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Working with People at High Risk of Developing
Psychosis A Treatment Handbook 1st Edition Jean
Addington Digital Instant Download
Author(s): Jean Addington, Shona Francey, Anthony P. Morrison
ISBN(s): 9780470034170, 0470034173
Edition: 1
File Details: PDF, 1.58 MB
Year: 2006
Language: english
Working with People at High Risk
of Developing Psychosis
A Treatment Handbook

Edited by
Jean Addington
Department of Psychiatry
University of Toronto, Canada
PRIME Clinic, Centre for Addiction and Mental Health
Shona M. Francey
PACE Clinic, Orygen Research Centre, Victoria, Australia
and
Anthony P. Morrison
School of Psychological Sciences
University of Manchester, UK
Psychology Services, Bolton, Salford and Trafford Mental Health Trust
Working with People at High Risk
of Developing Psychosis
Working with People at High Risk
of Developing Psychosis
A Treatment Handbook

Edited by
Jean Addington
Department of Psychiatry
University of Toronto, Canada
PRIME Clinic, Centre for Addiction and Mental Health
Shona M. Francey
PACE Clinic, Orygen Research Centre, Victoria, Australia
and
Anthony P. Morrison
School of Psychological Sciences
University of Manchester, UK
Psychology Services, Bolton, Salford and Trafford Mental Health Trust
Copyright

C 2006 John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester,
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Library of Congress Cataloging-in-Publication Data

Working with people at high risk of developing psychosis : a treatment handbook / edited by Jean Addington,
Shona M. Francey and Anthony P. Morrison.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-0-470-01162-1 (cloth : alk. paper)
ISBN-10: 0-470-01162-9 (cloth : alk. paper)
ISBN-13: 978-0-470-01163-8 (pbk : alk. paper)
ISBN-10: 0-470-01163-7 (pbk : alk. paper)
1. Psychoses—Handbooks, manuals, etc. 2. Psychoses—Treatment—Handbooks, manuals, etc.
I. Addington, Jean. II. Francey, Shona M. III. Morrison, Anthony P., 1969–
[DNLM: 1. Psychotic Disorders—diagnosis. 2. Psychotic Disorders—therapy. 3. Risk Factors.
WM 200 W926 2006]
RC512.W67 2006
616.89—dc22 2005018265

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
ISBN-13 978-0-470-01162-1 (hbk) 978-0-470-01163-8 (pbk)
ISBN-10 0-470-01162-9 (hbk) 0-470-01163-7 (pbk)
Typeset in 10/12pt Times by TechBooks Electronic Services, New Delhi, India
Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham, Wiltshire, UK
This book is printed on acid-free paper responsibly manufactured from sustainable forestry
in which at least two trees are planted for each one used for paper production.
To Oliver, Zoë, Leo, Jack and Don, who are always encouraging,
supportive and tolerant.
—JA

To Mark, for all his emotional, practical and intellectual support

and for our wonderful Ned and Abbey.
—SF

To Soph, who has taught me that earlier is better, but that some
things are worth waiting for.
—APM
 Contents

About the Editors ix

List of Contributors x
Foreword xii
Acknowledgements xiii

Chapter 1 Introduction 1
Shôn Lewis
Chapter 2 Identification of the Population 7
Alison R. Yung
Chapter 3 Assessment and Developing a Formulation 25
Shona M. Francey and Henry J. Jackson
Chapter 4 Engagement and the Therapeutic Alliance 41
Jean Addington and David Penn
Chapter 5 Assessing and Managing Stress 53
Lisa Phillips
Chapter 6 Treatment Targets in the Pre-psychotic Phase 75
Paul Patterson, Amanda Skeate and Max Birchwood
Chapter 7 Substance Use and the ‘At Risk’ Period 93
Steven Leicester
Chapter 8 Addressing Attenuated Symptoms in ‘At Risk’ Clients 111
Samantha E. Bowe, Paul French and Anthony P. Morrison
Chapter 9 Brief Limited Intermittent Psychotic Symptoms (BLIPS):
A Cognitive Behavioural Approach to Formulation and
Intervention 129
Andrew I. Gumley
Chapter 10 Working with Families Following the Diagnosis of an At Risk
Mental State 153
April A. Collins and Jean Addington
viii CONTENTS

Chapter 11 Group Therapy for People at High Risk of Developing Psychosis 169
Andreas Bechdolf, Verena Veith and Joachim Klosterkötter
Chapter 12 Future Challenges 181
Anthony P. Morrison, Shona M. Francey and Jean Addington

Index 187
 About the Editors

Jean Addington completed her PhD at the University of Calgary, Alberta. She is currently
Director of the PRIME Clinic and Director of Psychosocial Treatments in the First Episode
Psychosis Program at the Centre for Addiction and Mental Health in Toronto, Canada.
She is also an Associate Professor in the Department of Psychiatry, University of Toronto.
The Toronto PRIME Clinic is a research-based clinic for individuals who have an ‘at risk
mental state’. Her clinical and research interests lie in the understanding and management
of this ‘at risk mental state’ and of early psychosis. She has published widely in this
area: including psychosocial interventions, cognition, social functioning and substance use
in early psychosis and the development of early intervention services. Her current work
includes the development of risk assessment models for the conversion to psychosis and
cognitive behaviour therapy in the ultra high risk period.

Shona M. Francey is a clinical psychologist with 20 years’ experience in public mental

health. She began working in the field of early intervention for psychosis when the Early
Psychosis Prevention and Intervention Centre (EPPIC) was first established in 1992 in
Melbourne, Australia. Within the EPPIC programme she worked as a case manager, COPE
therapist and Group Programme leader. COPE is a cognitively oriented psychotherapy that
was developed at EPPIC to promote recovery from first episode psychosis. Shona has also
been involved in education and training about early psychosis, and the establishment of the
PACE Clinic for young people thought to be at risk of developing psychosis. At PACE she
has contributed to the development and evaluation of psychological therapy for this at risk
group. She completed her PhD examining neurocognitive indicators of risk for psychosis
in the PACE population and is currently the Clinical Coordinator of the PACE Clinic.

Anthony P. Morrison is a Reader in Clinical Psychology at the University of Manchester

and is also a Consultant Clinical Psychologist in a specialist programme of care for people
with early psychosis in Salford and Trafford. He has published a number of articles on
trauma and psychosis, cognitive therapy for psychosis and experimental studies of cognitive
processes in psychosis, and has been involved in a number of treatment trials for cognitive
therapy for early psychosis and the prevention of psychosis. He has also published several
books on the topic of psychological approaches to the understanding and treatment of
psychosis. Unkind observers have suggested his interest in both trauma and losing touch
with reality stem from his support of Manchester City Football Club.
 List of Contributors

Jean Addington, Associate Professor, Department of Psychiatry, University of

Toronto, Director, PRIME Clinic, Director, Psychosocial Treatments, First
Episode Psychosis Program, Centre for Addiction and Mental Health, 250 College
Street, Toronto, Ontario M5T 1R8, Canada.
Andreas Bechdolf, Consultant Psychiatrist, Early Recognition and Intervention
Centre for Mental Crisis – FETZ, Department of Psychiatry and Psychotherapy,
University of Cologne, Joseph-Stelzmann-Str. 9, 50924 Cologne, Germany.
Max Birchwood, Director, Birmingham and Solihull Early Intervention Service,
Birmingham and Solihull Mental Health Trust. Professor of Mental Health,
University of Birmingham, 97 Church Lane, Aston, Birmingham B6 5UG, UK.
Samantha E. Bowe, Clinical Psychologist, Psychology Services, Bolton, Salford
and Trafford Mental Health NHS Trust, Bury New Road, Prestwich, Manchester
M25 3BL, UK.
April A. Collins, Deputy Administrative Director, Schizophrenia Program, Centre
for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario M6J
1H4, Canada.
Shona M. Francey, Clinical Coordinator, PACE Clinic, ORYGEN Research
Centre, Department of Psychiatry, University of Melbourne, Locked Bag 10,
Parkville, 3052, Australia.
Paul French, Coordinator, EDIT Service, Bolton, Salford and Trafford Mental
Health NHS Trust, Salford Psychology Services, Bury New Road, Prestwich,
Manchester M25 3BL, UK.
Andrew I. Gumley, Senior Lecturer in Clinical Psychology, University of
Glasgow, Department of Psychological Medicine, Gartnavel Royal Hospital, 1055
Great Western Road, Glasgow G12 0XH, UK.
Henry J. Jackson, Professor and Head of School of Behavioural Science,
Department of Psychology, Redmont Barry Building, University of Melbourne,
Parkville, 3010, Victoria, Australia.
Joachim Klosterkötter, Professor of Psychiatry and Director, Department of
Psychiatry and Psychotherapy, University of Cologne, Joseph-Stelzmann-Str. 9,
50924 Cologne, Germany.
LIST OF CONTRIBUTORS xi

