Pastoring the mentally ill

Even devout Christians are not immune to serious mental illness. When such illness surfaces, whether to refer and to whom to refer can pose real problems to the pastor, who must worry about how that person can get help without suffering spiritual harm in the process. There are guidelines, however, for arriving at wise decisions in this area where the concerns of psychiatry and Christianity intersect.

Pastors can unwittingly allow great and lasting harm to befall mentally disturbed members of their congregations in two very different ways. First, they can fail to realize that such persons may urgently need treatment that they as pas tors are totally unable to give. Medications and certain physical agents such as light or electricity, when appropriately and judiciously applied, can be not only lifesaving but also life-enhancing as they normalize chemical derangements of brain physiology and function.

But pastors can also err in the opposite direction. Instead of shunning medical and psychiatric help altogether when it is especially needed for correction of disturbed physiology, they may make the mistake of handing over their parishioners to supposed experts to perform healing functions of mind and spirit that they as ministers of the gospel could better do themselves.

In the former case they place too much confidence in the all-sufficiency of the spiritual resources of which they are agents; in the latter case, too little. They sell themselves and their resources short. They underestimate the mental health-producing powers of the gospel of our Lord Jesus Christ. Perhaps the "scientific" aura of psychotherapy beguiles them, leading them to suppose that Mr. Worldly Wiseman can more effectively unloose poor Christian's burden than can the contemplation of Golgotha.

Since physical and biochemical agents are not mediated through conscious thought processes, the area of psychiatric expertise that involves their use holds no potential for adversely altering the client's spiritual value system. But psychotherapy, the other area of psychiatric expertise—one that physicians share with clinical psychologists, marriage and family counselors, and others—definitely poses spiritual dangers. And these dangers are not lessened by the fact that the client's value system may need to be altered.

This distinction in psychiatric help is a practical one. The various psychotherapies can accomplish much good. But they can also do great harm. The physician's prime maxim, "Do no harm," should also govern the pastor in this situation, especially in regard to referral or choice of collaborator.

Benefits of timely psychiatric referral

Schizophrenia illustrates well the importance of early referral. With the onset of this disease, the symptoms of which usually begin to appear in the young or middle-aged, an individual will gradually or suddenly begin to lose contact with reality, as signaled by auditory hallucinations ("voices") and delusional, paranoid, or disjointed thinking. Often schizophrenics believe alien forces are controlling them. The anxiety thus en gendered may lead to bizarre and occasionally dangerous behavior.

While the more bizarre symptoms make apparent the need for referral, milder degrees of odd thinking or behavior may not alert the pastor. Or he or she may recognize incipient mental illness but feel that spiritual practices—confession of sins and greater exercise of faith, prayer, and positive thinking—should prove adequate for healing.

But these pastoral efforts may actually accelerate the disease process by delaying psychiatric treatment. Many schizophrenics can recover if they are treated early and adequately; the first year provides a golden opportunity. In this stage, antipsychotic medications can normalize the chemical alterations responsible for the symptoms, and, together with important auxiliary measures, can go far toward preventing lifelong chronicity.

Another major class of mental illnesses, one more commonly seen by pas tors and more amenable to a team approach, consists of the depressive and bipolar disorders. Here again, medications help because biochemical alterations play prominent roles in causing or continuing the disorders.

Bipolar disorders used to be called manic-depressive disease. At times the person involved will for days or weeks experience "high" periods characterized by hyperactivity, racing thoughts, talkativeness, sleeplessness, and impaired judgment. At certain other times he or she goes through painfully low depression.

This disorder tends to run in families. Untreated, it often has ruinous effects upon careers, marriages, and bank accounts. In most cases the mood swings can be prevented or effectively controlled by the maintenance use of a simple salt of lithium or one of the newer agents such as carbamazepine. Pastors can do a great service for people with such disorders by referring them promptly if they are not already under treatment. If they are being treated, pastors can help by impressing upon them the importance of continuing with their medication.

Dealing with depression

A more common but no less serious condition is unipolar depression. In this illness the "lows" periodically take over completely—there never are any "highs." Untreated, these episodes have an average duration of 8 to 10 months and are characterized not only by depression (sometimes masked) but often also by loss of interest in usual enjoyments, alteration in sleep pattern (especially early-morning insomnia), weight change (up or down, reflecting increased or decreased appetite), hopelessness, and suicidal thoughts or actions.

Sometimes anxiety is prominent. Often, however, those severely afflicted with this illness evince a marked slowing down of thought processes and body movements, a condition termed psycho-motor retardation. They often complain of sundry bodily aches and pains and of generalized fatigue; yet physical examinations usually find nothing wrong.

