to the editor: Let's face it. Despite unprecedented pharmacologic advances, treating patients with mental illnesses in the 21st century remains challenging and time-consuming. Unlike the euphoric pill-swallowers featured in pharmaceutical company advertisements, our patients' responses are more often modest at best. Definitive diagnosis of clear-cut psychopathology with dramatic response to pharmacologic treatment occurs but remains the exception rather than the rule.

Most of the patients who fill our waiting rooms resist tidy classification into the research-based diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). The multifactorial etiology of patient complaints often eludes the magic pharmacologic bullet, and the risk-benefit ratio of expensive medication blurs.¹ Counseling, while clearly of additional benefit in numerous studies, remains time-consuming and is often ongoing. Without doubt, these are the cases that try our patience and strain our office schedules.

It was therefore with no small interest that I read The Awakening: One Man's Battle with Darkness,² an account of a 19th century German pastor named Blumhardt, who unintentionally attracted similar patients in an era when psychopharmacologic medications were practically nonexistent. On some days he saw up to 35 people, with complaints running the gamut of physical to mental disorders. Many had exhausted the medical options of their day.

In an unsensational, down-to-earth manner, this book documents remarkable improvement in many of these people. The unassuming style and authenticity of the accounts make quick dismissal difficult. Blumhardt wrote to a government official, “It was never my intent to treat mental illness.”² In fact, Blumhardt had the greatest respect for the medical profession, noting that “especially in the case of mental illness, most pastors cut a pathetic figure alongside physicians.”²

What then, was Blumhardt's secret, and why did people flock to his rectory in such numbers that the civilian authorities had to restrict his “practice”? Primarily, Blumhardt recognized the tremendous need people have to be forgiven. In an amoralistic age, when values have become relative, the concept of forgiveness may sound dated; however, regardless of their religious or secular background, people still have a sense of right and wrong and suffer when they violate their internal code of ethics. Most modern counselors see the associated guilt, rather than the wrong-doing itself, as the problem. Blumhardt encouraged his parishioners to confess the actions that troubled them most and to make restitution wherever possible. The results were remarkable!

Since reading this book, I have become more aware of the spiritual aspects of mental illness. I have noted concrete improvement in patients with mental illness who had found a sense of forgiveness by simply sharing their past wrong-doings with a trusted confidant. While many physicians may be more comfortable relegating spiritual matters to the clergy, we can't afford to trivialize or ignore the importance of spiritual issues to our patients. This book is a must-read for persons who wish to broaden their understanding of the complex interplay between medical, psychiatric and spiritual components of the human experience. After all, the patient before us contains all three.