Steven Leicester, Psychologist, PACE Clinic, ORYGEN Research Centre,

Department of Psychiatry, University of Melbourne, Locked Bag 10, Parkville,
3052, Australia.
Shôn Lewis, Professor of Psychiatry, School of Psychiatry, and Behavioural
Sciences, University of Manchester, Education and Research Centre, Wythenshawe
Hospital, Manchester M23 9LT, UK.
Anthony P. Morrison, Reader in Clinical Psychology, University of Manchester,
Manchester M13 9PL, UK.
Paul Patterson, Project Manager, Early Detection & Intervention Team (ED:IT),
Harry Watton House, 97 Church Lane, Aston, Birmingham B6 5UG, UK.
David Penn, Associate Professor, Department of Psychology, Adjunct Associate
Professor, Department of Psychiatry, University of North Carolina-Chapel Hill,
Department of Psychology, Davie Hall, CB#3270, Chapel Hill, NC 27599-3270,
USA.
Lisa Phillips, Clinical Psychologist and Research Co-ordinator, PACE Clinic,
ORYGEN Research Centre, Department of Psychiatry, University of Melbourne,
Locked Bag 10, Parkville, 3052, Australia.
Amanda Skeate, Clinical Psychologist/Clinical Lead, Early Detection &
Intervention Team (ED:IT), Harry Watton House, 97 Church Lane, Aston,
Birmingham B6 5UG, UK.
Verena Veith, Clinical Psychologist, Early Recognition and Intervention Centre
for Mental Crisis – FETZ, Department of Psychiatry and Psychotherapy,
University of Cologne, Kerpener Str. 62, 50924 Cologne, Germany.
Alison R. Yung, Associate Professor and Principal Research Fellow, PACE
Clinic, ORYGEN Research Centre, Department of Psychiatry, University of
Melbourne, Locked Bag 10, Parkville, 3052, Australia.
 Foreword

Most people who develop a psychotic disorder, such as schizophrenia, do so gradually

with initially rather subtle changes in experience, emotional state and behaviour. These
changes are usually distressing and impact insidiously on relationships, cognitive capacities
and daily functioning. This frequently unfolds during the critical period of adolescence or
young adulthood, at a time when such changes may be difficult to distinguish from normal
developmental vicissitudes, but also when they can derail and constrain the pathways to
fulfilment of one’s potential. Even when the young person, their family, teachers or the
family doctor may be aware that ‘something is not quite right’, the problem is difficult
to characterise and diagnose. This undifferentiated clinical state has been termed the ‘at
risk mental state’, a label that underlines the change in mental state and implies that the
person is at risk for something more serious. If the person progresses to a fully fledged
psychotic episode because the positive symptom dimension has become more severe and
sustained, then and only then are we able to use the term ‘prodromal’ (retrospectively) for
this preceding sub-threshold stage.
Even though people in this ‘at risk mental state’ are below the diagnostic threshold for
an Axis 1 psychotic disorder, they are often clinically unwell with distress and functional
impairment. They may meet criteria for other syndromes such as depression. Frequently
they or their families do seek help. What are we to offer them? Whatever we offer should
ideally be not only helpful, but safe. We are on firm ground when we offer needs-based
intervention, e.g. treating their depression, improving their relationships, tackling comorbid
substance abuse and/or monitoring risk. Less secure is the attempt, based on the fact that
between 20 and 50% of these young people will progress to first episode psychosis within a
year if something more specific is not offered, to try to prevent progression to psychosis. Re-
cent landmark studies, conducted by the authors of this handbook and their colleagues, have
shown that cognitive-behaviour therapy is effective in reducing the risk of early transition
and at least delaying the onset of frank psychosis. In contrast to antipsychotic medication,
also effective in this regard, cognitively based therapies are appealing in that they are essen-
tially safer and better accepted by most patients, at least as a first line therapy. The authors of
the various chapters are international experts and pioneers of the psychological approach in
the earliest phases of psychotic illness, and have much accumulated clinical wisdom and on-
going innovative techniques to impart to the reader. This book forms part of the renaissance
of the psychological interventions in the psychotic spectrum and focuses on a phase where, at
least for some patients, psychological approaches may be not only necessary but sufficient.

Patrick McGorry MD, Professor, University of Melbourne,

Director, ORYGEN Youth Health (incorporating EPPIC),
and President, International Early Psychosis
Association (IEPA)
 Acknowledgements

Many people have been supportive, encouraging and helpful in the development of this
book. I would first like to acknowledge Jane Edwards from EPPIC for ‘encouraging’ me
to put this book together. I would like to thank the research staff of the PRIME Clinic, in
particular Amanda McCleery, Maria Haarmans, and Huma Saeedi, for all of their work in
editing and proof reading chapters. Last but certainly not least I would like to thank Diane
Kirsopp for her tremendous effort and work involved in developing the idea of this book
until its final completion.
Jean Addington
 CHAPTER 1

Introduction
Shôn Lewis

AT RISK MENTAL STATES IN PSYCHOSIS: AN INTRODUCTION

The idea that a set of subjective experiences exist which, in many cases, herald imminent
psychosis has a long history in psychiatry. However, the operational delineation of these
features, often coupled with alterations in functioning and a background of demographic
risk factors, was only developed to the extent that it was reliably definable and therefore
useable in research, by Alison Yung, Patrick McGorry and colleagues in the mid 1990s
(Yung et al., 1998). These criteria, which comprise four sub-sets, have given rise to a
paradigm of research which promises much in terms of early detection and secondary, or
even primary, preventions. The closest previous attempt at a set of reliable criteria was made
by the Bonn group in the 1970s (Huber & Gross, 1989).
Terminology in this area continues to be confusing. The term ‘prodrome’ to describe
this collection of subjective features is widely used, although it is technically wrong and
possibly misleading to the sufferer. Epidemiologists define a prodrome as a set of symptoms,
which in all cases will lead on to the full syndrome. This is not the case with this set of
features described by Yung and colleagues (1998). Only a proportion of such cases go on
at follow-up to develop psychosis, which means that the epidemiologically correct term is
that this set of features is a ‘precursor’. This term has not caught on, perhaps because it
lacks clinical immediacy. Instead, the terms ‘at risk mental state’ (ARMS) or ‘ultra-high
risk mental state’ (UHR mental state) have been applied in an attempt to convey the message
that nothing is inevitable.
The descriptive epidemiology of ARMS, how common they are, who gets them, how
long they last and so on, is still in its infancy. We have little reliable data about the incidence
and prevalence of this constellation of symptoms in the general community. Part of the
reason for this is that studies which have set out to identify such cases are often in the
context of treatment studies or clinical trials where, for ethical reasons as well as reasons
of convenient ascertainment, clients are seeking help for these symptoms. Factors which
cause an individual to seek help on the basis of these symptoms are not well understood.
Community surveys, especially in Europe, have shown that a surprisingly high proportion
of apparently healthy individuals, perhaps 5–15%, will report isolated psychosis-like phe-
nomena for which most will not seek help. Presumably, the decision to seek help is partly

Working with People at High Risk of Developing Psychosis: A Treatment Handbook.

Edited by J. Addington, S.M. Francey and A.P. Morrison.

C 2006 John Wiley & Sons, Ltd.
2 WORKING WITH PEOPLE AT HIGH RISK OF DEVELOPING PSYCHOSIS

driven by the subjective distress and this will vary from one individual to another. On top
of that, individuals will vary in the extent to which they seek help for a given level of dis-
tress, which will depend on a range of internal and external trait and state factors, including
health beliefs, perceptions that the abnormalities constitute a threat to health and might be
amenable to intervention, availability of health care and so on.
These currently unmeasured factors will inevitably mean that sample structure will be
very sensitive to social context and thus collected samples will differ from one another in
ways which are likely to be important, and influence final transition rates to psychosis, but
are essentially unknown. Nonetheless, follow-up studies are in general agreement that the
risk of developing an operationally defined Axis 1 psychosis over the next 12 months is
massively increased. Rates of transition to psychosis in follow-up studies published so far
vary between 10% and 50%. While some commentators see this five-fold variation as a
weakness in the field, it is small in comparison to the increased risk this represents over
the base population. An age-matched community sample of young adults would show an
incidence rate of new cases of no more than five per 10 000 per year. Even a 10% risk of
psychosis in the year following detection of an ARMS will therefore represent a 200-fold
increased risk. This huge increase in risk, particularly in a population of young people,
immediately raises the prospect of intervention to head off the psychosis.

INTERVENTION STUDIES: GENERAL METHODOLOGICAL

ISSUES

Two plausible treatment modalities present themselves straight away, by inference from the
treatment of psychosis: antipsychotic drug treatment and specifiable psychological treat-
ment, specifically cognitive behaviour therapy. The evidence base for the effectiveness of
antipsychotic drug treatments in psychosis is incontrovertible. The evidence base supporting
the effectiveness of cognitive behaviour therapy in psychosis is more recent and smaller.
However, several systematic reviews and meta-analyses have supported its effectiveness
(Cormac, Jones & Campbell, 2002; Pilling et al., 2002), although only as an adjunct to
antipsychotic drug treatment: it has not formally been assessed in the absence of drug
treatment.
Three randomised controlled trials of interventions have now published interim or final
data. The first was the Personal Assessment and Crisis Evaluation (PACE) trial by McGorry
and colleagues (2002) in Melbourne, which evaluated the effectiveness of a six-month com-
bined intervention of low dose risperidone, a second generation antipsychotic drug, plus
cognitive behaviour therapy in addition to case management, compared to case manage-
ment alone. This was an open trial. The second trial by McGlashan and colleagues (2003)
at Yale was a double-blind randomised placebo controlled trial of low dose olanzapine, an-
other second generation antipsychotic drug, versus placebo, for 12 months. The third trial,
the Early Detection and Intervention Evaluation (EDIE) trial by Morrison and colleagues
(2004) in Manchester, compared the effectiveness of a six-month (26 sessions) package of
cognitive behaviour therapy versus monthly monitoring. The trials had important similari-
ties. Each used the Melbourne criteria for defining cases; had a 12-month follow-up after
commencement of treatment; randomised about 60 subjects and had rates of transition to
psychosis as the primary outcome. The trials had important differences too, particularly
in case-finding strategies. Assessment measures at baseline differed too: the PACE trial
INTRODUCTION 3

