by Fr. George Morelli 
This course has recently been updated and soon to be published in a chapter in an American Psychological Association book. The updated reference for the upcoming book is: Morelli G. (in press). Eastern Orthodox Churches. In Scott Richards, (Ed.), "Handbook of Psychotherapy and Religious Diversity" (2nd edition). Washington, DC: American Psychological Association.
2.0 Bio-Cultural Elements
2.1 Emotion and Neural Processes
Studies from various areas in psychology, suggest cognition, emotion and behavior interact with each other in complex ways (Weitan 1995). There are currently various psychological models to explain this interaction. One model based on Darwinian evolutionary theory is that emotion develops as an adaptive value to a stimulus. The different laboratories of Izard (1984), Tomkins (1991) and Plutchik (1984) come remarkably similar findings on the presence of primary emotions shortly after birth. These researchers agree on six emotions (fear, anger, joy, disgust, interest and surprise) out of about eight or ten primary emotions. Phylogenetically these emotions occur before the brain structures supporting cognition initiate development. That is, subcortical brain areas such as the hypothalamus and the limbic system develop before the cerebral cortex.
Researches have shown that emotional responding in lower animals appears to be an innate reaction to certain stimulus. In human brain architecture the limbic system and hypothalamus are connected by neural structures to these, later developing cortical structures allowing communication between these two areas. Research on neurophysiological processes and psychopharmological processes summarized by Izard suggests that these areas serve as the possible neural architecture (sub cortical and cortical) pathways of emotion. Early Christians knew nothing of the taxonomy and biological substrates that are understood today. They were limited to the understanding of their times. The word passion is the term most closely used by the Church Fathers in describing what today by scientific investigation are called emotions.
2.2 Cognition, Emotion, and Psychospiritual Perspectives
The research literature demonstrating the cognitive elicitation of emotion is ubiquitous. Appraisals, anticipations, attributions, beliefs, construals, inferences, judgments and memories of stimulus situations all fall in the cognitive domain. In one early pivotal study out of Richard Lazarus’ laboratory (1991), appraisal strategies of subjects were manipulated before they viewed a film depicting an aboriginal male puberty rite. Subjects in a neutral or “intellectualized” condition displayed significantly less emotion as measured by self-report and physiological monitoring then subjects in the “sensitized” condition. Other studies in this area are use variations of this paradigm. In recent years a substantial body of information has been collected on cognitive-emotion interaction. (Bandura, 1986; Erwin, 1980; Galanter, E. 1962; Kahneman, D. 1973; Marmor, J. 1962; Posner & Snyder, 1975; Shriffren, 1988). Cognition has also been extended to the behavioral processes of parenting, (Patterson, 1976).
The question that arises for the use of psychospiritual intervention to address emotional disorders is to what extent cognition plays a role in initiation, sustaining and possible attenuation of emotional responding? If one were to maintain that emotions can be triggered even in humans by sub-cortical processes, would cognitive processes have any role in their modulation? This is not a trivial question, because it is at the foundation of the various Cognitive therapies and it goes to the heart of the moral and spiritual teachings of the Church Fathers.
Fundamentally the question is: “To what extent can we control our emotions or what the Church Fathers refer as our “passions”? Is it true that emotions generated at more basic systems such as sub cortical or neural processes are less cognitively controllable than cortical (cognitive) processes? To what extent do individual differences play in such control processes? In other words are some individuals able to control the various systems of emotional activation over others? In as much as we do not have a comprehensive individual difference model of emotion activation, we must proceed with caution and at best heuristically. Each person should be evaluated individually as to what emotion systems are influencing an emotional reaction and the person’s ability to have cognitive control of these systems.
Some patients with lower levels of cognitive control may benefit from interventions targeting the neural sensori-motor or affective systems directly (i.e. psychotropic treatment, environmental change) as the primary treatment. Patients with higher levels of cognitive control may benefit from more focused cognitive treatment programs (i.e. Beck’s  Cognitive Therapy). It has been my clinical observation however, that even patients with limited cognitive resources however (with the exception for example of low functioning cognitively impaired individuals) benefit from some cognitive interventions. This makes neurophysiological sense if it is remembered that in humans the brain subcortical pathway (emotion) and cortical (cognitive) pathways are connected. These findings in no way contradict the teachings of the Church Fathers. They point out man, created in God’s image has “free will”. However as the Fathers tell us any number of factors may diminish the capacity of voluntary-involuntary acts (St. Clement of Alexandria, Stromata, Book II).