Of special interest to the pastor are the symptoms typical of depressed religious people. They commonly express feelings of worthlessness and great sinfulness, feeling that they have been cut off from God, that their prayers ascend no higher than the ceiling, and that they have committed the unpardonable sin. Regardless of how many times they may have recovered from similar periods in the past, they are sure that this time is different—that this time they will not recover.

The pastor may be tempted to exhort church members in this state to think positive thoughts, to exercise more faith, to pray harder and longer. Alas, these are exactly the things that the mentally exhausted are unable to do; they have probably already-tried a hundred times to perform these Christian duties. At this point such individuals do not need more "thou shalts." Their inability to perform them merely adds to their sense of failure and guilt.

Instead, rest—physical, mental, and spiritual—is the answer, along with prompt referral to a physician (preferably a psychiatrist), who will administer antidepressant medication for the altered brain chemistry that accompanies and perpetuates serious depression. Under such a treatment program, the psychomotor retardation will probably disappear in a few weeks, the depression will lift, natural sleep will return, and some sparkle and verve will be restored. Then such individuals will be ready for spiritual therapy and relatively open to the sweet influences of the gospel of grace—influences to which, in the state of deep depression, they were virtually impervious. What is more, a prompt treatment referral from the pastor may have averted a suicide or suicide attempt.

When Elijah was deeply depressed ("Now, O Lord, take away my life; for I am not better than my fathers"), the angel refrained from exhorting him to perform spiritual calisthenics. He offered him food and drink and rest, tenderly explaining, "because the journey is too great for thee." Only after these physical measures had been taken was Elijah ready to journey to the mount of God and hear the still small voice.

Dangers in psychotherapy

To conclude from the foregoing that depressed people need only to have their physical and biochemical abnormalities corrected by taking medicine would be as great a mistake as to suppose that they could end their depression simply by exercising more faith. Depression—like all mental illnesses—has physical, mental, and spiritual components. One cannot treat it adequately by focusing exclusively on only one or two of those components. Mental disease is complex. It requires attention to the whole person.

A practical distinction exists between physical and biochemical factors on the one hand, and mental and spiritual ones on the other. Work in the latter two areas carries greater danger of spiritual harm because it involves more directly the conscious value system. Perhaps the failure to acknowledge potential threats or the tendency to minimize their gravity poses the greatest dangers.

To understand the dangers inherent in working with the mental and spiritual factors of personality, one must comprehend something of how profoundly the viewpoints, goals, and philosophies of life of Christian soul-healing and the secular psychotherapies differ. Albert C. Outler has expertly articulated the seriousness of these differences in a penetrating little book entitled Psychotherapy and the Christian Message. In the preface he states: "My single intention has been to define the problems of alliance and conflict between psychotherapeutic thought and the Christian message and to analyze the basic issues that lie between them." ¹

In the book's conclusion, after emphasizing the benefits psychotherapy offers Christianity, he says: "But the disagreements which have also appeared in our analysis run very deep; indeed, they serve to vitiate or undermine a real and honest alliance. We have identified, I think, a serious class in primitive assumptions which divides the general movement of psychotherapy from the main traditions of historic Christianity. It is a conflict of basic truth claims respecting basic faiths, a disjunction between world views and first principles. The general import of modern psychotherapy involves a serious denial of the essential truth claims of the Christian doctrines of nature, man, and God, and the assertion (if only by implication) of a full budget of contrary premises. The vast majority of psychotherapists regard historic Christianity as an obsolescent mode of interpreting human problems which is now in process of being superseded by the superior wisdom of the new sciences of man, among which psychotherapy stands chief." ²

Significantly, these two orientations differ as to the grand purpose of life. In the words of the Westminster Confession, for the Christian "the chief end of man is to glorify God and enjoy Him forever." For the secular therapist, the chief end of man is to actualize his potential through the joyous and harmonious development of existing human faculties—in short, to glorify humanity. The first philosophy fosters dependence on God; the second fosters ultimate dependence upon self. The contrast between God-centeredness and anthropocentricity could hardly be more pronounced.

Opposite directions

Such a marked difference in goals naturally leads to very different methods of reaching them. David E. Roberts observes: "The theologian has a remedy for sin and the psychiatrist has a remedy for neurosis, but the remedies seem to be utterly different, if not incompatible. On the one hand, salvation comes from outside the self as a gift of God's forgiving grace. . . . On the other hand, integration comes about through an internal development which enables the individual to become more self-sufficient."³

Roberts opines that this "antinomy between dependence on God and growth of human self-sufficiency" may, at least in some respects, be irresolvable.

