceremony she began experiencing the condemnatory auditory hallucinations.

Case Conceptualization

I attempted to understand Lucia's symptoms from a cognitive biopsychosocial perspective. For example, her distal and current stressors likely triggered a previously dormant biological vulnerability to panic attacks and depression. Regarding social context, her on-going marital distress led to internalized anger and depressogenic cognitions around themes of rejection and worthlessness. Lucia's unsuccessful attempt to cope with her situation by utilizing her Christian faith produced further depressive cognitions about herself, the future, and her world. Finally, her latest coping attempt, seeing a Macumba practitioner, exposed her to spiritual deception and produced great guilt and anxiety. The experience may have left her vulnerable to the condemnatory auditory hallucinations she now experienced. She not only feels disconnected from her husband, but now faces a spiritual crisis as well.

Lucia noted many questions from the crisis: Has God rejected me for seeking a black magic resolution to my problems? Am I going to live under a curse the remainder of my life? Does my faith [evangelical Christianity] contain any interventions that may be of help to resolve my spiritual and marital crisis?

Treatment Justification

Lucia's crisis also contained questions for me: Am I culturally competent for this case? How do I handle the lack of access to psychiatrists, psychotropic medications, and quality inpatient facilities as potential resources for Lucia? Normally, these are critical components I consider in developing treatment plans for psychotic symptoms such as auditory hallucinations. Are my typical Christian cognitive behavioral strategies adequate for her case? Clearly, my normal integration methods needed examination in this very different cultural context.

One aspect of the context was the seminar setting itself. Lucia came to the conference expecting to receive individual ministry consistent with Neil Anderson's approach rather than western psychotherapy or psychiatric medications. Would I be imposing my cultural values on her if I simply shelved Anderson's approach?

Further, I recognized some overlap between Anderson's principles of ministry and my typical Christian cognitive approach. The Steps would encourage restructuring of some of Lucia's depressive cognitions (for example, cognitions about God rejecting her and a hopeless future) and would also invite her to recognize her anger at her husband. With her permission, I decided to administer portions of the Steps to Freedom as a starting point and carefully assess the outcome. As intonated in the above, had I additional clinical resources, the treatment plan likely would have been quite different.

Interventions

Treatment occurred in one intensive 7-hour session. An informal intake, portions of the Steps to Freedom, and a marital consultation comprised the interventions. In the Steps to Freedom, I focused on the portions most pertinent to Lucia's situation. These included step 1 (renunciation of occult involvement), step 3 (forgiveness), and part of step 6 (the section on wrong sexual use of the body). Breaks were taken approximately every hour.

In step one, Lucia made a detailed list of all the folk religion and occult practices in which she had previously participated. She endorsed several other folk religion rituals from earlier years of her life. After making this list, Lucia asked God's forgiveness for these activities and renounced each one individually. She appeared to experience a great sense of relief from her guilt following the activity.

Step three (forgiveness) followed. Lucia asked the Lord to bring to her mind everyone against whom she was holding an offense. In accordance with the step, rather than saying a blanket prayer to release these wounds, Lucia described the offenses in detail and how they made her feel about herself. Injuries with her parents, other relatives, and her husband came to mind. Much affect was displayed as she released these to God. Lucia also confessed anger at God over some of the things that had happened to her and, later, anger at herself over some of her choices. She was able to reconcile with God and to forgive herself. Some unanticipated history also emerged. In another coping attempt, Lucia confessed to having a brief extra-marital affair.

Given the affair, the step which focuses on sexual sin areas (step six) followed naturally. Lucia confessed the wrong usage of her body, asked the Lord to cleanse her of any harmful effects from this experience, and rededicated her body as God's holy temple. As the prayer ended the last portion of the Steps intervention for Lucia, she expressed a sense of God's forgiveness and restoration.

I debriefed with Lucia about her experience. She felt a great sense of emotional relief, reconnection with God, and renewed hope. She also reported the auditory hallucinations had stopped. While it was unclear at which point in the ministry session this occurred, I chose to focus on continuing her brief treatment rather than lose time in such an assessment. Lucia consented to meet with her spouse.

