Psychiatric problems in the parish

Common mental health disorders and pastoral intervention.

George R Gibbs is chaplain, Harding Hospital, Worthington, Ohio.

Most pastors would agree that their primary concern is care of the human soul and the avenue to the soul, that deep-seated origin of all that makes us human--the mind. It follows, then, that pastors can't remain unconcerned about the mental health of the members of their congregations.

I have heard it said that a person with true, strong faith shouldn't suffer mental distress, that if a person would just pray or fully trust God they would be free of depression, anxiety, and emotional confusion. While prayer and faith are certainly part of any program of good mental health, at times that may not be enough. When a person suffers from a mental illness, his or her ability to rely on a faith system is compromised. Thoughts may deteriorate to suicide or other self-destructive behaviors that seem profoundly incompatible with sincerely espoused spiritual commitment.

Common mental health disorders

The fact is that mental health problems do strike people of faith. While parish pastors ought not attempt to practice psychiatry, they should have sufficient knowledge to screen for common mental health problems. These problems fall into four broad categories.

Depression and mood disorders are the most likely to be encountered. Sometimes people say they're depressed when they're only discouraged or unhappy. But clinical depression is a specific, debilitating condition that impairs family relationships, work function, appetite, sleep, concentration, decision making, and sexual interest. It can also lead to suicidal thinking. People are often reluctant to get help for depression, feeling that they shouldn't have it at all, that they ought to be able to overcome it alone, or feeling self-conscious about revealing a "weakness." Pastors may be tempted simply to tell them to "cheer up," "stop thinking about yourself," or "pray more." But, left untreated, serious depression can lead to broken lives and suicide.

Sometimes periods of depression are interrupted by periods of high energy. During the high energy phase the person may seem well or even better than well. He or she may do wonderful things for church and family and may suddenly appear so completely devoted to God that it may seem odd for a pas tor to question it. But in this kind of bipolar illness, emotional letdown and depression inevitably follow the high energy phase. A psychiatric professional can give medication to stabilize extreme mood swings.

Anxiety disorders affect people who chronically worry to the extent that their daily activity is hampered. One may become housebound, unable to face the world or be around people. They may develop specific, illogical, but very debilitating, fears, such as of germs or crowds. Anxiety disorders include obsessive-compulsive disorders: constant and repeated thinking of repulsive or unwelcome thoughts; compulsions to perform tasks that seem to alleviate anxiety such as washing hands, cleaning excessively, or organizing life pat terns in a particular invariable way, like having to separate articles in the trash before it can be discarded.

Thought disorders most frequently encountered are schizophrenia and delusional disorders. One with thought organization problems might switch subjects rapidly without warning or cause, making conversation difficult. He or she may see things, hear voices, and smell things that aren't real or have illogical fears of conspiracies or persecution. Such problems invariably require professional help, and the most serious demand hospitalization.

It is the bizarre nature of thought disorder illnesses that have helped to generate the common caricatures and jokes about mental illness. This is also the reason people find them the most disturbing and frightening illnesses. Pastors must be careful not to become discouraged when ministering to people with thought disorders; although the patient maybe saying things that sound nonsensical, they can still respond to and gain strength from well-directed love and concern.

Personality disorders are often difficult to describe because of the natural differences between personalities. Yet we all know people who have ongoing problems with relationships, are prone to explosive or emotional extremes, or seek isolation and avoid social activities. These personality problems lead to chronic vocational and relationship problems. In depression, anxiety, and thought disorders the sufferer is in great distress; but personality disorders are often more upsetting to friends and family than to the person himself or herself. Borderline or schizoid personality disorders fall into this group.

When pastoral intervention is not enough

When compassionate pastoral support isn't enough, what should you do?

Your parishioners might call on you to resolve their problems through applying the verities of the faith through practices such as pastoral conversation, prayer, and scriptural guidance. These can provide a vital sup port and yet may not contribute the resolution so desperately needed. The belief that people of faith should not have mental illness often contributes to guilt and anxiety about getting proper and effective treatment. At this point you would do well to consider recommending the help of a mental-health professional.

Pastors are sometimes afraid of referring parishioners to psychiatrists, having in mind an outdated image of the bearded Freudian who disparages all religious faith. In fact, mental health professionals who are offended by religion or who would challenge a patient's religious commitments are a minority. Good psychiatrists and psychologists appreciate the spiritual dimensions of a patient's life and realize the therapeutic value of a church community.

I recommend that parish pastors make the acquaintance of several kinds of mental-health professionals to whom they can refer. Psychiatrists are medical doctors who can prescribe medications as well as do talk therapy. Psychologists can do psychological testing and talk therapy. Social workers and clinical counselors are skilled in family and individual therapy. Some of the these are also trained in specialties like working with children or addictions.

Good mental-health professionals will be willing to meet and openly discuss their approaches with you. You can ask directly what the doctor thinks about the element of religion in a client's life and at the same time inquire about any area of specialty and fees. You may find such a professional open to an occasional phone consultation with you when you are attempting to make an early assessment of a problem. This is especially true when an appropriate sense of colleagueship or comradery has been cultivated with the professional.

If you are successful in making the referral, it is important to continue your involvement with your parishioner. This is the time when he or she most needs your love and support. Some mental-health problems are expressed through extremes of religious ideation. As a pastor, you can be very helpful to the treatment process by providing balance to such religious extremes of thought. Good mental-health professionals find a pastor's continued involvement very important, so a close working relationship is ideal.

Be very careful about interfering with your parishioner's treatment. For example, never recommend that your parishioner stop taking a medication prescribed by a psychiatrist unless he or she talks with the doctor. This may actually be damaging to the patient's health. If your parishioner tells you something that his or her doctor said that doesn't seem right to you, don't accept it at face value without checking first. Ask for a signed confidentiality release and talk with the professional personally. Some of the emotional upheaval the sufferer is experiencing can lead him or her to distort or misunderstand the doctor's words.

Though great strides have been made in the medical treatment of serious mental illnesses, there are few perfect cures. Some bipolar, depressed, or schizophrenic patients may not respond to medication right away, some not at all. Successfully treated patients may relapse. You may be the person in the best position to help a parishioner-patient accept that a mental illness may be something he or she has to live with in this life, even while you build hope that we'll someday live in God's perfect, illness-free kingdom.

Finally, keep confidences. To even casually mention to other church members or staff that a parishioner is seeing a psychiatrist, or to mention the nature of their problem, is not only unethical but illegal. It also destroys the elements of trust so critical in all of our professional and personal relationships.

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George R Gibbs is chaplain, Harding Hospital, Worthington, Ohio.

May 1999

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