used the Comprehensive Assessment of At Risk Mental States (CAARMS) structured as-
sessment tool (see Chapter 2), the Prevention through Risk Identification Management and
Education (PRIME) trial used the Structured Interview for Prodromal States (SIPS: Miller
et al., 2003), and the EDIE trial used the Positive and Negative Syndrome Scale (PANSS).
Results showed that each of the interventions had some therapeutic effect in terms of re-
ducing transition rate, although this tailed off after treatment was discontinued. Differences
between the results of the trials appeared in other areas. One important finding to emerge
was that consent rates from eligible subjects differed between these studies and were lowest
for the double-blind drug study and highest for the psychological treatment study. This is in
no way surprising given the way that subjects themselves tend to formulate their problems,
often not in the framework of a medical model. It does have implications for the generalis-
ability of any findings and for considerations about how useful any treatment might be. Even
if a treatment is highly effective, if it is not acceptable to the target population it is of little
use. This difference in ascertainment is the most likely reason that the three trials reported
differences in final transition rates, regardless of randomised treatment group. Transition
rates at one year were highest for the double-blind trial (27%) and lowest for the psycholog-
ical treatment trial (15%). One explanation for this is that only those people who are most
distressed and urgently seeking help will elect to go into a double-blind placebo controlled
trial, whereas a higher proportion of the eligible population, including less distressed cases,
will consent to an open psychological treatment trial. That this is the case appears to be
supported by data from the PACE trial, which usefully followed up subjects who declined
to go in to the trial (McGorry et al., 2002). Surprisingly, those subjects did better than the
clients overall who consented to the treatment trial. In almost all other clinical trial contexts,
refusers do worse than those consenting to go in to the trial: presumably the explanation here
is that the non-consenters did not feel sufficiently distressed or in need of urgent treatment
that they wished to go in to the trial.
One of the still unanswered issues which is important from the public health viewpoint
when trying to judge the potential impact of an effective preventive intervention is not
‘How many help-seeking ARMS cases go on to develop psychosis?’ but ‘What proportion
of new cases of psychosis came through the prior route of help-seeking ARMS?’ From
this, the population attributable fraction can be estimated: what proportion of new cases of
psychosis would be prevented by an effective intervention for people with ARMS? These
are difficult data to collect accurately since they involve retrospective accounts by people
with first episode psychosis.

ETHICAL ISSUES

There are particular ethical dilemmas thrown up by research and the possibility of treatment
in this area. The first, and in some ways the most obvious, concerns the giving of treatment
to a group of at risk individuals where most of whom (60% or more) will not, even without
treatment, develop the disorder. To what extent is it justified to expose all the at risk group to
treatment in that case? Not surprisingly, any answers in this area are not black and white but
rather a matter of degree. What is the level of risk of transition at which it becomes acceptable
to treat the whole group? To give a related real-life example, we know that about 20% of
individuals following a first episode of psychosis will not have a subsequent episode, even
without treatment. Yet we make the judgement clinically that treating all individuals with
4 WORKING WITH PEOPLE AT HIGH RISK OF DEVELOPING PSYCHOSIS

maintenance drug treatment after the first episode is justified, since 80% will benefit. It is not
possible currently to predict accurately who will be in the 20% who will not need ongoing
treatment, in the same way that it is not currently possible to predict who are the 60% or
more of ARMS who will not go on to develop psychosis. The assumption implicit with the
relapse prevention example is that 80% is a sufficiently large number to justify intervention
across the board. Clearly, a judgement is also being made about the undesirability of the
outcome: one can argue that a first episode of psychosis (or a first relapse) is a sufficiently
severe outcome to warrant intervention in all cases. Further dimensions are the effectiveness
of the intervention (will it reduce transition rates from 30% to 0%, or merely to 20%) and
the risk of adverse effects, which is clearly specific to the type of intervention used. For
drug treatments the risk of adverse effects may be relatively high and the effects themselves
serious. For psychological interventions it is assumed that risk is lower and this may indeed
be the case, although there are plausible risks inherent in psychological treatments too,
including stigmatisation.
The central ethical dilemma here can be circumvented if the main therapeutic target is
defined differently. Currently, the debate circles on the issue of prophylaxis: how many
cases of a psychotic disorder can be prevented is weighed against the cost of treating
unnecessarily a majority who will not go on to get the disorder in any event. However, other
outcomes may be at least as appropriate. Delaying the onset of psychosis or ameliorating
its severity once it begins would also be important therapeutic gains from an intervention.
The primary outcome of most immediate relevance to people seeking help for ARMS is
reducing the severity and functional impact of the symptoms themselves. If the primary
therapeutic target is to alleviate these current sub-threshold symptoms rather than explicitly
to prevent future psychosis, then all those who receive an experimental treatment may expect
benefits. Current models of how symptoms develop in early psychosis are still at an early
stage, but it seems inherently likely that reducing current symptoms will lessen the risk of
future transition, so as a therapeutic target it makes sense. Severity of baseline sub-clinical
symptoms was one of two predictors of outcome, the other being treatment allocation in
the EDIE trial. Furthermore, transition to psychosis sounds as if it is an all or nothing
phenomenon. In fact, the operational definitions used are rating scales with continuously
distributed properties and the definition of transition is based on passing an essentially
arbitrary threshold of severity. Again, this makes it less clear that one is best off dealing
with a binary or categorical outcome.