In the meeting, her husband, a tall medium stature bearded man, appeared open. Through the translator, we discussed "time with family" as a significant issue and did some problem-solving. I suggested marital counseling might also be helpful; however, this was done very delicately. I framed the counseling more as "consultations" to help Lucia than therapy sessions (something that would be very threatening to the typical enculturated Brazilian male). Neither of them knew of any potential resources in their area. No mention was made to the husband of the marital affair, given the lack of treatment time to process this issue. We all agreed to look for marital counseling resources during the remainder of the conference.

Two days later, I briefly saw Lucia again. Her affect was noticeably brighter, she appeared relaxed, and the circles underneath her eyes were gone. She smiled often, and reported sleeping well the last two nights. No panic attacks or auditory hallucinations had recurred. Her husband likewise noted great improvement. Though encouraged by these reports, the lack of marital and individual follow-up continued to concern me. I eventually met a Christian psychologist as well as a pastor of a local Christian emotional healing ministry at the conference. They both introduced themselves to Lucia and agreed to continue working with her. They gave her their contact information. Five days after our intensive treatment appointment, I met again with Lucia and her husband and they continued to report no return of symptoms.

Discussion

Many issues worthy of debate emerge from Lucia's case. Theologians, culturally competent therapists, and medical researchers all would examine this case report with enriching critique and commentary. Accordingly, I will attempt to pose the primary questions that might emerge from such an interdisciplinary roundtable discussion while acknowledging that I am not necessarily an expert in all the issues raised.

Questions Theologians Might Have

I imagine the theologians sitting at the table would be focused on Lucia's faith status and the role of the demonic in her life. Specifically, was Lucia truly a Christian before she went through the Steps to Freedom? This question matters because she may have been experiencing significant demonic oppression. Her syncretistic practice of seeking out a Macumba practitioner, along with her resentment towards her husband, may have exposed her to this vulnerability (Bufford, 1988).

Some theologians at the table would argue that Lucia's behavior demonstrates she did not have saving faith prior to the Steps. They would assert that a Christian cannot have a demon, and that Lucia only became a true Christian when she repented of her folk religion practices. Others would object, saying she was indeed a Christian and exposed herself to demonic oppression through her sinful behavior but not possession. Oppression implies influence but not the complete control intonated in possession. The debate will be noted here but certainly not resolved. See Dickason (1987) for examples of the arguments and Boyd (1997) for more in-depth theological context.

Some liberal theologians at the table hearing this exchange might become squeamish. They have relegated demons to a past that they believe now has been "demythologized" a la Bultmann (1952). The facts of this case would create significant cognitive dissonance for them. Indeed, I imagine them listening intently to the questions medical researchers would have later.

Questions Culturally Competent Therapists Might Have

Psychologists and counselors are both now ethically mandated to practice religiously and culturally sensitive treatment as a component of diversity (APA Ethical Standard 1.08 and ACA standard A.2.c). At the table they would be considering whether this was done for Lucia. Her case illustrates the challenges of developing truly sensitive approaches, especially in circumstances where the client's worldview may vary widely from the practicing clinician's. In the discussion, the difference between Lucia's Brazilian cultural norms and western psychological norms I had been trained in would carefully be explored. From Lucia's perspective, demons, black magic, and curses were real problems to be dealt with versus being interpreted as abnormal delusional fantasies to be analyzed or medicated. The prayers of confession and renunciation in Step 1 seemed to resolve her concerns rapidly in these matters in a way in which other interventions I normally use may not have. Perhaps Anderson's intervention style was more consistent with the cultural norms and expectations that Lucia had for what might be a reasonable treatment to resolve such issues, and this facilitated the outcome.

The therapists might also explore the forgiveness step further. It appeared equally important in helping Lucia. She was able to release her anger at her parents and her husband for offenses against her, while also forgiving herself and reconciling with God. The intervention's utilization of sacred text passages to affirm God's forgiveness and build a positive identity fit with Lucia's religious expectations that Christianity would have resources to help her combat her depressogenic cognitions. My therapist friends also would point out that part of the forgiveness intervention's success related to Lucia's personal characteristics. She was able to process painful negative affect fully. Other clients may have been more defended against such emotions. The therapists would agree with me that Lucia's lack of features commonly found in Schizophrenia and severe dissociative disorders also helped the outcome.

