Kata; qeo;n: the use of II Corinthians 7:10 in a cognitive therapy for depression

Marshall H. Lewis

This paper is dedicated to Alejandra,[1]

who attempted suicide as it was being written.

Suicide resulted in the deaths of 877,000 people worldwide in the year 2002.[2] A leading cause of suicide is clinical depression,[3] some form of which afflicts 10% to 20% of the population at some point in their lives, most commonly during their most productive years.[4] Numerous studies have demonstrated the effectiveness of cognitive therapy for the treatment of depression and new research suggests that it is effective for suicide prevention.[5] Cognitive therapy is easy to learn and apply. However, it is difficult for many people to turn that understanding into true and lasting emotional transformation.[6] In my own practice of cognitive therapy, I have found that transformation is made easier by joining the principles of cognitive therapy with a person's existential beliefs. Transient thoughts of suicide along with exaggerated feelings of guilt characterize many persons suffering from a major depressive episode.[7] These thoughts and feelings can be mitigated by disputing the beliefs that support them.[8] II Corinthians 7:10 presents a dichotomy which easily allows for this disputation. "Sorrow of the world produces death" (or thoughts of it) is contrasted with "Sorrow according to God produces repentance to salvation free from regret." A person bound by feelings of guilt cannot only be liberated from those feelings, but actually empowered by a reinterpretation of events which at first elicited sorrow. This paper will begin with a description of the general characteristics of II Corinthians 7:10, including Sitz im Leben. It will then provide a brief outline of one technique of cognitive therapy, including a discussion of a recognized weakness of cognitive therapy. The paper will conclude with a clinical illustration of a way in which that weakness can be overcome. II Corinthians 7:10 as I have used it in the cognitive therapy of depression provides the illustration.

hÔ ga;r kata; qeo;n luvph metavnoian eijV swthrivn ajmetamevlhton ejrgavzetai

hJ de; tou: kovsmon luvph qavnaton katergavzetai

For sorrow according to God produces repentance to salvation free from regret,

but sorrow of the world produces death.[9]

Translation issues are few. Only one alternative rendering is extant for this verse: the apparent transposition of katergavzetai into the first part of the verse, replacing ejrgavzetai. Furnish remarks that there is no contextual reason to translate these verbs differently and that Paul uses them interchangeably elsewhere.[10] Furnish translates metavnoian as "contrition" rather than "repentance" on the grounds that Pauline theology incorporates the Hebrew Bible's concept of "repentance" under "faith." The term kata; qeo;n is a Greek expression referring to the will of God. The use of swthrivn is here, according to Furnish, a general term for living in the fullness of life. Finally, he notes that ajmetamevlhton appears to be something of an oxymoron when coupled with luvph.[11] This, however, provides the means for the clinical use of the verse.

This section of II Corinthians is part of the correspondence between Paul and the Corinthian church that is widely held to have taken place between 52 - 55 C.E.[12] II Corinthians is not as well attested or as unified as I Corinthians. It is certainly part of the Pauline corpus circulated from the middle of the second century, but prior to this it is not clear that II Corinthians was widely known. Despite this lack of circulation, most scholars accept Paul's authorship of it. Furthermore, there is a discontinuity between chapters 1-9 and 10-13 that have led many scholars to conclude that II Corinthians is a combination of at least two Pauline epistles. As early as 1776, Semler hypothesized that the latter chapters were from a later letter. The consensus since the twentieth century, however, is that chapters 10-13 were written before chapters 1-9; some suggest that it constitutes the "tearful letter" Paul refers to in II Corinthians 2:4.[13] Others suggest three letters.[14]

