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A shrink thinks… Pastor vs psychiatrist?

June 2019 | by Alan Thomas

Am I in conflict with myself? I am not referring to Romans 7 and wrestling with my sin, but rather to a potential role conflict. As both a serving elder with some pastoral responsibility and a practising consultant psychiatrist, do I experience a tension between these two roles? Do I find that my ‘psychiatrist self’ has a set of views and practices which are in opposition to my ‘eldership self’?

I do not. But if you read my recent article on ‘Unconscious sin’ then you might respond that I am not best placed to answer my own question! For I may unconsciously be working as a psychiatrist in a way which contradicts my biblical approach as an elder. Well, all I can say is that having thought about it and worked it through I still don’t think so. But why might there be a conflict?

There have long been suspicions about psychiatry (and psychology) because it deals with human behaviour. Since pastors also deal with human behaviour then it seems reasonable to conclude they might find themselves dealing with the same people with the same problem behaviours. Hence, they could be in conflict.

But as I have written in detail elsewhere (see my book, Tackling Mental Illness Together) it all depends on how psychiatry is practised and on how mental illness is defined. Psychiatrists, as doctors, deal with illness. Pastors do not. Thus, when mental illness is properly defined as illness then the potential for conflict (in theory at least) disappears.

When someone in church is mentally ill then he can see a doctor, perhaps even a psychiatrist, and receive healthcare, including medication. And the pastor can visit and encourage him in his Christian walk with the Lord, just as he does for anyone else who is ill in the church. No conflict. But today mental illness is not defined like this. It is looser, more fluid and this creates potential conflict.

Nowadays you rarely hear the phrase ‘mental illness’. Instead we read and hear of ‘mental health problems’ and ‘mental health issues’. These are nebulous terms. Have you ever heard anyone explain what they mean? I haven’t. Mental illness can be clearly defined and so may be likened to a solid substance. Its solidity means its territory is well demarcated and thus clearly seen to be separate, as above, from the domain of the pastor.

But ‘mental health issues’ is undefined and thus fluid. So depression, properly defined as a solid illness with evidence-based treatments, liquefies and flows everywhere as a ‘mental health problem’. And so we find there are vast numbers of people with this liquid depression. It flows everywhere and so brings people with undefined ‘emotional issues’, labelled as ‘depression’ into healthcare and psychiatry and into the territory of the pastor.

Does it matter? A pastor or elder reading this might be thinking that he isn’t best equipped to deal with such emotional matters anyway. He is quite content for people in the church to see their GP or a psychiatrist or psychologist. I agree. Whilst I think it is important to understand the issues and the potential for confrontation, this doesn’t mean the pastor should be claiming exclusive rights for caring for such people in his church.

But real conflict arises when the underlying reasons for the ‘mental health issues’ are sinful behaviours. ‘Mental health issues’ are often the emotional froth arising from deeper bad behaviour. Not necessarily. They can arise from mental illnesses or from traumatic circumstances or from stress, none of which are the result of the person’s bad behaviour.

But then there is the young Christian woman sleeping with her non-Christian boyfriend who has ‘mental health issues’. Or the middle-aged man who has been found out at work to have achieved his promotion by embellishing his CV with fictitious awards and achievements who is now off work sick with ‘mental health issues’. Or the young man staying up late at night watching porn who, struggling at church, declares he has ‘mental health problems’ and is seeing his GP about them. Here, there are clearly matters which are pastoral and where conflict can and does arise.

Conflict arises when the doctor/psychiatrist/psychologist does not regard such behaviours as sinful. The woman’s old-fashioned views on sex are causing these emotional problems. Just relax. The CV embellisher is jokingly encouraged to ‘do it better next time’ and to apologise and move on. Here health service professionals stick the sword into biblical morality and seek to overthrow our worldview. Alternatively, the young man may use his antidepressants as a shield to ward off his pastor. The young woman shields herself from pastoral attention by declaring she is receiving counselling.

In some cases, it can be difficult. If someone won’t engage there is little one can do. Initially at least. Later the pastor (and elders) need to decide when and how to deal with a member who won’t engage when clearly struggling. But for those who do engage the key is to understand the cause of the distress.

Emotions are normally responses to thoughts and behaviours and experiences. (The exceptions are those mental illnesses which are primarily due to mood disturbances.) Pastors and mature Christians are equipped to explore why someone is upset, to seek the roots of their emotional distress.

Such exploration may identify all sorts of contributors: bullying at work, time-pressures for assignments, family losses and so on. And for these we are able through the church to offer personal and practical support which can be very effective. Sometimes such exploration will uncover sins, as in the above examples, which are the root cause and need tackling.

If no such factors are found, then perhaps a health service opinion is needed for potential treatment of mental illness. The person may legitimately be in the psychiatrist’s domain. As above, this doesn’t preclude the pastor crossing the line to help. Biblical advice and encouragement, especially for any moral issues, is appropriate.

The church fellowship has an important role in visitation too and in loving practical encouragements, some shopping done, a meal cooked, a text sent, a trip together. All help. Most important is prayer, informed by personal knowledge and unclouded by prejudice about the illness, and the encouragement to continue together in worship with the church and in service of the Lord.

Alan Thomas is a professor and consultant in psychiatry and elder at Newcastle Reformed Evangelical Church.