Paul C. Vitz, an associate professor of psychology at New York University, wrote a book that Karl Menninger described as one of the most satisfying books he had read recently. Menninger went on to say that Vitz's book communicates "what ought to have been said long ago—bravely, clearly, and constructively." In this book, Psychology as Religion: The Cult of Self-worship, Vitz minces no words. He writes: "Selfism derives from an explicitly anti-Christian humanism, and its hostility to Christianity is a logical expression of its very different assumptions about the nature of the self, of creativity, of the family, of love, and of suffering.

"In short, humanistic selfism is not a science but a popular secular substitute religion, which has nourished and spread today's widespread cult of self-worship." ⁴

It is beyond question that secular psychotherapy has helped multitudes of emotionally stressed people to achieve fuller, more productive, and more enjoyable lives. Therapists of various orientations have done great service to mankind. However—and this is a caveat underscored by Vernon Grounds of Conservative Baptist Theological Seminary and by Calvin Schoonhoven of Fuller Theological Seminary—the persons so benefited by secular psychotherapy may, in their newly found satisfaction and security, be further from the kingdom of God, less perceptive of their need for divine grace, and more firmly entrenched in their maturity and self-sufficiency than they were before.

Those who see themselves as psycho logically integrated, mature, and whole feel little need for the Physician of the soul. As Vernon Grounds has observed: "Healthy-mindedness may be a spiritual hazard which keeps an individual from turning to God precisely because he has no acute sense of need."⁶

Grounds goes on to point out that "mental illness may be an experience which drives a believer into a deeper faith commitment; hence mental illness may sometimes be a gain rather than a loss." ⁷ This insight accords with modem crisis intervention theory. It was early recognized by the Congregationalist minister Anton Boisen (himself afflicted with mental illness), who is credited with pioneering the pastoral counseling movement in the United States in the 1920s.

It would seem logical to conclude that if secular therapy can have such harmful results, if its principles are so at odds with those of genuine Christianity, then believers should use some form of "Christian psychotherapy." Unfortunately, while plausible in theory, this idea does not resolve the problem. In fact, all too often attempts along this line compound the problem.

When Christian believers go to non-professing therapists, they screen what they hear to avoid being led astray by worldly philosophies. But when they go to believing therapists, especially to those who purport to have duly integrated psychology and religion, they will likely be more relaxed and off guard. They may think, This man [or this woman] is a Christian: he believes in the Bible, in faith, in prayer, and in Jesus Christ. He can safely counsel me regarding my mental problems.

Counselees who have not chosen their counselors with great care are liable to have their Christian belief system subtly subverted and molded to conform to those principles of secular psychotherapy that are most alien to genuine Christianity. And all the while the therapists may believe that they are conducting their therapy in a Christian framework.

This "seduction of Christianity" ⁸ is by no means confined to the liberal wing of Protestantism. It is widespread among Evangelicals as well. Those involved use Christian terminology, and so beguile the unwary. They may extol nonbiblical principles, such as the necessity to love oneself, and defend them by the misuse of Bible texts, such as the one setting forth the-second great commandment. ⁹

Suggested guidelines

What then can a pastor do when a church member needs psychiatric help? First, he or she can promptly refer the person for diagnosis and treatment of the physical and biochemical components of the illness. The pastor should refer the " member to a psychiatrist if one is available. If not, a well-trained internist or family practitioner may have to suffice. The physician need not be a professing Christian to carry out this phase of the treatment effectively. When someone needs the services of a psychiatrist, it is far better to refer that person to one who is competent in his field but who professes no religion than not to refer the person to anyone.

Some cases will necessitate only psychotherapy—medications will not be helpful. And in most of the cases in which medication is the necessary first treatment, the church member will soon reach the point where he or she is ready for supportive follow-up psychotherapy.

In either situation, the pastor should en courage the member to employ the services of a well-trained Christian counselor who is aware of the dangers psychotherapy can pose to one's relationship with God.

If no such counselor is available, the next best alternative might be for the pastor to give supportive counseling in collaboration with a psychiatrist who would be responsible for managing medications and assessing and sharing responsibility for suicide risk in a depressed patient. Some psychiatrists are willing to work with a knowledgeable pastor, and some are not. There will be cases in which specialized counseling expertise will be needed and should be sought.

Pastors who elect to be active members of the healing team can best serve by ministering God's grace. They should direct their major efforts to filling the spiritual needs of the hurting ones. They will do them more lasting good by filling this role than by straying into other fields —trying, for instance, to do a work that marriage and family counselors are better trained to do.

Under the guidance of the Holy Spirit, a minister can make an outstanding contribution to the healing of the whole per son. True soul healing, mediated through the spilled blood of the Lamb, floods over the whole being and brings soundness to the mind and vigor to the body. The genuine fruit of the Spirit— agape love, joy, and peace—contains unrivaled health-producing power. Above all else, the heavy-laden need to find rest in the forgiving grace of Him who ever pleads, "Come unto me."