American Christian Engagement With Mental Health and Mental Illness

Mental health clinicians have in recent years recognized the relevance of religion and spirituality for the experience of mental illness and the delivery of mental health services. Religious practices and beliefs affect mental health outcomes and often serve as important coping resources among individuals with serious mental illness (1,2). Spiritually themed recovery programs have long been important in substance abuse treatment and recovery. Religious communities can be important loci for support and care for persons with mental illness, particularly but not exclusively for persons from racial-ethnic minority groups (3,4).

Although these findings suggest the possibility of constructive collaboration among clinicians, health care institutions, and faith-based organizations, barriers exist. People can be harmed in the context of religious communities (5). Mental health clinicians may lack familiarity with particular faith traditions, and faith-based approaches to mental illness are extraordinarily diverse. Some traditions, such as Judaism, have historically embraced the vocational role of the mental health clinician. Some non-Western traditions contain healing practices that complement Western medical theory and practice. Others, such as American Christianity, are internally divided about the proper limits of scientific and psychological methods in relation to scripture and theology. To orient clinicians and researchers to important and diverse perspectives within what continues to be the most frequently subscribed religious tradition in the United States, this Open Forum explores five movements in American Christianity that continue to shape professional and organizational approaches to mental health care and mental health service delivery. [A table summarizing information about these movements is available in an online supplement to this Open Forum.]

Pastoral Care and Counseling

Although scholars commonly describe a “troubled history between psychiatry and religion” (5), this tension has never been uniform within either psychiatry or American Christianity. Beginning in the early 20th century, many Christian clergy used psychiatry to inform their practices of “soul-care” (6). The emergence in the 1920s of clinical pastoral education, which brought seminarians into direct contact with psychiatric inpatients, accelerated this trend. Clergy often looked to psychiatry and psychology for pastoral insight, and there was some professional overlap—for example, psychotherapists Carl Rogers and Rollo May studied in Protestant seminaries before pursuing psychological training. By midcentury, many clergy pursued psychotherapeutic training to inform their pastoral work. These clergy were generally sympathetic to psychiatry and were supported by certain leaders in the mental health field. William C. Menninger (7), for example, noted in 1950 that “there is need for the co-operation of clergymen and psychiatrists. Pastors should learn to recognize when the persons who come to them for help are mentally ill and need psychiatric consultation. Psychiatrists should recognize the powerful emotional support that many individuals derive from their religious faith. . . . Despite a few irrationally prejudiced remarks and articles written by those who would stir up antipathies, psychiatrists and clergy are working together, and understanding and borrowing support from each other.”

The pastoral care and counseling movement has spawned numerous movements relevant for modern health care. Health care chaplains provide spiritual care and support in many contemporary health care settings and are supported by organizations, such as the Association of Professional Chaplains (www.professionalchaplains.org) and the Association for Clinical Pastoral Education (www.acpe.edu), and by journals, such as the Journal of Pastoral Care and Counseling. Pastoral counselors, who may be chaplains or ordained clergy, are often licensed professional counselors (L.P.C.s) and may be certified by the American Association of Pastoral Counselors (www.aapc.org). The pastoral care and counseling movement has also influenced the development of interfaith mental health advocacy organizations such as NAMI FaithNet (www.nami.org/NAMIFaithnet) and Pathways to Promise (www.pathways2promise.org), which in turn have informed the advocacy and lobbying efforts of many Christian organizations (8).

Biblical Counseling

The congenial approach to psychiatry in modern pastoral care and counseling, however, has not been shared by all Christian pastors and churches. Protestant Christianity in the United States was sharply divided in the 20th century between more “liberal” theologies that interpreted Christian concepts within modern approaches to science and reason and more “fundamentalist” or “evangelical” theologies that were more guarded about these approaches. This division manifested itself with respect to psychiatry most visibly in the movement now known as “biblical counseling.” Biblical counseling originated with Jay Adams, a pastor who rejected the psychoanalytic teaching he received in seminary and, influenced by Thomas Szasz and the behavioral psychologist O. Hobart Mowrer, founded a new movement that he came to call “nouthetic counseling.” Nouthetic counseling was marked by four distinctive commitments: emphasis on personal responsibility and, correlatively, on personal sin as the core human problem; strong affirmation that the Bible should be the primary text used in pastoral counseling; marked distrust of psychology and psychiatry; and promotion of pastors, and not mental health clinicians, as preferred counselors. Nouthetic counseling was, and is, directive and sometimes confrontational, with frequent and authoritative references to Christian scripture (9).

Although nouthetic counseling continues to exist within Adams’ own Institute for Nouthetic Studies (www.nouthetic.org) and the Association of Certified Biblical Counselors (www.biblicalcounseling.com), the movement is now more broadly known as “biblical counseling” and incorporates the Christian Counseling and Educational Foundation (www.ccef.org), the Association for Biblical Counselors (www.christiancounseling.com), and the Journal of Biblical Counseling, which display Adams’ influence but often display more openness to modern psychology and especially to modern biological psychiatry (because mental disorders, if proved to be organic, are properly the domain of medicine) (10). Biblical counseling plays an influential role in the way that many clergy are trained and in the way that many conservative Protestant congregations respond to mental illness; for example, it is currently the dominant model of pastoral training within several of the seminaries of the Southern Baptist Convention, the nation’s largest Protestant religious body. Biblical counselors, some of whom are credentialed as licensed professional counselors, usually work within churches or faith-based organizations (including addiction treatment centers).