2.3 Factors Affecting Human Behavior
Such Church Fathers as St. John of the Ladder and St. Gregory Palamas indicate that continual sin becomes habitual. [Thereby making behavioral patterns less voluntary.] Habits can “darken the spirit”, [habits] work by “darkening our minds, which guides us, pushes people to do things only the mad would think of.” (Philokalia, 1984-93) The Church Fathers suggest on reducing the strength of the habits by removing sensory factors and stopping memories [thoughts] as they begin. With repetition, these new techniques become stronger. This is not unlike ‘thought stopping’ techniques proposed by Cognitive-behavioral therapists. For the Christian, putting these techniques, in a spiritual perspective, suggested by the Church Fathers provides added motivation and rationale for the treatment.
2.4 Cultural Values in Psychospiritual Therapy
Cultural (and to a lesser extent spiritual) factors have received increased emphasis in understanding mental disorders and psychological treatment (DSM IV, American Psychiatric Association, 1994; McGoldrick, et.al. 1996). It would be unthinkable for Christians not to include spiritual factors in the understanding and treatment (healing) of mental disorders. The Christian spiritual tradition, including the prayers and practice of the Church, Sacred Scripture and the writings of the spiritual fathers lends itself to an elegant integration with the Cognitive therapy methods noted above. While non-religious clinicians will not of course employ prayer for and/or with their patients, ethically they are required to include the religious values of their patients, even merely as a tool for understanding and treatment as suggested by McGoldrick, et.al. (1996). Christians are committed to do all in Christ’s name. Jesus told His followers: 26. “For whoever is ashamed of me and of my words, of him will the Son of man be ashamed when he comes in his glory and the glory of the Father and of the holy angels.” (Lk 9: 26) St Paul told the Corinthians: “knowing that in the Lord your labor is not in vain.” (1 Cor 15: 58) Thus following the advice of McGoldrick et.al., it behooves the clinician to interweave the treatment with the patients spiritual value system.
A clinical example follows: One of my patients had discontinued regular psychotherapy due to a terminal illness. Her initial presenting problems and treatment focus involved family problems. Being a deeply religious woman, I made clinical-pastoral visits to her during up to her death in a hospital. The nature of her treatment shifted from family issues to the acceptance of her impending death. Because of her deep commitment to Christian teaching, the concept of her spirituality was integrated into exploring and addressing the “meaning of her life”. It was great comfort to her to know she had brought Christ to her family and that He would continue to care for them spiritually after she would be dwelling with Jesus, after her physical death. By addressing her cultural value of being a devout Christian and integrating this into her psychotherapy, she became fulfilled spiritually and could die in peace.
2.5 Cognitive Distortions
Keeping in mind the caveats above the cognitive-behavioral model of emotional dysfunction (Beck, Rush, Shaw and Emery, 1979; Ellis, 1962) has been shown to be effective in dealing with dysfunctional emotions, decreasing inappropriate behavior and increasing appropriate behavior. According to this model basic dysfunctional emotions such as anger, anxiety, depression and mania as well as more complex emotions such as anticipation, awe, jealousy and remorse (Plutchik, (1984) are produced by distorted or irrational appraisals, attitudes, beliefs and/or cognitions. Situations (something that someone has said or done or events that have happened) do not produce or cause the emotional reaction. Rather we upset ourselves over people and events by our cognitive processing of these situations. If our thinking is clear, rational and non-distorted we have normal feelings like annoyance, concern and disappointment.
Even opening this model to a less strict position, (allowing for sub cortical activation of emotion) it would be maintained that some control over emotions initiated by these sub-cortical centers could be had by cognitive (cortical) methods. In Beck’s model, individuals have automatic thoughts (which are similar to primed cognitions investigated by Loftus, 1980) about activating events. These include selective abstraction (drawing conclusions unwarranted by the facts), personalization (attributing neutral events to be referred to you), polarization (viewing events in all or nothing terms), generalization (the tendency to conclude events will never change or always remain the same), demanding expectations ([Ellis, 1962], the belief that there are laws or rules that must or should be obeyed) and catastrophizing ([Ellis, 1962], the perception that something is more than 100% bad, awful or terrible).
Another cognitive model with clinical utility is attribution theory (Weiner, 1974; Abramson, Seligman & Teasdale, 1978). In this model explanations of events as due to combinations of internal or external and unstable (temporary) or stable (permanent) factors influence felt emotion and subsequent behavior. After rapport, diagnosis and treatment goals have been established the Cognitive-behavioral treatment strategies usually involve some form of didactic presentation of the cognitive model. Bibliotherapy is often used adjunctively. [Some recommended, books include, Beck, A.T. (1988), Love is Never Enough; Burns, D. (1980), Feeling Good; Ellis, A. (Ellis and Harper, 1975) A Guide to Rational Living] The patient is then helped to recognize, pinpoint and identify his/her cognitive distortions. The patient learns to challenge and restructure the irrational distorted cognitions that are initiating or sustaining the dysfunctional emotions to more accurate non-distorted cognitions. Use of notes and charts in the treatment session and outside the office is encouraged to facilitate the patient’s integration of these concepts.