Thera-priest, anyone?

You may have heard it said that everyone should get therapy, because we’ve all got mental health issues.

As someone who works in mental health, you might expect me to agree, but I have a reservation which breaks down into two parts:

The idea that we all need therapy potentially medicalises the human condition and overlooks a key aspect of that condition that’s lacking in therapy: community.

I did psychiatry training in Nigeria, and it was during that time I became concerned about mental healthcare becoming more accepted in mainstream culture. So it’s been striking to come to realise that things are at the opposite extreme in wealthier countries. To put the difference simply, whereas in Nigeria (and many low and middle income countries), the tendency is to downplay mental health disorders, it would appear that the tendency in richer countries is to play them up. Where one setting leans away from diagnoses, no matter how justified, the other leans toward them, however unjustified.

The two behaviours seem dissimilar, but actually share in common a disregard for the evidence. And both are dangerous, albeit in different ways.

Most of us are aware why it’s a problem to resist the reality of mental disorders. I’m not sure many of us think a lot about the opposite extreme—of desiring, so to speak, a diagnosis of mental disorder. And a problem we aren’t aware of, may for that very reason, be more dangerous than one that’s actually larger but at least gets our attention, so we can address it.

Why does this happen, though? As with many things in the real, complex world, multiple factors are involved, but I’ve often wondered:

What if we assume everyone needs a therapist precisely because we have—subconsciously—come to see therapists the way humanity historically viewed priests?

Sessions are the new confessions

The most obvious set of similarities would be how today’s therapy sessions in many ways resemble the centuries-old Roman Catholic practice of confession. In confession, the priest sits behind a screen while the parishioner opens up about where they have messed up since their last time at confession. The screen, and the knowledge that the priest was subject to a vow of confidentiality, enables the parishioner to feel more at ease. Both facilitate a one-way vulnerability: you’re vulnerable with the priest, but not vice versa—any wish of the priest to confess must be directed to another priest.

A therapist is expected to maintain a similar confidentiality and one-way vulnerability, but without the screen. I’ve seen friends trying therapy for the first time being struck by this: for the first time in their lives they could open up about how they were feeling without the need to ask how their therapist was. Many practitioners undergo therapy themselves as part of their training, however, and I imagine a fair number keep that up.

The two are also similar in another, more subtle way: they both engage the philosophical—one might even say, spiritual—question of what it means to be human. And religion and mental health alike have ways of measuring progress in personal growth, each based on its own document: not for nothing that is the Diagnostic and Statistical Manual of Mental Disorders (DSM for short, and currently in its fifth version) sometimes referred to called as “the Bible of mental health.”

And one more thing: given the lack of access many have to therapy (either for cost reasons, long waiting times or just poor awareness of mental health), a lot of emotional support, for good and ill, continues to happen within the setting of religious communities.

So much for the similarities. But as I mentioned earlier, there’s an important difference (besides the obvious ones) between therapist and priest: absence of community.

It takes a village to make a human

Should you go to see either your therapist or your priest, you would likely do so alone. But only one of the two disciplines offers a community to welcome you as you walk back out. And however we may disagree on what it means to be fully human (and we all will), most of us will agree that relationships are a key part of it.

I’m reminded from back when I trained in Nigeria how one of my consultants used to say mental healthcare was often like a car wash, where the clean cars had to go back home on a muddy road, and ended up messy again by the time they got home. In other words, the difference we were able to make in people’s lives were limited by the nature of the environment they were returning into. And I’ve since seen how much likelier people are to rise above mental disorders and emotional problems when surrounded by supportive relationships.

The therapist can (and will) help with relationships, to be sure, but that’s not quite the same as being part of a community that bonds around a shared set of ideas and values. Nor is that lack the fault of mental healthcare: it’s not what it’s for. But if therapists really are the new priests, it’s useful to be aware of the trade-off involved: what really is the value of the community?

As someone who works in both mental health and is a practising Christian, I can think of at least three major ones:

  1. Culture (and accountability): A community is built around shared values: what Seth Godin calls “people like us do things like this”. And where there’s shared values, there’s accountability: one of the challenges with mental healthcare is people not following up on sessions, not wanting to do the work of, well, working on their emotional maturity and growth. But medications won’t confer maturity, nor will diagnoses repair relationships. There’s just no way around emotional work.
  2. Connection (and peer support): instead of medicalising social problems. People are often lonely. But it’s hard to make friends if you don’t have a space that feels safe enough for you to reach out to people. A lot of social settings try to offer this, and where it exists and people engage, it works. The problem is people often don’t engage—which comes back to accountability—communities of peers can provide pressure in ways that would be unprofessional in a trained healthcare worker.
  3. Contribution (and meaning): Being part of the community comes with responsibilities and roles. These are typically voluntary, which means those who engage are likelier to do so because they believe in the community’s shared values. In this way, communities offer opportunities to do work that matters, work they can believe in.

The importance of social support is well recognised within mental healthcare, and has been for awhile, but it’s proven difficult to get going in practice on anything like a large scale. I think some of that is related to what I said earlier about the professional ethics creating necessary limits. That’s why patient driven groups have over time come to prominence. But even those have limits: people often come expecting to be served rather than recognising themselves as part of a community to which they are expected to contribute.

We have lots of organisations, but what we need—what every human needs—is community.

My thanks to Salman Ansari, Aengus McMillin, Eneni Sowande, Precious Ajoonu, IbukunOluwa Shotubo and Progress Oladimeji for reading drafts of this.

Header photo courtesy Mindy Jacob (Unsplash)

Published by Doc Ayomide

I’m a medical doctor with specialty training in psychiatry, and I love thinking and writing about what it means to be human.

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