The DSM in one hand and the Summa in the other

What does a 13th-century friar and theologian have to do with mental health care today? Quite a lot, according to Warren Kinghorn, for whom Thomas Aquinas’s thought both fuels a challenge to current approaches and plots a course for an alternative vision of mental health.

Kinghorn, a psychiatrist and ethicist who holds theological and medical faculty appointments at Duke University, begins Wayfaring by critiquing the way mental health is typically characterized in terms of data, diagnosis, and labeling. He points to the crisis of mental health in the United States—rises in suicide, drug overdoses, and depression. (About 46 percent of the population will meet the criteria for a mental disorder at some point in their lives.) Mental health care in the US is fragmented and inadequate due to inpatient facility closures, budget reductions, rising costs, industrialization of care, and the dominance of business models that create a wealth-driven consumer market for treatment. Not only do these conditions commodify care, they reduce it to technical fixes. When patients seek help with deep inner suffering, the dominant practice is to dissect and classify it into diagnoses that call for particular interventions. The belief that body and mind can be tinkered with and even fixed with pharmaceuticals and therapy—an approach which Kinghorn calls “the machine metaphor”—does a disservice to mental health care.

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Kinghorn advocates replacing this model with the Christian image of the wayfarer on a journey of seeking and being sought by God. Humans, in this view, are not machines but creatures, image-bearers, knowers, and lovers. Such a perspective offers radical hope that modern psychology on its own terms cannot. Christianity affirms that we were created in and for relationship with God and that God is faithful to that relationship. God loves every creature, especially those who are unable to feel or reciprocate that love. Using biblical and christological rationales, Kinghorn shows how a shift from bare existence to beloved existence parallels the movement from shame to healing.

The author engages Aquinas’s notion of the wayfarer (viatore), along with scripture, philosophy, psychology, and ethical perspectives on the virtues and vices. In opposition to the mind-body dualism of Descartes, Kinghorn applies Aquinas’s lovely idea of flourishing rooted in union with God—beatitudo, which Kinghorn translates as “participation in blessing.” Beatitudo consists of goods that are good insofar as they participate in God’s goodness. In pursuing God, the wayfarer finds themself progressively free to know and act in ways consistent with what is true, to approach the higher goods. This is very different from the platitude that if you just have Jesus, everything will be alright. It is, rather, a theological rationale for regarding our journeys from and to the triune God as a resource for mental health.

The Diagnostic and Statistical Manual of Mental Disorders situates mental health problems within individuals, as a dysfunction of the body or mind. Kinghorn argues that this “inside-out” view, which sets the context for DSM labeling, is misleading when used as the sole narrative for mental health care. The internalization of mental health problems feeds shame and stigma by perpetuating the notion that although stressors from the outside may contribute, the real problem is a deficit in the person. This can lead to the tyranny of self-vigilance and control. While self-care is important, it can lead to the false idea that one can regulate everything. And while control in mental health care is often essential, it can also be dangerous in obscuring the ultimate good.

Kinghorn proposes moving to an “outside-in” view of the origins of mental illness. Instead of coming solely from biological or neurological disorders within individuals, mental health problems should be seen as rooted in relationships, communities, and cultures. In the inside-out view, conditions in the external world such as abuse or trauma are named as risk factors, but mental illness is still seen as developing inside the person. Turning the model around—relocating what is wrong from inside to outside of the person—regards mental illness as a way of operating in a particular context, responding to external things. Such a view regards mental health problems as relational and communal—a biosocial, ecological understanding.

This perspective aligns with the Christian affirmation that we are in relationship with each other and with a God who knows and loves us. Mental health is not for the patient alone, because we do not live in isolation. Informed by Wendell Berry’s understanding of the body along with Aquinas’s, Kinghorn notes that the “dust-nature of human life” forms us for relationship, radical vulnerability, and dependence on God.

The treatment of emotion in Aquinas’s Summa Theologiae indicates that there is a place for somatic approaches to mental health care, Kinghorn writes, but understanding the emotions as signs of what individuals love can assist in healing. Many barriers to mental health are in part reflections of what is loved, and there is much to learn from tracing these to their source. Rather than viewing the emotions as an enemy to be conquered, it can be productive to see how our emotions reveal what we love—and then perhaps to reorder these loves toward what is life-giving.

What does pursuit of God as the highest truth look like for people struggling with mental health concerns? Aquinas paints a picture of the journey toward agency and freedom through both active and contemplative means, and Kinghorn believes it is no surprise that many successful therapies engage forms of contemplation. Contemplation is not just a tool for altering mood. It entails a set of practices by which we attend to God and move from control to wonder, creating a mental state characterized by the cultivation of love and joy. For clinicians and pastors alike, the goal is to accompany wayfarers and to help nurture their capacities for this kind of knowing and loving.

Kinghorn knows his way around philosophy, and in true pedagogical spirit he imparts it with clarity and relevance. This book makes a significant contribution to the mental health scholarship, and I recommend using it in pastoral theology classes. It will engender fruitful dialogue about mental health care for students preparing for ministry among the wayfarers who seek to participate in the blessing that leads to feasting, wonder, and hope.