WHAT THE FUTURE HOLDS

Research in this emerging area of at risk mental states is only just beginning. On the
epidemiological front, more clarity is needed about base rates and the natural history of
ARMS. The role of external factors such as street drug use is still unclear. Biological issues
have begun to be explored. Potentially important is the issue of progression with preliminary
longitudinal evidence suggesting progressive regional structural abnormalities during this
early phase can be replicated (Pantelis et al., 2003). The role of normal genetic variants in
mediating risk, perhaps via particular cognitive traits and styles, is likely. Connected to this
are two interfaces which require more exploration if models for psychological interventions
are to be refined. One is the interface between ARMS and full psychosis. The other is the
Other documents randomly have
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the head of a calf, the arms stretched in a posture of receiving; the
image was heated with fire, and the priest put the child in his arms,
where it was burnt to death; in the meantime a noise was made
with drums, that the cries of the child might not be heard, and
hence was it called Tophet, from toph, which signifies a drum; so
that the name and shape of the image shews that it was used to
these execrable cruelties.141
These Scripture evidences, if we were backward to credit what
histories say of this matter, may assure us of the temper and
disposition of Satan, and may enable us to believe what bloody work
he hath made in the world, which I shall briefly sum up in these
particulars:—
[1.] First, These inhuman, or rather, as Purchas calls them, over-
human sacrifices, were practised in most nations. Not only the
Indians, Parthians, Mexicans, &c., but Æthiopians, Syrians,
Carthaginians, Grecians, Romans, Germans, French, and Britons
used them.
[2.] Secondly, These cruelties were acted not only upon slaves and
captives, but upon children, whose age and innocency might have
commanded the compassions of their parents for better usage.
[3.] Thirdly, These sacrificings were used upon several occasions,
as at the sprouting of their corn, at the inauguration, coronation,
and deaths of their kings and noblemen, in time of war, dearth,
pestilence, or any danger; in a word, as the priests in Florida and
Mexico used to say, whenever the devil is hungry or thirsty, that is,
as oft as he hath a mind.
[4.] Fourthly, In some places the devil brought them to set times
for those offerings; some were monthly, some annual. The Latins
sacrificed the tenth child; the annual drowning of a boy and a girl in
the lake of Mexico; the casting of two yearly from the Pons
Milvius142 at Rome into Tiber, are but petty instances in comparison
of the rest.
[5.] Fifthly, We cannot pass by the vast number of men offered up
at one time. So thirsty is Satan of human blood, that from one or
two, he hath raised the number incredibly high. In some sacrifices
five, in some ten, in some a hundred, in some a thousand have been
offered up. It was the argument which Montezuma, the last Emperor
of Mexico, used to Cortez to prove his strength and greatness by,
that he sacrificed yearly twenty thousand men, and some years fifty
thousand. Some have reserved their captives for that end, others
have made war only to furnish themselves with men for such
occasions.
[6.] Sixthly, There are also several circumstances of these
diabolical outrages that may give a further discovery of his cruelty,
as that these miserable creatures thus led to be butchered have
been loaden with all the cursings, revilings, and contumacious
reproaches as a necessary concomitant of their violent deaths. Thus
were those used who were forced to be the public καθάρματα, or
expiation, for the removal of common calamities. Death also was not
enough, except it had been most tormenting in the manner of it, as
of those that suffered by the embracements of Moloch. The joy and
feastings of such sacrificings, which were in themselves spectacles of
mourning and sorrow, were cruelties to the dead, and a barbarous
enforcement against the laws of nature in the living. But the dashing
of the smoking heart in the idol’s face, and the pulling off the skins
from the massacred bodies, that men and women might dance in
them, were yet more cruel ceremonies. And lastly, In those that
have been prepared for those solemnities, by delicious fare,
gorgeous ornaments, and the highest reverence or honours, as was
the manner of several countries; yet was this no other than Satan’s
insulting over their miseries, of which we can say no otherwise, than
that his tenderest mercies are cruelties.
 [7.] Seventhly, I may cast into the account, that in some places
Satan, by a strange madness of devotion, hath persuaded some to
be volunteers in suffering these tortures and deaths. Some have cast
themselves under the chariot-wheels of their idols, and so have been
crushed to pieces.143 Some sacrifice themselves to their gods: first
they outcut off several pieces of their flesh, crying every time, ‘For
the worship of my god, I cut this my flesh;’ and at last say, ‘Now do
I yield myself to death in the behalf of my god,’ and so kills himself
outright.
[8.] Eighthly, It is wonderful to think that the devil should, by
strange pretexts of reason, have smoothed over these barbarous
inhumanities, so that they have become plausible things in the
judgments of those miserable wretches. In piacular sacrifices they
believed that except the life of a man were given for the life of men,
that the gods could not be pacified.144 In other sacrifices, both
eucharistical and for atonement, they retained this principle, ‘that
those things are to be offered to the gods that are most pleasing
and acceptable to us; and that the offering of a calf or a pigeon was
not suitable to such an end.’ This maxim they further improved by
the addition of another of the same kind, ‘that if it were fit to offer a
human sacrifice, it must also be innocent, and consequently little
children are the fittest for such a purpose.’ And some have also
conjectured that the devil hath not been awanting to improve the
example of Abraham sacrificing his son, or the law in Lev. xxvii. 28,
or the prophecies concerning the death of Christ, as the great
sacrifice of atonement, to justify and warrant his hellish cruelty.145
In some cases cruelty hath arisen from the very principles of
reverence and love which children have to parents, and friends to
friends: as in Dragoian, when any are sick, they send to their oracle
to know whether the parties shall live or die; if it be answered they
shall die, then their friends strangle them and eat them; and all this
from a kind of religious respect to their kindred, to preserve, as they
imagine, their flesh from putrefaction, and their souls from
torment.146 The like they do at Javamajor, when their friends grow
old and cannot work, only they eat not their own friends, but carry
them to the market and sell them to those that do eat them.147
[9.] Lastly, Let us call to mind how long the devil domineered in
the world at this rate of cruelty. When the world grew to a freer use
of reason and greater exercise of civility, they found out ways of
mitigation, and changed these barbarous rites into more tolerable
sacrifices; as in Laodicea, they substituted a hart to be sacrificed
instead of a virgin; in Cyprus, an ox was put instead of a man; in
Egypt, waxen images instead of men. Images of straw at Rome were
cast into Tiber in the place of living men; and the terrible burnings of
Moloch, which was not peculiar only to the nations near to Canaan,
but was in use also at Carthage, and found in the American islands
by the Spaniards; the like brazen images were also found in
Lodovicus Vives his time, by the French, in an island called by them
Carolina.148 These were at last changed into a februation,149 and
instead of burning their children, they only passed them betwixt two
fires; but it was long before it came to this. In the time of Socrates,
human sacrifices were in use at Carthage, and they continued in the
Roman provinces till the time of Tertullian, Eusebius, and Lactantius;
though they had been severely forbidden by Augustus Cæsar, and
afterward by Tiberius, who was forced to crucify some of the priests
that dared to offer such sacrifices, to affright them from those
barbarous customs. In other places of the world, how long such
things continued, who can tell, especially seeing they were found at
Carolina not so very long since?
How impossible is it to cast up the total sum of so many large
items! When these terrible customs have had so general a practice
in most nations, upon so many occasions, upon such seeming
plausible principles; when such great numbers have been destroyed
at once, and these usages have been so long practised in the world,
and with such difficulty restrained, what vast multitudes of men
must, we imagine, have been consumed by Satan’s execrable
cruelty!
 6. Sixthly, There remains one instance more of the devil’s cruelty,
which is yet different from the former, which I may call his personal
cruelties; because they are acted by his own immediate hand upon
certain of his vassals, without the help or interposure of men, who,
in most of the fore-mentioned cases, have been as instruments
acted by him. Here I might take notice of his fury to those that are
possessed. Some have been as it were racked and tortured in their
bodies, and their limbs and members so distorted, that it hath been
not only matter of pity to the beholders to see them so abused, but
also of admiration150 to consider how such abuses should be
consistent with their lives, and that such rendings and tearings have
not quite separated the soul from the body. In the Gospels we read
of some such ‘cast into the fire, and into the water,’ [Mat. xvii. 15;]
others, conversing ‘with tombs and sepulchres,’ in the cold nights
‘without clothes;’ and all of them spoken of as creatures sadly
tormented, and ‘miserably vexed.’ The histories of later days tell us
of some that vomited crooked pins, pieces of leather, coals, cloth,
and such like; of others snatched out of their houses, and tired even
to fainting, and waste of their spirits, as Domina Rossa, mentioned
by Bodin, with a great many more to this same purpose. We may
take a view of his dealing with witches, who, though he seem to
gratify them in their transportations from place to place, and in their
feastings with music and dancings, are but cruelly handled by him
very often. The very work they are put upon—which is the
destruction of children, men, women, cattle, and the fruits of the
earth—is but a base employment; but the account he takes of them,
of the full performance of their enterprizes, and the cruel beatings
they have of him, when they cannot accomplish any of their
revenges, is no less than a severe cruelty. He gives them no rest
unless they be doing hurt; and when they cannot do it to the
persons designed, they are forced to do the same mischief to their
own children or relations, that they may gratify their tyrannical
master. Bodin relates the story of a French baron, [p. 180,] who was
afterward put to death for witchcraft, that after he had killed eight
children, was at last upon a design of sacrificing his own child to the
devil. And if at any time they grew weary of so execrable a slavery,
or confess their wickedness, they are so miserably tormented that
they choose rather to die than live. And what else but cruelty can
these slaves expect from him, when the ceremonies of their
entrance into that cursed service betokens nothing else; for their
bonds and obligations are usually writ or subscribed with their own
blood; and some magical books have been writ with the blood of
many children; besides, the farewell that they have of him at their
usual meetings, is commonly this thundering threatening, ‘Avenge
yourselves, or you shall die.’ All these particulars are collected from
the confessions of witches by Bodin, Wierus, and others.
But leaving these, let us further inquire into Satan’s carriage
toward those that in America and other dark and barbarous places
know no other god, and give their devoutest worship to him. To
those he is not so kind as might be expected; but his constant way
is to terrify and torment them, insomuch that some know no other
reason of their worship but that he may not hurt them. And since
the English colonies went into these parts, these Americans have
learned to make this distinction between the Englishman’s God and
theirs, that theirs is an evil god, and the other a good God; though
that distinction in other places is in the general far more ancient,
where they acknowledge two gods, one good, the other bad; and
the worse the god is, the saddest, most mournful rites of sacrificing
were used, as in caves, and in the night—the manner of the worship
fitly expressing the nature of the god they served.151 Our
countrymen have noted of the natives of New England, that the devil
appeared to them in ugly shapes, and in hideous places, as in
swamps and woods. But these are only the prologue to the tragedy
itself, for they only serve to impress upon the minds of his
worshippers what cruelties and severities they are to expect from
him; and accordingly he often lets them feel his hand, and makes
them know that those dark and dismal preludiums are not for
nothing. For sometimes he appears to the worshippers, tormenting
and afflicting their bodies, tearing the flesh from the bones, and
carrying them away quick152 with him; sometimes six have been
carried away at once, none ever knowing what became of them.153
By such bloody acts as these he kept the poor Americans in fear and
slavery; so that as bad a master as he is, they durst not but pay
their homage and service to him. All these particulars being put
together, will shew we do the devil no wrong when we call him cruel.