The Sitz im Leben of this portion of II Corinthians is based on the hypothesis that Paul wrote at least four letters to the church in Corinth. The first letter, referred to in I Corinthians 5:9 and known to scholars as Letter A, is now lost.[15] Snyder, however, holds that part of Letter A, which he refers to as the "previous letter," may be found in II Corinthians 6:14 - 7:1.[16] Letter B is the canonical I Corinthians. The "tearful letter" is Letter C, while at least most of the first part of II Corinthians is Letter D, Paul's fourth letter to the Corinthians. In the time between the writing of Letter B and Letter C, it appears that the Corinthians became enamored of a group of "super apostles" (referred to in II Corinthians chapter 11) who brought criticisms against Paul and his gospel. Paul made a brief, "painful" visit to Corinth were he was wronged by someone associated with the Corinthian church. This lead to the "tearful letter." Letter D, of which the current verse is a part, was written from Macedonia after Paul learned from Titus that Letter C had been effective and that the Corinthian church was returning to Paul's teachings.[17] The luvph referred to in II Corinthians 7:10 is the "sorrow" the Corinthians experienced after wronging Paul during his brief visit and refers to their metavnoian upon returning to his teachings. Furnish sets the date of composition in the late summer or early fall of 55. This is based upon the timing of a threat to Paul's life in Asia, his imprisonment in Ephesus, and the time of year when the sea lanes would be open for travel.[18] Snyder identifies this document as the "joyful letter" which is comprised of II Corinthians 1:1-6:13 and 7:2-9:15. He describes chapter 5 as "God standing with us in the midst of our brokenness" and considers it one of the greatest sections of the Bible.[19] It is to this document that the present verse belongs.

The immediate context for verse 10 can be found in verses 8, 9 and 11. It is clear that Paul at first may have "regretted" or "changed his mind about" (metemelovmhn) writing the letter because it "sorrowed" (ejluvphsen) the Corinthians. However, as a consequence of this sorrow, Paul describes the Corinthians as responding with positive qualities (earnestness or diligence, eagerness to prove innocence, indignation, fear, desire, zeal, rendering of justice) which constitute their repentance. Upon learning of this change of heart from Titus, Paul is able to rejoice. A psychological exegesis seeking to interpret this verse as an expression of sorrow either on the part of Paul or of the Corinthians will not be attempted.[20] Rather, I will demonstrate the way in which this verse can be used in the contemporary cognitive treatment of depression.

Major Depressive Disorder is defined by the American Psychiatric Association as a constellation of symptoms, a certain number of which are essential for the diagnosis to be made. In addition, these symptoms must have persisted for at least two weeks and must interfere with a person's social or occupational functioning, or cause significant distress to the sufferer. Either a feeling of sadness or emptiness must be present, or else loss of interest in activities must be present. Additional symptoms that may appear include a disturbance of appetite, a disturbance of sleep, a disturbance of psychomotor function, loss of concentration and fatigue. Of specific relevance to this discussion are the symptoms of recurrent thoughts of death, suicidal ideation, and "feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)."[21] These symptoms may also occur as part of a Bipolar Disorder or other forms of Mood Disorder.[22] One recent study found that 5.28% of adults in the United States had experienced Major Depressive Disorder within the prior 12 months and that 13.23% had experienced the condition at some point in their lives.[23] A higher prevalence of the disorder was found in this study than estimated in the 1980s and the 1990s. Also, a shift was apparent in that the greatest lifetime risk was more likely among middle aged adults than among young adults, which had appeared to be the case in earlier decades.[24] Only about 60% of persons meeting criteria for the disorder received treatment for it. A desire to die was present in 45.5% of the sample; 36.4% experienced frequent thoughts of suicide while 8.8% attempted suicide.[25]

Effective treatments are available for Major Depressive Disorder: electroconvulsive therapy, antidepressant medication and psychotherapy. Electroconvulsive therapy is rarely used.[26] Antidepressant medication has been found to be superior to placebo while cognitive-behavioral therapy[27] and interpersonal therapy have been found to be superior to psychodynamic therapy.[28] Moreover, cognitive-behavioral therapy has been found to be as effective as medication even for cases of severe depression.[29] Cognitive-behavioral therapy does not pose problems of side-effects and there is increasing evidence that this method may reduce the client's risk of future struggles with this disorder.[30] One study found that 25% of persons receiving cognitive-behavioral therapy experienced a relapse of major depressive symptoms while 80% of those being maintained on antidepressant medications experienced such a relapse.[31] Gains in efficacy by combining medication with cognitive-behavioral therapy are either not significant[32] or modest.[33] The exception to this is in cases of severe depression.[34] Only a single study has found medication to be superior to cognitive-behavioral therapy for most cases. This result has not been replicated. Disputed by numerous other studies both before and since, this single study became the basis for the treatment guidelines adopted by the American Psychiatric Association in 2000.[35] These guidelines are obviously in need of revision. Results for adolescents with moderate to severe depression are similar. One recent study found an 86% recovery rate with combined medication and psychotherapy treatment compared to an 81% recovery rate for treatment with either cognitive-behavioral therapy alone or medication alone after 36 weeks of treatment. However, of those receiving medication alone, 14.7% experienced a suicidal event compared to 8.4% of those receiving combination treatment and 6.3% of those receiving cognitive-behavioral therapy alone.[36]