At some point, the theologians would interrupt our discourse and maintain the important role of the Holy Spirit in Lucia's outcome. We would concur, and clarify that our observations do not denigrate the role of the Holy Spirit in the outcome; rather, the observations merely help us understand some of the mechanisms God may have used without implying they were exhaustive.

The therapists and theologians might continue their discussion examining the step dealing with sexual sin. It contained something I had never seen in integration therapies. Most Christian clinicians would endeavor to address Lucia's guilt over the marital affair, but the petition for spiritual restoration of the body was a novel approach to me. Lucia showed great relief from guilt when this step was completed. The therapists might reason that the intervention was religiously and culturally congruent with Lucia's background, which aided the response, while the theologians would explore with us the hermeneutical interpretation of New Testament passages that Anderson uses as a rationale for this strategy.

Finally, the therapists might ask me if Lucia portrayed any characteristics consistent with a client who might have reported a resolution to her symptoms simply to please the treating clinician. Lucia's more relaxed physical appearance following the intervention, the absence of dark circles under her eyes later in the week, and her husband's report of improvement later in the week would appear to support a true symptom remission.

Questions Medical Researchers Might Have

The medical researchers at the table would focus on the case study design. Was the design sound? Is a 1-week outcome analysis sufficient? Lucia's case did not have pre and post outcomes measures, a recommended 6-month follow-up testing, and no control group cases for comparison. Certainly, the doctors would insist, her case is not something scientifically sound enough to build a theory.

I would readily agree with the researchers on these points. Indeed, this was a naturalistic setting and the case study itself was serendipitous. One week's worth of qualitative follow-up is not sufficient to insure there would not have been a relapse. Indeed, Anderson himself warns that one must not consider the Steps a final treatment but rather that each person should seek sufficient spiritual and emotional support to maintain their freedom (Anderson & Miller, 1999; Anderson, 2003). He recommends attending a healthy church, continuing to grow through fellowship and Bible study, support groups, and Christian counseling as needed (Anderson, Zuehlke, & Zuehlke, 2000). He likely would agree that marital counseling as a follow-up is important in maintaining Lucia's outcome. If Lucia's husband returns to his behavioral pattern and she does not have such supports, she could relapse.

Even with these caveats, the observed 1-week outcome of the case went heavily against my own empirically-based theoretical predictions. For at least 7 days, the auditory hallucinations stopped, Lucia slept well, and she had renewed hope in her marriage.

The researchers' next question would focus on the interpretation of this outcome. Could Lucia's improvement be accounted for by placebo effects? Perhaps. Yet, what have we actually said in simply labeling a process "placebo" without understanding its underlying mechanism? If Lucia's faith and expectancy alone were powerful enough to stop auditory hallucinations, then we certainly need to understand the underlying mechanism much more fully rather than simply consoling ourselves by attaching this label. Researchers from a variety of disciplines are increasingly recognizing the power of expectancy and are beginning to search for underlying mechanisms involved in placebo effects (e.g., Harrington, 1997).

Even with this possibility, I could not allow my medical researcher colleagues to dismiss Lucia's outcome out of hand in this way. Ending here basically denigrates the role of empirical investigation. My culturally encapsulated scientific ideas might be preserved, but at the expense of my intellectual honesty. Lucia rapidly and dramatically improved. I cannot account for this so smugly.

Consequently, I have begun digging further, using empirical methods. Preliminary research on the Freedom in Christ model has started (e.g., Garzon, Garver, Kleinschuster, Tan, & Hill, 2001; Anderson, Garzon, & King, 2002; Hurst, Williams, King, & Viken, in press). While not focused on clients with psychotic symptoms, the results thus far appear positive. The studies have methodological limitations inherent in most exploratory research, but their findings suggest that higher quality designs, such as randomized control group studies, are warranted. Perhaps the medical researchers and I will have more to talk about sometime in the future.