CHAPTER VII.
Of Satan’s diligence in several instances.—The question about the
being of spirits and devils handled.—The Sadducees’ opinion
discovered.—The reality of spirits proved.
The last particular observed in the text is his diligence. This adds
force and strength to his malice, power, and cruelty, and shews they
are not idle, dead, or inactive principles in him, which, if they could
be so supposed, would render him less hurtful and formidable. This I
shall despatch in a few instances, noting to this purpose,
1. First, His pains he takes in hunting his prey, and pursuing his
designs. It is nothing for him to ‘compass sea and land,’ to labour to
the utmost in his employment; it is all his business to tempt and
destroy, and his whole heart is in it. Hence intermission or cessation
cannot be expected. He faints not by his labour; and his labour, with
the success of it, is all the delight we can suppose him to have. So
that, being pushed and hurried by the hellish satisfactions of deadly
revenge, and having a strength answerable to those violent
impulses, we must suppose him to undergo, with a kind of pleasing
willingness, all imaginable toil and labour. If we look into ourselves,
we find it true, to our no small trouble and hazard. Doth he at any
time easily desist when we give him a repulse? Doth he not come
again and again, with often and impudently-repeated importunities?
Doth he not carry a design in his mind for months and years against
us? And when the motion is not feasible, yet he forgets it not, but
after a long interruption begins again where he left; which shews
that he is big with his projects, and his mind hath no rest. He
stretcheth out his nets all the day long. We may say of him, that he
riseth up early, and sitteth up late at his work, and is content to
labour in the very fire, so that he might but either disturb a child of
God or gain a proselyte.
2. Secondly, Diligence is not only discovered in laboriousness, but
also in a peculiar readiness to espy and to close in with fit occasions,
which may in probability answer the end we drive at. In this is Satan
admirably diligent; no occasion shall slip, or through inadvertency
escape him. No sooner are opportunities before us, but we may
perceive him suggesting to us, ‘Do this, satisfy that lust, take that
gain, please yourselves with that revenge.’ No sooner obtains he a
commission against a child of God, but presently he is upon his
back, as he dealt with Job; he lost no time, but goes out
immediately from the presence of the Lord and falls upon him.
Besides what he doth upon solemn and extraordinary occasions,
these that are common and ordinary are so carefully improved by
him, that everything we hear or see is ready to become our snare,
and Satan will assay to tempt us by them, though they lie something
out of the way of our inclination, and be not so likely to prevail with
us.
3. Thirdly, It is also a discovery of his diligence, that he never fails
to pursue every advantage which he gets against us to the utmost.
If the occasion and motion thereupon incline us, so that if we are
persuaded by them, he follows it on, and is not satisfied with either
a lower degree of acting sinfully, or with one or two acts; but then
he presseth upon us to sin to the height, with the greater contempt
of God and grievance of his Spirit, the greater scandal and offence to
our brethren; and having once caused us to begin, he would never
have us to make an end. His temptations roll themselves upon us
like the breaking in of waters, which, by the fierceness of their
current, make a large way for more to follow. He knows how to
improve his victories, and will not, through slothfulness or pity,
neglect to complete them. Hence it is that sometimes he reaps a
large harvest where he had sown little, and from one temptation not
only wounds the soul of him that committed it, but endeavours to
diffuse the venom and poisonous steam of it to the infection of
others, to the disgrace of religion, the hardening the hearts of
wicked men, and the turning the ignorant out of the way of truth. In
like manner, if he perceive the spirits of men grow distempered and
wounded, he then plies them with threatenings, fills them with all
manner of discouragements, dresseth every truth with the worst
appearance, that it may be apprehended otherwise than it is, and
puts such interpretations on all providences, that everything may
augment the smart of the wound, till they be overwhelmed with
terrors.
4. Fourthly, The various ways which he takes, shews also his
diligence. If one plot take not, he is immediately upon another. He
confines not himself to one design nor to one method; but if he find
one temptation doth not relish, he prepares another more suitable.
If covetousness doth not please us, then he urgeth to profuseness; if
terrors do not affright us to despair, then he abuseth mercies to
make us careless and presuming. If we are not content to be openly
wicked, then he endeavours to make us secretly hypocritical or
formal. Sometime he urgeth men to be profane; if that hit not, then
to be erroneous. If he cannot work by one tool, then he takes
another; and if anything in his way disgust, he will not urge it over-
hard, but straight takes another course. Such is his diligence, that
we may say of him, as it was said of Paul upon a better ground, he
will ‘become all things to all men, that he may gain some,’ [1 Cor. ix.
19.]
5. Fifthly, Diligence will most shew itself when things are at the
greatest hazard, or when the hopes of success are ready to bring
forth. In this point of diligence our adversary is not wanting. If men
are upon the point of error or sin, how industriously doth he labour
to bring them wholly over, and to settle them in evil! One would
think at such times he laid aside all other business, and only
attended this. How frequent, incessant, and earnest are his
persuasions and arguings with such! The like diligence he sheweth in
obstructing, disturbing, and discouraging us when we are upon our
greatest services or near our greatest mercies. What part of the day
are we more wandering and vain in our thoughts, if we take not
great care, than when we set about prayer? At other times we find
some more ease and freedom in our imaginations, as if we could
better rule or command them; but then, as if our thoughts were only
confusion and disorder, we are not able to master them, and to keep
the door of the heart so close but that these troublesome,
unwelcome guests will be crowding in, is impossible. Let us observe
it seriously, and we shall find that our thoughts are not the same,
and after the same manner impetuous at other times as they are
when we set about holy things; which ariseth not only from the
quickness of our spiritual sense in our readier observation of them at
that time, but also from the devil’s busy molestation and special
diligence against us on such occasions. Besides, when he foresees
our advantages or mercies, he bestirs himself to prevent or hinder
us of them. If ministers set themselves to study and preach truths
that are more piercing, weighty, or necessary, they may observe
more molestations, interruptions, or discouragements of all sorts,
than when they less concern themselves with the business of the
souls of men. He foresees what sermons are provided, and often
doth he upon such foresight endeavour to turn off those from
hearing that have most need and are most likely to receive benefit
by them. Many have noted it, that those sermons and occasions that
have done them most good, when they came to them, they have
been some way or other most dissuaded from and resolved against
before they came; and then when they have broken through their
strongest hindrances, they have found that all their obstruction was
Satan’s diligent foresight to hinder them of such a blessing as they
have, beyond hope, met withal. The like might be observed of the
constant returns of the Lord’s day. If men watch not against it, they
may meet with more than ordinary, either avocations to prevent and
hinder them, or disturbances to annoy and trouble, or bodily
indispositions to incapacitate and unfit them. And it is not to be
contemned, that some have observed themselves more apt to be
drowsy, dull, or sleepy on that day. Others have noted greater bodily
indispositions than ordinarily, than at other times; all which make no
unlikely conjecture of the devil’s special diligence against us on such
occasions.
Let us cast in another instance to these, and that is, of those that
are upon the point of conversion, ready to forsake sin for Christ. Oh,
what pains then doth the devil take to keep them back! He visits
them every moment with one hindrance or other. Sometimes they
are tempted to former pleasures, sometime affrighted with present
fears and future disappointments; sometime discouraged with
reproaches, scorns, and afflictions that may attend their alteration;
otherwhile obstructed by the persuasion or threatening of friends
and old acquaintances; but this they are sure of, that they have
never more temptations, and those more sensibly troubling, than at
that time—a clear evidence that Satan is as diligent as malicious.
I should now go on to display the subtlety of this powerful,
malicious, cruel, and diligent adversary. There is but one thing in the
way, which hitherto I have taken for granted, and that is, Whether
indeed there be any such things as devils and wicked spirits, or that
these are but theological engines contrived by persons that carry a
goodwill to morality and the public peace, to keep men under an
awful fear of such miscarriages as may render them otherwise a
shame to themselves and a trouble to others. It must be
acknowledged a transgression of the rules of method to offer a proof
of that now, which, if at all, ought to have been proved in the
beginning of the discourse: and indeed the question at this length,
whether there be a devil, hath such affinity with that other, though
for the matter they are as different as heaven and hell, whether
there be a God, that as it well deserves a confirmation,—for the use
that may be made of it to evidence that there is a God, because we
feel there is a devil,—so would it require a serious endeavour to
perform it substantially. But it would be not only a needless labour to
levy an army against professed atheists, who with high scorn and
derision roundly deny both God and devils—seeing others have
frequently done that—but also it would occasion too large a
digression from our present design. I shall therefore only speak a
few things to those that own a God, and yet deny such a devil as we
have described: and yet not to all of these neither, for there were
many heathens who were confident assertors of a deity, that
nevertheless denied the being of spirits as severed from corporeity;
and others were so far from the acknowledgment of devils, that they
confounded them in the number of their gods. Others there were
who gave such credit to the frequent relations of apparitions and
disturbances of that kind, that many had attested and complained
of, that they expressed more ingenuity154 than Lucian, who
pertinaciously refused to believe, because he never saw them; and
yet though they believed something of reality in that that was the
affrightment and trouble of others, they nevertheless ascribed such
extraordinary things to natural causes, some to the powers of the
heavens and stars in their influences upon natural bodies, or by the
mediation of certain herbs, stones, minerals, creatures, voices, and
characters, under a special observation of the motion of the
planets.155 Some refer such things to the subtlety and quickness of
the senses of hearing and seeing, which might create forms and
images of things, or discover I know not what reflections from the
sun and moon. Some [Pomponatius, Epicureans] fancy the shapes
and visions to be exuviæ, thin scales or skins of natural things,
giving representations of the bodies that cast them off, or