The earliest cognitive-behavioral therapy is Rational Emotive Behavior Therapy (REBT) developed by Albert Ellis beginning in 1955. Originally conceived as a purely cognitive therapy, Ellis nevertheless incorporated many behavioral techniques. During the 1960s, behavioral therapists came to see cognitions as behaviors subject to learning theory. This convergence ultimately resulted in cognitive-behavioral therapy as it is known today, of which REBT remains a prime example.[37] The basic concepts of REBT are not difficult to master. Ellis has written books both for the professional therapist as well as for the layperson.[38] The basic premise underlying REBT is that an emotional consequence is the result of both an environmental event as well as a personal belief about that event. Strong, unpleasant emotions such as depression, rage and terror are supported by irrational beliefs[39] that do not accurately reflect reality. REBT teaches a person to ask herself a series of questions that serve to identify the irrational beliefs and to replace them with rational ones, that is, beliefs that do accurately reflect reality. Thus, depression, rage and terror can be transformed into ordinary sadness, frustration and apprehension. While these feelings may be unpleasant, they are normal and tolerable parts of life, unlike their exaggerated, irrational counterparts.[40]

An example comes from my own case files. The client was a man in his late 40's whose grown son had been killed in an automobile accident. The man had been depressed for a number of years before seeking psychotherapy. This depression had been maintained by the irrational belief that the man had been a "bad father." The man had been an authoritarian parent who, as he grew older, was becoming less rigid regarding a number of matters and felt excessive guilt regarding his previous behaviors. After several sessions of REBT, the man came to the more moderate, rational belief that he had made some mistakes as a father, but had also done some good as a father. In this regard, he came to believe that in his human imperfection he was no better or worse than any other father who has ever lived. He was then able to effectively grieve for his son without being impaired by excessive guilt.

Ellis reminds us that for REBT to work, the client must be willing to practice the REBT exercises.[41] As a practicing psychotherapist, I am aware that motivating the client is one of the greatest challenges to a successful therapy. Ellis recognizes this problem and offers the following advice to the layperson, "Make yourself a good, happy life by giving yourself something to life for."[42] Elsewhere, he identifies this as a "vital absorbing interest" and contrasts it with Viktor Frankl's search for meaning, which, Ellis argues, lies outside the bounds of a scientific approach.[43]

Nevertheless, it is the work of Viktor Frankl that explains why Ellis's advice for the layperson is helpful. Quoting Nietzsche, Frankl asserts, "He who has a why to live for can bear almost any how."[44] Frankl asserts that the "will to meaning" is the basic source of motivation for human beings.[45] Take, for example, a case offered by Frankl: The client is a rabbi who is grieving for the death of his children and has fallen into a state of depression. One may imagine that Ellis would challenge the rabbi to uncover his irrational thoughts, such as, "I have failed as a father because I was unable to protect my children," similar to my clinical example. Rational thoughts may then be developed such as, "It was not humanly possible to protect my children."[46] Current research would support the idea that this therapy would have reduced the rabbi's symptoms of depression.[47] Frankl's approach, however, was to understand the meaning of the children's death for the rabbi. Specifically, the rabbi believed that he would never see his children in heaven. They were young innocents when they died, while he was a grown man who had committed many sins. During therapy with Frankl, the rabbi came to believe that the meaning of his suffering was to thereafter live in such a way so that he would be able to see his children again.[48] This approach not only relieved the rabbi's depression, but also allowed the rabbi to interpret his period of suffering as a meaningful and life-changing experience.

