What, then, are the implications for mental health professionals and clergy who are seeking to help Catholic clients or members of a Catholic congregation? The following recommendations for application are based on the existing research, clinical experience, and common sense. We begin with a real life case vignette that illustrates some of the issues that may be encountered with Catholics and how a clinician might respond.

Case Vignette

Mr. T is a 42 year old married Catholic with a long history of alcohol abuse, who developed severe anxiety and depression following a recent diagnosis of lymphoma. While the oncologist had told him that his prognosis for long-term survival was good with treatment, the news hit him hard. He realised that death was possible in his near future, and he was not ready to go. His wife and son encouraged him to seek help from a psychiatrist. The psychiatrist placed him on antidepressant therapy, and encouraged him to stop drinking, which he did. Despite taking therapeutic doses of antidepressants for months, Mr. T experienced little relief. In fact, his symptoms worsened. As a result, he underwent a series of electroconvulsive treatments (ECT). The ECT treatments produced temporary relief, but the anxiety and depression soon returned, so his psychiatrist referred him to a counsellor who might help him with the underlying issues that were driving his emotional symptoms.

One day after several weeks of therapy, his wife called Mr. T’s therapist (a non-Catholic) and asked him to talk with Mr. T about a large donation he had recently made to the Catholic Church without telling her. The amount was much more than they could afford, given the bills accumulating from his healthcare. She also mentioned that he was going to confession as often as twice a month and attending Mass several times per week. When questioned by the therapist about the donation and increased religious activity, Mr. T asked: “Do you know what restitution means? I’ve done some bad things in my life.” When encouraged to elaborate, Mr. T slowly and tearfully revealed: “I’ve been cheating customers in my business. I cheated on my wife over and over again for years. The woman I had the affair with got pregnant and I forced her to have an abortion. I need restitution.” The therapist urged him to continue. “I’m afraid I’m going to Hell. The donation will help to pay off some of my sins.” When asked about his increased religious activity, Mr. T said “Going to confession and Mass give me some relief.”

After listening to Mr. T, the therapist gently suggested he see a Catholic priest with mental health training to discuss his concerns. Mr. T agreed to see a Catholic pastoral counsellor, who helped him understand the present day teachings of the Catholic Church a little better. After several months of counselling and continued medication therapy, Mr. T’s anxiety slowly improved and his religious activities normalised.

One in five patients seen by mental health professionals in the U.S. will be Catholic and many will be active in their religious faith. How can knowledge about the beliefs, practices, and values of Catholics, along with information gathered from systematic research, assist clinicians when treating Catholic patients? The following are recommendations for mental health professionals and clergy who might be called on to provide counsel to Catholics.

(1) Take a Spiritual History. Find out how active the person is in their faith community and how important being Catholic is to them. If previously involved in the Catholic Church, but now no longer active, gently explore this. Determine if they were raised Catholic or have converted to Catholicism. If raised Catholic, ask whether their Catholic upbringing was a positive or negative experience. Ask how important Catholicism is to their parents, and whether this was also true during the client’s childhood. If a convert to Catholicism, ask what led up to the conversion. Ask about specific religious practices now engaged in, such as how often they attend Mass, participate in other social Catholic functions, go to confession, pray, say the rosary, fast, or have pictures or statues of Jesus, Mary, or Saints in their home. Ask about any positive or negative experiences concerning their Catholic faith or interactions with Catholic clergy. Ask how important it is for them to follow Catholic teachings.

(2) Support for Therapy/Treatment. Ask clients if members of their family or support group are Catholic and how active they are. Are there any strong opinions among persons who are close to them about their decision to receive counselling? This will provide information about whether progress made in therapy will be supported or resisted outside the therapist’s office.

(3) Safe Place. Provide a friendly and safe place where clients can talk freely about their religious faith, good or bad, without judgement. Maintain a respectful, interested, and receptive attitude at all times to the client’s Catholic faith (whether the person is currently active or not, whether he or she speaks well of it or not).

(4) Confession. If clients have gone to confession, ask about what the experience was like for them, and whether it was helpful. If the client has not gone to confession lately, gently explore why not without implying that they should have gone or should go in the future.

(5) Role in Current Problem. Determine what role their Catholic faith may be playing in the current problem that help is being sought for. If they have trouble answering this question, ask them to think about it and then raise the question again during a subsequent visit. Obtaining collateral information from family members may also be useful.

(6) Guilt. Listen for feelings of excessive guilt over real or imagined transgressions. Don’t try to immediately rationalise or remove the guilt; rather, seek to understand it better from the client’s faith perspective. Identify core beliefs that may be driving the guilt, but be careful in overtly challenging religious beliefs. It may be necessary to seek counsel from Catholic clergy or even to arrange co-therapy with a Catholic pastoral counsellor (as in the case above).

(7) Challenge/Re-educate. Regardless of Hailparn and Hailparn’s (1994) suggestion to “exorcise” the “punitive superego” of Catholics, don’t be too ready to do this. After a solid therapeutic relationship has been established and a safe space created, the gentle challenge of harshly punitive core beliefs may be indicated and necessary. As noted above, it may be best to wait until obtaining consultation with a mental health or religious professional who is knowledgeable about the Catholic tradition. Re-education regarding religion should probably only be done by someone whom the client views as an authority in the Catholic faith. Of course, non-Catholic therapists can always use gentle “Socratic questioning” that gently imply that beliefs or practices may not be consistent with mainstream Catholic theology and therefore be contributing unnecessarily to the person’s distress.

(8) Role of the Sacraments. In addition to possibly recommending confession (if this has not already been tried), for devout Catholics with serious mental illness, the mental health professional may consider suggesting they see a Catholic priest to administer the sacrament of the “Anointing of the Sick” (see discussion above). Although such a suggestion is admittedly controversial, since little or no research exists that might indicate benefit, this recommendation may be reasonable in some cases depending on the patient and the openness of the Catholic priest whom he or she is being referred to. Even more caution should be displayed before suggesting that a devout Catholic with serious mental illness see a priest for the rite of exorcism (see discussion above). This should only be considered for someone with dissociative identity disorder, and even with this disorder, there is no good data to support its use. Exorcism for psychotic illnesses such schizophrenia does not help (personal communication William P. Wilson, M.D., Duke University professor emeritus of psychiatry).

(9) Support Beliefs/Practices. Don’t be too reluctant to support the Catholic religious beliefs or practices that the client finds helpful (or might find helpful in the future as a way of coping with emotional issues), but do so from the client’s perspective. If the client is receptive and open to healthy religious practices, then these may be encouraged; if the client shows resistance, don’t push too hard. However, it may be informative to gently explore where the resistance is coming from at a future session. Never give clients the impression that they are not religious enough, since they probably get plenty of that from family and fellow church members. Whether it is a psychiatrist prescribing biological therapies or a therapist providing counselling, the mental health professional should be viewed by the client as neutral, interested in, open to, and supportive of the client’s Catholic faith, but always on the client’s side and never judgemental. The same applies to Catholic clergy who are counselling members of their congregation.