Integrationism

Biblical counseling, however, is not the only approach to contemporary psychology and psychiatry within American evangelical Christianity. Other midcentury American evangelicals, more sympathetic to psychological science and practice, formed training programs and organizations that are now often referred to as “integrationist” because of their commitment to integrate clinical psychology with Christian doctrine (11). This commitment has over time led the integrationist movement into closer alignment with clinical psychology than its “pastoral care and counseling” counterpart. Integrationist doctoral training programs, such as Fuller School of Psychology (www.fuller.edu/sop) and Rosemead School of Psychology (www.rosemead.edu), maintain American Psychological Association accreditation, and graduates are board eligible for licensure in clinical psychology. Integrationist organizations publish the Journal of Psychology and Theology and the Journal of Psychology and Christianity and are professionally linked within the Christian Association for Psychological Studies (www.caps.net). More broadly and variably, integrationist thought informs institutions such as the Meier Clinics (www.meierclinics.com) and Pine Rest Christian Mental Health Services (www.pinerest.org), as well as numerous master’s-level counseling programs and the American Association of Christian Counselors (www.aacc.net). Like the pastoral care movement, integrationism has given rise to support and advocacy movements for persons with mental illness within Christian congregations and denominational bodies (for example, Mental Health Grace Alliance [www.gracealliance.org]) that are generally accepting of medical models of mental illness (12). Integrationist thought also informs psychiatric professional networks such as the Psychiatry Section of the Christian Medical Association (www.cmda.org/ministry/detail/psychiatry). While not all graduates of integrationist training programs advertise themselves as faith-based clinicians or work in faith-based care settings, many self-identify as “Christian psychologists” (Ph.D. and Psy.D.) or “Christian counselors” (M.S.W., L.P.C., and others).

Christian Psychology and the Institute for the Psychological Sciences

Two additional movements, although younger and less institutionally mature, are nonetheless noteworthy within the diverse terrain of American Christian engagement with mental health and mental illness. The first, which self-identifies as “Christian psychology,” is linked through the Society of Christian Psychology (www.christianpsych.org) and the journal Christian Psychology (formerly Edification). Christian psychology so far is primarily a scholarly movement in which clinicians, philosophers, and theologians explore ways that the Christian theological tradition might shape distinctively Christian models of mental health care and inform empirical research (13).

The second movement is centered primarily on the Institute for the Psychological Sciences (IPS [www.ipsciences.edu]), an accredited Psy.D. training program in Arlington, Virginia, and displays a specifically Catholic form of engagement with modern psychology. Although many American Catholic institutions sponsor clinical training programs indistinguishable from those at non-Catholic universities, IPS describes itself as pursuing a distinctively Catholic vision of psychology and mental health, rooted in church teaching. Scholars and clinicians associated with IPS have published numerous articles and monographs interpreting mental health and mental illness through Catholic traditions of philosophy and moral theology (14).

Recommendations for Clinicians and Policy Makers

Although the movements described above are often unfamiliar to mental health clinicians and policy makers, each is relevant to the way that mental health care is delivered and received in the United States, particularly among highly religious populations. I close by suggesting four appropriate responses to these movements.

Ask and Explore

As the discussion above makes clear, self-described “Christian counselors” or “pastoral counselors” possess various forms of licensure and may embody radically different approaches to mental health care, depending on their own theological convictions and the location of their clinical training. It is appropriate for referring providers and policy makers to ask faith-based clinicians to describe their approaches to mental health care and to locate themselves within, or outside, the various traditions described above. This applies also to the staff of faith-based homeless shelters or substance use recovery programs to which patients with substance use disorders and severe mental illness are often referred. Correlatively, mental health clinicians should always be able to obtain a respectful and adequate spiritual history in the context of patient care (15).

Collaborate and Refer When Appropriate

Most of the Christian movements described above affirm the therapeutic value of modern psychology and psychiatry and, for theological reasons, are committed to supporting and to caring for persons with mental illness. Collaboration between professional and clinical organizations and faith-based organizations may therefore be productive and useful. When patients have strong religious values and desire additional resources, mental health clinicians may also cautiously consider referring patients to trusted faith-based counselors or established faith-based recovery programs.

Listen and Learn

It is easy for clinicians and policy makers to simply ignore faith-based movements that are suspicious of modern psychiatry, given these movements’ location within religious subcultures. But this would be a mistake. Movements such as biblical counseling are influential precisely because they capture the fears, longings, and convictions of many Americans, including many Americans with mental illness.

Look for Exceptions and Surprises

Finally, clinicians and policy makers should be aware that the world of Christian engagement with mental health care is never entirely predictable. Pastors and clinicians trained within one of the aforementioned movements may substantially change after several years in ministry or practice. Others may experience changes in their own religious understanding and may, for example, cease to think of themselves as faith-based providers. Other Christian organizations, pastors, and clinicians fall outside this classification entirely. Clinicians and policy makers should expect Christian approaches to mental health and mental illness to reflect the diverse and varied terrain of Christianity in the United States.