In my experience, this type of cognitive restructuring overcomes the lack of motivation in therapy and brings about lasting transformation. II Corinthians 7:10 can produce this type of transformation in the following manner: A Christian client presents with a sense of overwhelming guilt and a desire to die following the death of his son. Using REBT techniques, the client is taught to identify irrational beliefs such as, "I was a bad father," and, "My son must always have hated me for the bad things I did." The client understands that disputing and replacing these thoughts with more moderate thoughts will help him to feel better, but he does not practice the REBT exercises. Further exploration with the client reveals the irrational beliefs, "I should feel guilty for my poor job of parenting," and "God must judge me harshly because I was so bad." At this point, II Corinthians 7:10 can be used to dispute those beliefs by demonstrating that a feeling of guilt or sorrow which leads to death, such as having thoughts of suicide, is a feeling "of the world" and not "according to the will of God." The verse also describes what an emotional consequence would be for sorrow that was "according to God" -- repentance with no regret. The client may then be challenged to produce rational thoughts that lead to this emotional consequence. Moreover, most Christians will be able to recall a time when living according to the will of God was a "vital absorbing interest." Actively disputing the irrational thoughts that lead to death with the rational thoughts that lead to repentance free of regret is then motivated by the vital absorbing interest of living life kata; qeo;n. From the perspective of Frankl, the client has found meaning in the suffering -- the motivation to live a better life. From the perspective of REBT, the client is now practicing the thought disputation exercises leading to remission of the depression and suicidal thoughts.

Two case studies come to mind in which the use of this text has been significant. The first is a 34-year-old male actively and voluntarily participating in a 12 step program for his alcohol dependence. He was referred to me by his probation officer because of his exhibitionism. Having a traditional Protestant faith, he was approached with the text on his second visit as we discussed his feelings of guilt. Coming to believe that his guilt could be a source of strength for him, he has not reoffended during the past 6 months. Another example is that of an 18-year-old female referred to me in crisis following a suicide attempt. She had been sexually abused throughout much of her childhood. In the fourth session she revealed that she had been sexually abusive toward a younger child when she was 9 years old. In her guilt over this incident, she believed that her childhood behavior was no different from the behavior of the adults who had abused her. Consequently, she was reluctant to reveal to the authorities the crimes that had been committed against her. Coming to view this as "guilt from the world," she was finally able to abandon it after 9 years. In addition, she had been experiencing a hallucinatory voice calling her obscene names for a similar length of time. The hallucination, revealed in the third session, had ceased by the fourth session when actively confronted. This client was taking no psychotropic medication, choosing to be treated with psychotherapy alone. She remains in treatment without suicidal gestures or hallucinations.

This paper has translated and examined the literary characteristics of II Corinthians 7:10. It has reviewed current findings on the treatment of depression. Using examples from my own clinical practice, I have shown how II Corinthians 7:10 can be used as a tool of cognitive restructuring as well as a means to provide motivation to practice other techniques of cognitive therapy. This technique falls within the usual practice methods of REBT and shares many characteristics with the meaning-centered therapy of Viktor Frankl. I hypothesize that this "meaning-centered cognitive therapy" shares the same benefits as the established forms of cognitive-behavioral therapy and provides enhanced motivation for the Christian who struggles with guilt and depression.

Bibliography

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington, D.C.: American Psychiatric Association, 1994.

Beck, A. T., Depression: Causes and Treatment . Philadelphia: University of Pennsylvania Press, 1967.

--------------The Development of Depression: A Cognitive Model in Friedman, R.J. and Katz, M. M., The Psychology of Depression: Contemporary Theory and Research. Washington, D.C.: V.H. Winston and Sons, 1974.

Corey, G., Theory and Practice of Counseling and Psychotherapy. Pacific Grove, California: Brooks/Cole Publishing Co., 1991.

Dingfelder, S., Cognitive therapy shows promise for suicide prevention. Monitor on Psychology, Vol. 37, No. 9. American Psychological Association, 2006.