exhalations from sepulchres, representing the shape of the body.
Others [Cardan, Academics] make them the effects of our untrusty
and deceitful senses, the debility and corruption whereof they
conclude to be such, and so general, that most men are in hazard to
be imposed upon by delusive appearances. But with far greater
show of likelihood do some [Averrhoes] make all such things to be
nothing else but the issues of melancholy and corrupt humours,
which makes men believe they hear, see, and suffer strange things,
when there is nothing near them; or really to undergo strange fits,
as in lunacy and epilepsy.156 Leaving these men as not capable of
information from Scripture evidence, because disowning it, let us
inquire what mistaken apprehensions there have been in this matter
among those that have pretended a reverence to and belief of
Scripture. The Sadducees deserve the first place, because they are
by name noted in Scripture to have ‘denied the resurrection,’ and to
have ‘affirmed that there is neither angel nor spirit,’ Acts xxiii. 8, and
Mat. xxii. 23.
This opinion of theirs, could we certainly find it out, would make
much for the confirmation of the truth in question, seeing, whatever
it was, it is positively condemned in Scripture, and the contrary
asserted to be true. Many, and that upon considerable grounds, do
think that they do not deny absolutely that there were any angels at
all, but that, acknowledging that something there was which was
called an angel, yet they imagining it to be far otherwise than what
it is indeed, were accused justly for denying such a kind of angels as
the Scripture had everywhere asserted and described. For
considering that they owned a God, and, at least, the five books of
Moses, if not all the other books of the Old Testament—as Scaliger
and others judge, not without great probability, for neither doth the
Scripture—nor Josephus mention any such thing of the prophets—it
is unimaginable that they would altogether deny that there was
angel or spirit at all.157 They read of angels appearing to Lot, to
Abraham, and met with it so frequently, that, believing Scriptures to
be true, they could not believe angels to be an absolute fiction; for
one fable or falsity in Scripture, which so highly asserts itself to be
an unerring oracle of the true God, must of necessity have destroyed
the credit of all, and rendered them as justly suspected to be true in
nothing, when apparently false or fabulous in anything.
Again, If we call to mind what apprehensions they had of God,
which all consent they did acknowledge, we might more easily
imagine what apprehensions they had of angels, for in regard that
Moses made mention of God’s face and back-parts, Exod. xxxiii., and
that frequently hands and other parts of man’s body were attributed
to him, they concluded God to be corporeal; and seeing the best of
creatures which God created cannot be supposed to have a more
noble being than was that of their Creator, and, at the utmost, to be
made according to the pattern of his own image and likeness, they
might upon this bottom easily fix a denial of incorporeal spirits, and
by consequence that the soul of man was mortal, and therefore that
there could be no resurrection; so that the nature of angels being
described under the notion of spiritual substances, they are judged
to deny any such thing, supposing that to be incorporeal was as
much as not to be at all; and yet it were unreasonable to deny that
they had not some interpretation for those passages of Scripture
that mentioned angels, which in their apprehensions might be some
salvo to the truth of those historical writings, which they
acknowledged; but what that was we are next to conjecture. And
indeed Josephus, by a little hint of their opinion, seems to tell us
that they did not so much deny the being of the soul, as the
permanency of it; and so, by consequence, they might not so much
deny absolutely the existence of spirits, as their natural being and
continuance.158 Something there was that was called by the name
of angel—that they could not but own—and that this must be a real
and not an imaginary thing, is evident from the real effect, and
things done by them; yet observing their appearances to have been
upon some special occasion, and their disappearing to have been on
a sudden, they might conjecture them to be created by God for the
present service, and then reduced to nothing when that service was
done.
Their opinion, then, of angels seems to be one of these two:
either that they were corporeal substances created upon a special
emergency, but not permanent beings; or that they were but images
and impressions supernaturally formed in the fancy by the special
operation of God, to signify his mind and commands to men, upon
which they might fitly be called God’s messengers and ministers. I
put in this last into the conjecture, because I find it mentioned by
Calvin,159 as the opinion of the Sadducees; but both are noted by
Diodate,160 on Acts xxiii. 8, as with equal probability belonging to
them. His words are, ‘They did not believe they were subsisting and
immortal creatures, but transitory apparitions, or some divine actions
and motions to produce some special and notable effect.’
Others also have been lately hammering out the same
apprehension concerning angels, and profess themselves delivered
from it with great difficulty, differing only in this from some of the
heathens before mentioned, that what those ascribed to the
puissance of the stars, natural powers, or to weakness of senses and
corrupt humours, they, by the advantage of the general notions of
Scripture, have ascribed to God, putting forth his power upon the
minds and fancies of men, or working by the humours of the
body.161 Upon this foundation they will easilier make bold with
devils, to deny, if not their being, yet their temptations, imagining
that we may possibly do him wrong in fathering upon him these
solicitations and provocations to sin, which we by experience find to
be working and acting upon our minds, thinking that our own fancies
or imaginations may be the only devils that vex us; and this they
more readily hearken to, from the nature of dreams and visions
which happen to men in an ordinary natural way, where our fancies
play with us as if they were distinct from us; as also from this
consideration, that the lunatic, epileptic, and frenzical persons are in
Scripture called demoniacs, as Mat. xvii. 15, with Luke ix., where the
person is called lunatic, and yet said to be taken and vexed by a
spirit. So also John x. 20, he hath a devil, and is mad. But these
reasonings can do little with an intelligent, considering man, to make
him deny what he so really feels, and is so often forewarned of in
Scripture; for suppose these were called demoniacs by the vulgar, it
doth not compel us to believe they were so. Men are apt to ascribe
natural diseases to Satan, and Christ did not concern himself to cure
their misapprehensions, while he cured their diseases.162 This some
suggest as a reason that may answer many cases, though indeed it
cannot answer that of Mat. xvii., because, ver. 18, it is said expressly
that ‘Jesus rebuked the devil, and he departed out of him,’ which
would not have been proper to have been spoken on the account of
Christ by the evangelist, to express the cure of a natural disease, for
so would he unavoidably have been rendered guilty of the same
mistake with the vulgar. But if we should grant that divers mentioned
under the name of demoniacs were men disturbed with melancholy,
or the falling-sickness, all were not so; for those in Mat. viii. 31,
‘besought Christ, after their ejection,’ to have liberty ‘to go into the
herd of swine:’ that if Mr Mede intended to assert that all demoniacs
were no other than madmen and lunatics, I question not but he was
mistaken, and by his reason, not only must madmen and lunatic
persons pass for demoniacs, but all diseases whatsover; for the blind
and dumb were called also demoniacs, Mat. ix. 32, and xii. 22.163
But the matter seems to be this, that where men were afflicted with
such distempers, Satan took the advantage of them, and acted the
possessed accordingly; as he frequently takes the advantage of a
melancholy indisposition, and works great terrors and affrightments
by it, as in Saul; or at least that, where he possessed, he
counterfeited the fits and furies of those natural distempers, and
acted some like madmen, and others he made dumb and deaf—
which seems to have been the case of those in Mat. ix. and xii.,
where the deafness and dumbness did depend upon the possession,
and was cured with it—others were made to ‘fall on a sudden into
fire or water,’ as those that are epileptic, and therefore might such
be called both lunatic or epileptic, and also possessed with a devil.
As to that reason which some fetch from dreams, it is rather a
dream than a reason against the being of devils, seeing the effects
of these infernal spirits are far otherwise than the utmost of what
can be imagined to be acted upon the stage of imaginations; so that
the real and permanent being of devils may be easily proved:—
[1.] First, From those real acts noted to be done by angels and
devils. The angels that appeared to Lot were seen and entertained in
the family—seen and observed by the Sodomites. Those that
appeared to Abraham were more than fancied appearances, in that
they ‘ate and drank’ with him. The devil conveyed Christ from place
to place. This could not be a fancy or imagination. Their begging
leave to go ‘into the swine’ shews them real existences.
 [2.] Secondly, From the real effects done by them. We have
undoubted testimonies of men really hurt and tormented by Satan.
Of some really snatched away, and carried a great distance from
their dwellings. Of others possessed, in whom the devil really speaks
audible voices and strange languages, gives notice of things past,
and sometime of things to come. The oracles of the heathen, which
however they were for the most part false or delusory, yet, in that
they were responses from images and idols, were more than
phantasms.
[3.] Thirdly, From what the Scripture speaks everywhere of them.
Of their malice and cruelty; that devils are murderers from the
beginning; their daily waiting how they may devour; their arts, wiles,
and stratagems; their names and appellations, when styled
principalities, powers, spiritual wickednesses, the prince of the
power of the air, and a great many more to that purpose, shew that,
without apparent folly and dotage, we cannot interpret these of
motions only upon the minds and fancies of men. Besides, the
Scripture speaks of the offices of good angels, as their standing
continually before the throne, their beholding the face of God, their
accompanying Christ at his second coming, their gathering the elect
from the four winds, &c., Dan. vii. 10, which cannot be understood
of anything else but real and permanent beings; and this is also an
evidence that devils are, seeing the Scripture mentions their fall and
their punishment.
[4.] Fourthly, Seeing also the Scripture condemned the opinion of
the Sadducees, the contrary of that opinion must be true. And
expressly in Acts xii. 9, that which was done by an angel is opposed
to what might be visional or imaginary.
[5.] Fifthly, The reality of devils and their malignity hath been the
opinion of heathens. For there is nothing more common among
them than the belief of inferior deities, which they called δάιμονες or
δαιμόνια, that is, devils; and notwithstanding that they supposed
these to be mediators to the supreme gods, yet they learned to
distinguish them into good and evil.164 The Platonists thought that
the souls of tyrants after death became lemures and larvæ, that is,
hurtful devils; and at last the name devil became of so bad a
signification, that to say, ‘thou hast a devil,’ was reproach and not
praise; but what these groped at in the dark, the Scripture doth fully
determine, using the word devil only for a malignant spirit.