Conclusion

Lucia's case challenged me in many ways. I now find myself questioning my automatic clinical responses to cases which may need psychiatric consultation. My western-based, culturally bound views may not be as comprehensive or adequate as I had previously assumed. Certainly, I will continue to use psychiatric referrals and Christian cognitive therapy, but I now have an even greater appreciation for the complex interaction between client characteristics, cultural background, diagnostic issues, and my own experiential background in determining a case outcome.

Equally important, I find myself challenged to rethink integration. Perhaps more is available to us as Christian clinicians treating conditions like Lucia's than I formerly had realized. Her treatment not only contrasted sharply with my typical approach, but it also contrasted with the stereotypes that I had developed from my clients' accounts of deliverance experiences and my own observations in some churches. Truly, what occurred for Lucia did not seem to fit neatly into either "Christian therapy" or "deliverance" categories. Anderson (2000b, 2003) differentiates his model from deliverance practices, and I now would have to concur with his analysis. The case has left me with cognitive dissonance in my integration framework. Further scientific investigations, theological explorations, and multicultural considerations become important in my quest for resolution of this dissonance. Perhaps others in the Christian mental health field will join me on this journey.

References

Anderson, N. T. (1990a, 2000a). Victory over the darkness: Realizing the power of your identity in Christ. Ventura, CA: Regal Books.

Anderson, N. T. (1990b, 2000b). The bondage breaker. Eugene,OR: Harvest House Publishers

Anderson, N. T. (2003). Discipleship counseling: The complete guide to helping others walk in freedom and grow in Christ. Ventura, CA: Regal Books.

Anderson, N., Garzon, F., & King, J. (2002). Released from bondage, Revised edition. New York: Thomas Nelson Press.

Anderson, N. T. & Miller, R. (1999). Walking in freedom: A twenty-one day devotional to help establish your freedom in Christ. Ventura, CA: Regal Books.

Anderson, N. T., Zuehlke, T. E., & Zuehlke, J. S. (2000). Christ centered therapy. Grand Rapids, MI: Zondervan.

Boyd, G. A. (1997). God at war: The Bible and spiritual conflict. Downers Grove, IL: InterVarsity Press.

Bufford, R. K. (1988). Counseling and the demonic. Dallas, TX: Word Books.

Bultmann, R. (1952). Theology of the New Testament (Kendrick Grobel, trans.). London: SCM Press.

Dickason, F. C. (1987). Demon possession and the Christian. Chicago: Moody Press.

Foster, R. (1992). Prayer: Finding the heart's true home. San Francisco: Harper.

Garzon, F., Garver, S., Kleinschuster, D., Tan, E., & Hill, J. (2001). Freedom in Christ: Quasi-experimental research on the Neil Anderson approach. Journal of Psychology and Theology Special Edition: Christian Spirituality: Theoretical and Empirical Perspectives, 29, 41-51.

Harrington, A. (Ed.) (1997). The placebo effect: An interdisciplinary exploration. Cambridge, MA: Harvard University Press.

Hiebert, P., Shaw, R., & Tienou, T. (1999). Understanding folk religions. Grand Rapids: Baker Books.

Hurst, G., Williams, M., King, J., & Viken, R. (in press). Faith based intervention in depression, anxiety, and other mental health disturbances. Southern Medical Journal.

Fernando Garzon

Liberty University

Author

Fernando L. Garzon, Psy.D., is an Associate Professor in the Center for Counseling and Family Studies at Liberty University. His research interests include spiritual interventions in psychotherapy, multicultural issues, integration pedagogy, and lay Christian counseling. He may be contacted at fgarzon@liberty.edu.

Liberty University does not officially endorse Freedom in Christ Ministries. Rather, it supports the theological and scientific examination of this and other Christian approaches. Correspondence regarding this article should be addressed to Fernando Garzon, PsyD., Center for Counseling and Family Studies, Liberty University, 1971 University Blvd., Lynchburgh, VA 24502; fgarzon@liberty.edu.