Ellis, A., How to Stubbornly Refuse to Make Yourself Miserable About Anything, Yes, Anything. New York: Carol Publishing Group, 1988.

--------------Reason and Emotion in Psychotherapy, Revised and Updated. New York: Birch Lane Press, 1994.

Ellis, A. and MacLaren, C., Rational Emotive Behavior Therapy. San Luis Obispo, California: Impact Publishers, 1998.

Frankl, V., Man's Search for Meaning. Boston: Beacon Press, 1959 (English translation by I. Lasch).

--------------On the Theory and Therapy of Mental Disorders. New York: Brunner-Routledge, 2004 (English translation by J. Dubois).

--------------The Will to Meaning: Foundations and Applications of Logotherapy Markham, Ontario: New American Library, 1988.

Fava, G. A., et. al., Prevention of Recurrent Depression with Cognitive Behavioral Therapy. Archives of General Psychiatry, Vol. 55. American Medical Association.

Furnish, V. P., II Corinthians in The Anchor Bible. Garden City, N. Y.: Doubleday and Co., 1984.

Hasin, S., et. al., Epidemiology of Major Depressive Disorder. Archives of General Psychiatry, Vol. 62. American Medical Association, 2005.

Hollon, S. D., Thase, M. E., and Markowitz, J. C., Treatment and Prevention of Depression. Psychological Science in the Public Interest, Vol. 3, No. 2. American Psychological Society, 2002.

Mann, J. John, et. al., Clinician's Corner: Suicide Prevention Strategies, A Systematic Review. Journal of the American Medical Association, 2005, 294.

Robinson, L. A., Berman, J. S., and Neimeyer, R. A., Psychotherapy for the Treatment of Depression: A Comprehensive Review of Controlled Outcome Research. Psychological Bulletin, Vol. 108, No. 1. American Psychological Association, 1990.

Roetzel, C. J., The Letters of Paul: Conversations in Context, third edition. Louisville, Kentucky: Westminster / John Knox Press, 1991.

Snyder, G. F., First Corinthians: A Faith Community Commentary. Macon, Georgia: Mercer University Press, 1992.

Thase, M. E., et. al., Treatment of Major Depression with Psychotherapy or Psychotherapy-Pharmacotherapy Combinations. Archives of General Psychiatry, Vol. 54. American Medical Association, 1997.

The TADS Team, The Treatment for Adolescents With Depression Study. Archives of General Psychiatry, Vol. 64. American Medical Association, 2007.

Theissen, G., Psychological Aspects of Pauline Theology. Philadelphia: Fortress Press, 1987 (English translation by J. P. Galvin).

Greek Text, Grammars and Reference Consulted

Efird, J. M., A Grammar for New Testament Greek. Nashville: Abingdon Press, 1990.

The Greek New Testament, Third Edition. Stuttgart: Deutsche Bibelgesellschaft, 1975.

Jay, E. G., New Testament Greek. Cambridge: SPCK, 1958, 1978.

The Joint Association of Classical Teachers, Reading Greek. Cambridge: Cambridge University Press, 1978, 1980.

Thayer, J. H., The New Thayer's Greek-English Lexicon. Peabody, Mass.: Hendrickson Publishers, 1979, 1981.

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[1] An alias.

[2] Mann, J. J., et. al. Clinician's Corner: Suicide Prevention Strategies, A Systematic Review. Journal of the American Medical Association, 294, 2005, pp. 2064-2074.

[3] Hollon, S. D., Thase, M. E., and Markowitz, J. C. Treatment and Prevention of Depression. Psychological Science in the Public Interest, Vol. 3, No. 2. American Psychological Society, 2002, p. 39.

[4] Robinson, L. A., Berman, J. S., and Neimeyer, R. A. Psychotherapy for the Treatment of Depression: A Comprehensive Review of Controlled Outcome Research. Psychological Bulletin, Vol. 108, No. 1. American Psychological Association, 1990, p. 30.

[5] Dingfelder, S. Cognitive therapy shows promise for suicide prevention. Monitor on Psychology, Vol. 37, No. 9. American Psychological Association, 2006, p. 17.