CHAPTER VIII.
Of Satan’s cunning and craft in the general.—Several demonstrations
proving Satan to be deceitful; and of the reasons why he makes
use of his cunning.
We have taken a survey of our adversary’s strength, and this will
open the way to a clearer discovery of his subtlety and craft, which
is his great engine by which he works all his tyranny and cruelty in
the world, to the ruin or prejudice of the souls of men; of which the
apostle in 2 Cor. ii. 11 speaks, as a thing known by the common
experience of all discerning persons. His way is to overreach and
take advantages, and for this end he useth devices and stratagems,
which is a thing so ordinary with him, that none can be ignorant of
the truth of it: ‘We are not ignorant of his devices.’
This, before I come to the particulars, I shall prove and illustrate
in the general, by the gradual procedure of these few following
considerations:—
First, All the malice, power, cruelty, and diligence of which we
have spoken, with all the advantages of multitude, order, and
knowledge, by which these cruel qualifications are heightened—
these are but his furniture and accomplishment which fit him for his
subtle contrivances of delusion, and make him able to deceive;
neither hath he any rise of his power and knowledge but in
reference to deceit. In Eph. vi. 11, 12, which is a place wherein the
apostle doth of purpose present Satan in his way of dealing with
men, his whole practice is set forth under the term and notion of
arts and wiles: ‘that you may be able to stand against the wiles of
the devil.’ This is the whole work of Satan, against which the
furniture of that spiritual armour is requisite; and lest any should
think that his power or wickedness are other distinct things in him,
which are to be provided against by other means of help, he
presently adds, that these are no otherwise used by him but in order
to his wiles and cunning, and therefore not to be looked upon as
distinct, though indeed to be considered in conjunction with his
subtlety and cunning, as things that make his wiles the more
dangerous and hazardous: ‘For we wrestle not against flesh and
blood, but against principalities, against powers, against the rulers of
the darkness of this world, against spiritual wickedness in high
places;’ which words do but strengthen the apostle’s warning and
caution about the forementioned wiles, which are therefore the more
carefully to be observed and watched against, because his power is
so great that he can contrive snares with the greatest skill and art
imaginable; and his wickedness is so great, that we cannot expect
either honesty or modesty should restrain him from making the vilest
and most disingenuous proposals, nor from attesting a conveniency
or goodness in his motions, with the highest confidence of most
notorious lying.
2. Secondly, The subtlety that the Scriptures do attribute to sin, or
to the heart, is mostly and chiefly intended to reflect upon Satan, as
the author and contriver of these deceits. In Heb. iii. 13 there is
mention of the ‘deceitfulness of sin,’ but it is evident that something
else besides sin is intended, to which deceitfulness must be properly
ascribed; for sin being, as most conclude, formally a privation, or if
we should grant it a positive being, as some contend, yet seeing the
highest notion we can arrive at this way, excluding but the figment
of Flacius Illyricus, who seems to make original sin indistinct from
the very essence of the soul, is but to call it an act.165 Deceitfulness
cannot be properly attributed to it, but with reference to him who
orders that act in a way of deceitfulness and delusion; which
ultimately will bring it to Satan’s door. If here the deceitfulness of sin
be devolved upon the subject, then it runs into the same sense with
Jer. xvii. 9, ‘The heart is deceitful above all things.’ But why is the
deceitfulness fixed upon the heart? The ground of that we have in
the next words; it is deceitful, because it is wicked, ‘desperately
wicked.’ But who then inflames and stirs up the heart to this
wickedness? Is it not Satan? Who then is the proper author of deceit
but he? It is true, indeed, that our hearts are proper fountains of sin,
and so may be accused possibly in some cases where Satan cannot
be justly blamed; yet if we consider deceitfulness as a companion of
every sin, though our hearts be to be blamed for the sin, Satan will
be found guilty of the deceitfulness. It may be said a man complies
with those things which are intended for his delusion, and so
improperly by his negligence may fall under blame of self-deception;
but it is unimaginable that he can properly and formally intend to
deceive himself. Deceit then, not being from sin nor ourselves
properly, can find out no other parent for itself than Satan. Besides
this, that these texts upon a rational inquiry do charge Satan with
the deceitfulness of sin; they do over and above point at the known
and constant way of Satan, working so commonly by delusion, that
deceitfulness is a close companion of every sin. The deceitfulness of
one sin is as much as the deceitfulness of every sin. Nay, further,
that text of Jer. xvii. 9, shews this deceitfulness not to be an ordinary
sleight, but the greatest of all deceits above measure, and of an
unsearchable depth or mystery; ‘who can know it?’
3. Thirdly, All acts of sin, some way or other, come through Satan’s
fingers. I do not say that all sin is Satan’s proper offspring, for we
have a cursed stock of our own; and it may be said of us, as
elsewhere of Satan, sometime we sin out of our own inclination and
disposition; yet in every sin, whether it arise from us or the world,
Satan blows the sparks and manageth all. As David said to the
woman of Tekoah, ‘Is not the hand of Joab with thee in all this?’ [2
Sam. xiv. 19;] so may we say, Is not the hand of Satan with thee in
every sin thou committest? This is so eminently true, that the
Scripture indifferently ascribes the sin sometimes to us, sometimes
to the devil. It was Peter’s sin to tempt Christ to decline suffering,
yet Christ repelling it with this rebuke, ‘Get thee behind me, Satan,’
Mat. xvi. 23, doth plainly accuse both Peter and Satan. It is the
personal sin of a man to be angry, yet in such acts he ‘gives place to
the devil;’ both man and Satan concur in it, Eph. iv. 26. Paul’s ‘thorn
in the flesh,’ 2 Cor. xii. 7, whatever sin it was, he calls ‘Satan’s
messenger.’ He that submits not to God, doth in that comply with
Satan; as, on the contrary, he that doth submit himself to God, doth
resist the devil, James iv. 7.
Neither doth that expression of the apostle, James i. 14, ‘Every
man is tempted when he is drawn away of his own lust,’ &c., give
any contradiction to this. It is not the apostle’s design to exclude
Satan, but to include man as justly culpable, notwithstanding Satan’s
temptations; and that which he asserts is this, that there is sin and a
temptation truly prevalent when there is the least consent of our lust
or desire, and that it is that brings the blame upon us; so that his
purpose is not to excuse Satan, or to deny him to have a hand in
drawing or tempting us on to sin, but to shew that it is our own act
that makes the sin to become ours.
4. Fourthly, Such is the constitution of the soul of man, that its
sinning cannot be conceived without some deception or delusion;166
for, granting that the soul of man is made up of desires, and that the
soul were nothing else but, as it were, one willing or lusting power
diversified by several objects; and that this power or these faculties
are depraved by the fall, and corrupted; and that man in every
action doth consult with his desires; and that they have so great an
influence upon him, that they are the law of the members, and give
out their commands accordingly for obedience; yet still these three
things are firm and unshaken principles:—
[1.] First, That desires cannot be set upon any object but as it is
apprehended truly or apparently good. It is incompatible to a
rational soul to desire evil as evil: Omne appetit bonum.
[2.] Secondly, The will doth not resolvedly embrace any object till
the light of the understanding hath made out, some way or other,
the goodness or conveniency of the object.167
[3.] Thirdly, There is no man that hath not a competent light for
discovery of the goodness or evil of an object presented.
Unregenerate men have, (1.) The light of nature. (2.) Some have an
additional light from Scripture discovery. (3.) Some have yet more
from common convictions, which beget sensible stirrings and awful
impressions upon them. (4.) To those God sometime adds
corrections and punishments, which are of force to make that light
burn more clear, and to stir up care and caution in men for the due
entertainment of these notices that God affords them. Regenerate
men have all this light, and besides that, they have, (1.) The light of
their own experience, of the vileness and odiousness of sin; they
know what an evil and bitter thing it is. (2.) They have a more full
discovery of God, which will make them abhor themselves in dust
and ashes, Job xlii. 6; Isa. vi. 5. (3.) They have the advantage of a
new heart, the law of the spirit of life, making them free from the
law of sin and death. (4.) They have also the help and assistance of
the Spirit, in its motions, suggestions, and teachings. (5.) They
fortify themselves with the strongest resolutions not to give way to
sin.
Notwithstanding all these, it is too true that both regenerate and
unregenerate men do sin; the reason whereof cannot be given from
any other account than what we have asserted—to wit, they are
some way or other deluded or deceived; some curtain is drawn
betwixt them and the light; some fallacy or other is put upon the
understanding some way or other; the will is bribed or biassed;
there is treachery in the case, for it is unimaginable that a man in
any act of sin should offer a plain, open, and direct violence to his
own nature and faculties; so that the whole business is here, evil is
presented under the notion of good; and to make this out, some
considerations of pleasure or profit do bribe the will, and give false
light to the understanding. Hence is it, that in every act of sin, men,
by compliance with Satan, are said to deceive, or to put tricks and
fallacies upon themselves.168
 5. Fifthly, All kinds of subtlety are in Scripture directly charged
upon Satan, and in the highest degrees. Sometime under the notion
of logical fallacies; those sleights which disputants, in arguing, put
upon their antagonists. Of this import is that expression, 2 Cor. ii.
11, ‘We are not ignorant of his devices,’ where the word in the
original is borrowed from the sophistical reasonings of disputants.169
Sometime it is expressed in the similitude of political deceits; as the
Scripture gives him the title of a prince, so doth it mark out his
policies in the management of his kingdom, Rev. xii. 7, expressly
calling them deceits, and comparing him to a dragon or serpent for
his subtlety. Sometime he is represented as a warrior: Rev. xii. 17,
‘The dragon was wroth, and went to make war,’ &c.; and here are
his warlike stratagems pointed at. Mention is made, 2 Tim. ii. 26, of
his snares, and the taking of men alive, or captive, directly alluding
to warlike proceedings, [ἐζωγρήμενοι.] The subtle proceedings of
arts and craft are charged on him and his instruments. Men are said
to be enticed, James i., as fish or fowl, by a bait; others deluded, as
by cheaters in false gaming: Eph. iv. 14, ‘By the sleight of men, and
the cunning craft of those that lie in wait to deceive.’170 The
overreaching of merchants or crafty tradesmen is alluded to in 2 Cor.
ii. 11. All these sleights are in Satan, in their highest perfection and
accomplishment. He can ‘transform himself into an angel of light,’ 2
Cor. xi. 14, where he hath an occasion for it; in a word, all
‘deceiveableness of unrighteousness is in him,’ 2 Thes. ii. 10. So that
a general πανουργία, a dexterity and ability for all kind of subtle
contrivances, is ascribed to him, 2 Cor. xi. 3, and that in his very first
essay upon Eve, when the serpent deceived her ‘through subtlety;’
so that whatsoever malice can suggest, or wit and art contrive for
delusion, or whatsoever diligence can practise, or cruelty execute, all
that must be imagined to be in Satan.
6. Sixthly, All this might be further proved by instances. What
temptation can be named wherein Satan hath not acted as a
serpent? Who can imagine the cunning that Satan used with David
in the matter of Uriah? How easily he got him to the roof of the
house in order to the object to be presented to him! How he directs
his eye, wrought upon his passions, suggested the thought,
contrived the conveniences! What art must there be to bring a
darkness into David’s mind, a forgetfulness of God’s law, a
fearlessness of his displeasure, and a neglect of his own danger!
Surely it was no small matter that could blind David’s eye, or besot
his heart to so great a wickedness. But, above all instances, let us
take into consideration that of Eve, in the first transgression,
wherein many things may be observed; as (1.) That he chose the
serpent for his instrument, wherein, though we are ignorant of the
depth of his design, yet that he had a design in it of subtlety, in
reference to what he was about to suggest, is plain from the text,
‘Now the serpent was more subtle than any beast of the field.’ It had
been needless and impertinent to have noted the serpent’s subtlety
as Satan’s agent, if he had not chosen it upon that score, as
advantageous for his purpose. (2.) He set upon the weaker vessel,
the woman; and yet such, as once gained, he knew was likely
enough to prevail with the man, which fell out accordingly. (3.) Some
think he took the advantage of her husband’s absence, which is
probable, if we consider that it is unlikely that Adam should not
interpose in the discourse if he had been present. (4.) He took the
advantage of the object. It appears she was within sight of the tree,
‘She saw that it was good for food, and pleasant to the eyes;’ thus
he made the object plead for him. (5.) He falls not directly upon
what he intended, lest that should have scared her off, but fetcheth
a compass and enters upon the business by an inquiry of the affair,
as if he intended not hurt. (6.) He so inquires of the matter— ‘Hath
God said, Ye shall not eat of every tree of the garden?’—as if he
made a question of the reality of the command; and his words were
so ordered that they might cast some doubt hereof into her mind.
(7.) He, under a pretence of asserting God’s liberality, secretly
undermines the threatening, as if he had said, ‘Is it possible that so
bountiful a creator should deny the liberty of eating of any tree? To
what purpose was it made, if it might not be tasted?’ (8.) When he
finds that by these arts he had gained a little ground, and brought
her to some land of questioning of the reality of the threatening, for
she seems to extenuate it in saying, ‘lest we die,’ he grows more
bold to speak out his mind, and plainly to annihilate the threatening,
‘Ye shall not die.’ This he durst not do, till he had gained in her mind
a wavering suspicion, that possibly God was not in good earnest in
that prohibition. (9.) Then he begins to urge the conveniency and
excellency of the fruit, by equivocating upon the name of the tree,
which he tells her could make them knowing as gods. (10.) He
reflects upon God as prohibiting this out of envy and ill-will to them.
(11.) In all this there is not a word of the danger, but impunity and
advantage promised. (12.) This deadly advice he covers with a
pretence of greater kindness and care than God had for them. See in
this, as in a clear glass, Satan’s way of policy; after this rate he
proceeds in all his temptations.
If any inquire why so mighty and potent a prince useth rather the
fox’s skin than the lion’s paw, these reasons may satisfy:—