[6] Ellis, A. How to Stubbornly Refuse to Make Yourself Miserable About Anything, Yes, Anything. New York: Carol Publishing Group, 1988, p. 141.

[7] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington, D.C.: American Psychiatric Association, 1994, 327.

[8] Ellis, A. Reason and Emotion in Psychotherapy, Revised and Updated. New York: Birch Lane Press, 1994, p. 55.

[9] Translation is the responsibility of the author.

[10] Furnish, V. P. II Corinthians in The Anchor Bible. Garden City, N. Y.: Doubleday and Co., 1984, p. 388.

[11] Ibid., pp. 387-388.

[12] Roetzel, C. J. The Letters of Paul: Conversations in Context, third edition. Louisville, Kentucky: Westminster / John Knox Press, 1991, p. 87.

[13] Furnish, op. cit., pp. 30-35.

[14] Snyder, G. F. First Corinthians: A Faith Community Commentary. Macon, Georgia: Mercer University Press, 1992, p.14.

[15] Furnish, op. cit., pp. 35-42.

[16] Snyder, op. cit., p. 10.

[17] Furnish, op. cit., pp. 35-42 and Roetzel, op. cit., 87-96.

[18] Furnish, op. cit., p. 42.

[19] Snyder, op. cit., p. 14.

[20] Theissen, G. Psychological Aspects of Pauline Theology. Philadelphia: Fortress Press, 1987 (English translation by J. P. Galvin), p. 1, on the dangers of psychological exegesis.

[21] American Psychiatric Association, op. cit., p. 327.

[22] Ibid., pp. 317-318.

[23] Hasin, S., et. al. Epidemiology of Major Depressive Disorder. Archives of General Psychiatry, Vol. 62. American Medical Association, 2005, p. 1102.

[24] Ibid., p. 1097.

[25] Ibid., p. 1100.

[26] Robinson, op. cit., p. 30.

[27] Here, I retain the term "cognitive-behavioral therapy" as operationally defined in the various research studies. Unless referring to such operationally defined interventions, I use the shorter term "cognitive therapy." While there is a technical difference, most cognitive therapy practiced since the 1960s recognizes elements of learning theory; my use of the term corresponds to the way most therapists use the term today.

[28] Ibid., p. 53.

[29] Ibid., p. 63.

[30] Ibid., p. 68.

[31] Fava, G.A., et. al. Prevention of Recurrent Depression with Cognitive Behavioral Therapy. Archives of General Psychiatry, Vol. 55. American Medical Association, 1998, p. 816.

[32] Thase, M.E., et. al. Treatment of Major Depression with Psychotherapy or Psychotherapy-Pharmacotherapy Combinations. Archives of General Psychiatry, Vol. 54. American Medical Association, 1997, p. 1009.

[33] Hollon, op. cit., p. 64.

[34] Thase, op. cit., pp. 1012-1013.

[35] Hollon, op. cit., p. 61.

[36] The TADS Team. The Treatment for Adolescents With Depression Study. Archives of General Psychiatry, Vol. 64. American Medical Association, 2007, p. 1132.

[37] Corey, G. Theory and Practice of Counseling and Psychotherapy. Pacific Grove, California: Brooks/Cole Publishing Co., 1991, pp. 325-328.

[38] Ellis, op. cit., Reason and Emotion, p. xiii.

[39] Irrational and rational beliefs are technically defined within REBT.

[40] Ibid., pp. 63-64, 68-69.

[41] Ellis, A. and MacLaren, C. Rational Emotive Behavior Therapy. San Luis Obispo, California: Impact Publishers, 1998, p. 122.

[42] Ellis, op. cit., How to Stubbornly Refuse..., p. 144.

[43] Ellis, op. cit., Reason and Emotion, p. 318.

[44] Frankl, V. Man's Search for Meaning. Boston: Beacon Press, 1959 (English translation), p. 104.

[45] Ibid., p. 99.

[46] Ellis, op. cit., Reason and Emotion, pp. 160-166.

[47] Robinson, op. cit., p. 30.

[48] Frankl, op. cit., pp. 119-120.