[1.] First, There is a necessity upon him so to do.171 He must use

his craft, because he cannot compel; he must have God’s leave
before he can overcome; he cannot winnow Peter before he sue out
a commission, nor deceive Ahab till he get a licence; neither can he
prevail against us without our own consent. The Scripture indeed
useth some words that signify a force in tempting, as that he ‘put it
into the heart of Judas,’ ‘filled the heart of Ananias,’ ‘provoked David,’
‘rules in the hearts of the children of disobedience,’ and ‘leads them
captive at his will,’ &c.; yet all these and the like expressions intend
no more than this, that he useth forcible importunities, frames
strong delusions, and joins sometime his power to his temptations;
as sometime fowlers shew themselves to the birds they intend to
ensnare, that so they may be affrighted into an awe and
amazement, to give a better opportunity to spread their nets over
them.
[2.] Secondly, If he could compel, yet his way of craft and subtlety
is generally the most prevalent and successful. Force stirs up an
opposition; it usually alarms to caution and avoidance, and frights to
an utter averseness in any design; so that where force should gain
its thousands, subtlety will gain its ten thousands.
[3.] Thirdly, His strength is not useless to him. For besides that it
enables him to deceive with higher advantage than otherwise he
could do, as hath been said, he hath times and occasions to shew
his strength and cruelty, when his cunning hath prevailed so far as to
give him possession. What was said of Pope Boniface, that he
entered like a fox, and ruled like a lion, may be applied to him; he
insinuates himself by subtlety as a fox or serpent, and then rules
with rigour as a lion.

CHAPTER IX.
Of Satan’s deceits in particular.—What temptation is.—Of tempting to
sin.—His first general rule.—The consideration of our condition.—
His second rule.—Of providing suitable temptations.—In what
cases he tempts us to things unsuitable to our inclinations.—His
third rule.—The cautious proposal of the temptation, and the
several ways thereof.—His fourth rule is to entice.—The way
thereof in the general, by bringing a darkness upon the mind
through lust.
Our next business is to inquire after these ways of deceit in
particular; in which I shall first speak of such as are of more general
and universal concernment—such are his temptations to sin, his
deceits against duty, his cunning in promoting error, his attempts
against the peace and comfort of the saints, &c.—and then I shall
come to some ways of deceits that relate to cases more special.
As an introduction to the first, I shall speak a word of temptation
in the general. This in its general notion is a trial or experiment
made of a thing. The word that signifies to tempt, comes from a
word that signifies to pierce, or bore through,172 implying such a
trial as goes to the very heart and inwards of a thing. In this sense it
is attributed to God, who is said to have tempted Abraham, and to
put our faith upon trial; and sometime to Satan, who is said to have
tempted Christ, though he could not expect to prevail. But though
God and Satan do make these trials, yet is there a vast difference
betwixt them, and that not only in their intentions—the one
designing only a discovery to men of what is in them, and that for
most holy ends; the other intending ruin and destruction—but also in
the way of their proceedings.173 God by providence presents objects
and occasions; Satan doth not only do that, but further inclineth and
positively persuadeth to evil. Hence is it that temptations are
distinguished into trials merely, and seducements; suitable to that of
Tertullian, [De Orat.] Diabolus tentat, Deus probat, The devil tempts,
God only tries. We speak of temptation as it is from Satan, and so it
is described to be a drawing or moving men to sin under colour of
some reason.174 By which we may observe that, in every such
temptation, there is the object to which the temptation tends, the
endeavour of Satan to incline our hearts and draw on our consent,
and the instrument by which is some pretence of reason; not that a
real and solid reason can be given for sin, but that Satan offers
some considerations to us to prevail with us, which, if they do, we
take them to be reasons. This may a little help us to understand
Satan’s method in tempting to sin, &c., of which I am first to speak.
In temptations to sin, we may observe, Satan walks by four
general rules:—
1. First, He considers and acquaints himself with the condition of
every man, and for that end he studies man. God’s question
concerning Job, ‘Hast thou considered my servant Job?’ Job i. 8,
doth imply, not only his diligent inquiry into Job’s state—for the
original expresseth it by Satan’s ‘putting his heart upon Job, or laying
him to his heart’175—but that this is usual with Satan so to do; as if
God had said, It is thy way to pry narrowly into every man: hast
thou done this to Job? Hast thou considered him as thou usest to
do? And indeed Satan owns this as his business and employment in
his answer to God, ‘I come from going to and fro in the earth, from
walking up and down in it.’ This cannot be properly said of him who
is a spirit. Bodies go up and down, but not spirits; so that his
meaning is, he had been at his work of inquiring and searching. And
so Broughton translates it,176 from searching to and fro in the earth;
as it is said of the eyes of God, that they ‘run to and fro,’ which
intends his intelligence, search, and knowledge of things. It is such a
going to and fro as that in Dan. xii. 4, which is plainly there
expressed to be for the increase of knowledge.
The matter of his inquiry or particulars of his study are such as
these: (1.) Man’s state; he considers and guesseth whether a man
be regenerate or unregenerate. (2.) The degree of his state: if
unregenerate, how near or far off he is the kingdom of God; if
regenerate, he takes the compass of his knowledge, of his gifts, of
his graces. (3.) He inquires into his constitution and temper; he
observes what disposition he is of. (4.) His place, calling, and
relation; his trade, employment, enjoyments, riches, or wants. (5.)
His sex. (6.) His age, &c.
The way by which he knows these things is plain and easy. Most
of these things are open to common observation; and what is
intricate or dark, that he beats out, either by comparing us with
ourselves, and considering a long tract of actions and carriage; or by
comparing us with others, whose ways he had formerly noted and
observed.
The end of this search is to give him light and instruction in point
of advantage; hence he knows where to raise his batteries, and how
to level his shot against us. This Christ plainly discovers to be the
design of all his study, John xiv. 30, where he tells his disciples he
expected yet another onset from Satan, and that near at hand; ‘for
the prince of the world’ was then upon his motion, he was a-coming;
but withal, he tells them of his security against his assaults, in that
there was ‘nothing in Christ’ of advantage in any of these
forementioned ways to foot a temptation upon. It appears, then,
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