Biblical Counseling, a Clarification

Biblical Counseling, a Clarification

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Dr. David Powlison — author of the "Sane Faith" series on Boundless (part 1, part 2 and part 3) — appreciates the comments you've written on a blog post I wrote yesterday. This morning he sent me an e-mail responding to some of them.

Among other things, he writes that "faith actually changes how you perceive [someone] and respond to [them]." Later he adds, "How you're relating to God and how you're relating to [others] are not controlled by your body, but by your heart."

I find his clarifications helpful as I wrestle with the principles laid out in "Sane Faith."

* * *

I so appreciate the honesty of blog responders. Life is not easy street, but a hard road. Contrary to the glib self-confidence and easy answers that define our culture's style, the Bible respects that our lives are fundamentally fragile, vulnerable to coming unglued. The psalms are the voice of honest strugglers, which is why Psalm 23 (and the anti-psalm) play such a key role in the lead article I wrote.

I want to make sure that the purpose of those articles is not lost. Ted Slater's blog comments are right in saying that these articles are not about medications at all. They are about affirming our humanness. They seek to shine a light on our common bond in the human struggles. We're all in this together, and God comes to take us in hand. I'd hate to have the main point obscured by the discussion getting swallowed up in the medication issue. That is an important issue in its own right. Here are some thoughts to put in the mix in thinking about medications. But I hope that readers will also go back and ponder my original articles further.

About 10 years ago I watched a PBS special on the state of psychiatry in America. The head of the National Institutes for Mental Health (NIMH) was interviewed. He can fairly be called America's "top psychiatrist." He sits at the top of the pyramid that funds medication research, sets standards for care, and so forth. He knows his field. His comments were insightful and fascinating.

He said that society has given psychiatrists an impossible job. They are charged with trying to help people solve all their woes and struggles. Then he said that psychiatric medications can sometimes take the edge off symptoms, but they can't give people what they really need. People need meaning and relationships. Psychiatry can't give that. Medication can't give that.

You might want to reread that last paragraph. It contains a philosophy of medication that is sane and realistic, as well as knowledgeable. It's so different from what our culture tells us.

This psychiatrist was also seeing something about people that I believe can only be truly addressed by Christian faith. People need to find personal meaning and meaningful relationships. My articles are about what people really need.

I fully agree with the head of NIMH that medications can "sometimes take the edge off symptoms." He credits medication with possibly doing some modest good, not all the time, but sometimes. Modest good does not mean no good, or all bad, or useless. Nor does it mean the best good. People most need meaning and relationships. And "sometimes" does not mean always, or without the possibility of negative side effects. It means what it says, sometimes.

Most people who've tried medications would say that their experience mirrors what the head of the NIMH said. He knows the literature. He knows people. He knows that people might be helped a bit, but that they need more help and deeper help. In my 30 years of counseling, I've seen the same thing countless times. I've also seen that when people find more help and deeper help they often drop the meds and don't go back. They don't need the symptomatic relief, because they've found more significant change. (That's not always, but in my counseling experience it's more often than not.)

More help and deeper help is what my articles are about.

Here's an analogy you might find helpful. Let's say you go to visit your mother for lunch. The relationship can be a bit strained. She can be "difficult." When you are with her, and things take a wrong turn, you get tense. You feel a bit edgy, anxious, and irritable. You can get sarcastic. Later you might vent to your friends, "She's impossible!"

Let's say you've also learned that your relationship with God makes a huge difference. You love this promise and response:

He himself has said, "I will never leave you or forsake you." So we can confidently say, "The Lord is my helper. I will not fear. What can man do to me?" (Hebrews 13:5-6)

When you remember that, live it, take it to heart, you're calmer. You don't take your mom so personally. You're more constructive. You're able to forgive her. You pray for her rather than vent negative gossip. You're able to get on with the rest of your day in a positive frame of mind. You say to your friends, "I've got to say, it's hard to relate to my mom. But I'm very thankful to God for helping me not to return evil for evil." That passage of Scripture speaks sweet promises to you, in God's own voice: He himself says it! It also portrays how your faith comes to life: I can confidently say. Your thinking changes. What you say changes. How you feel changes. It doesn't mean your mom changes. But your faith actually changes how you perceive her and respond to her.

Now here's where our little analogy get interesting. Let's also say that when you drink three cups of coffee on an empty stomach and don't eat a good breakfast, you go into your day feeling tense. You get a bit edgy, anxious, and irritable. (Sound familiar?) Eating a good breakfast and laying off the caffeine makes you feel better. Similarly you find that healthy exercise and a good nights sleep also make you feel better, less prone to that tense frame of mind.

Here's the million dollar question. Will eating a healthy breakfast, taking a brisk walk and being well rested make your relationship with your mother tension-free and happy?

No, it won't. It might help you go into that lunch visit a bit less keyed up. It might help you not cancel because you can't face her. Maybe you won't be quite so reactive. But your relationship with your mother is a matter of "meaning and relationships." How you're relating to God and how you're relating to her are not controlled by your body, but by your heart.

Jesus puts all this in His usual pithy way. "Man does not live by bread alone, but by every word that proceeds from the mouth of God." Bread means bodily sustenance: breakfast, exercise, sleep. But bread alone can't bring energy and light, hope and love, to the meaning of your life and to your relationships. Whenever we make the connection, life makes much more sense. It's a connection to make every day, like eating a healthy breakfast.

The same sort of thing is true with medications. When they help, they tweak your body to feel and function better. But they can't touch your need for the things that Hebrew 13:5-6 touches. Perhaps this paraphrase catches the right sense of proportion: "Man does not live by meds alone, but by every word that comes from the mouth of God."

Our society attaches such inordinate hopes to medication. Pharmaceutical advertising makes such grandiose promises (not just about psychoactive drugs, but about many classes of meds). We want to say, things that help your body are good: healthy diet, exercise, and sleep, always; medications, sometimes. But they aren't the best. See these things for what they are and aren't, and you'll keep your life struggles in proper perspective.

The human touch that the articles seek to elicit and portray is always the most important. Those articles are about the YOU on the inside of who you are. They are about the YOU in your relationships.

I'd encourage readers to go back and read the lead articles again. As Ted Slater mentioned, Boundless and I have been working on this project for a year. In a culture of online information, people are not used to reading something more than once. But anything worth thinking about carefully is worth reading a second time. Print it out. Take it slowly. Underline. Write in the margins. Ponder what it means. Take it to heart.

I'd describe medication questions as a riff off from those articles — an important question in its own right, but a sidelight, even a distraction. You've probably seen how easily that happens in blogs. A riff carries the discussion far afield from the original topic.

I hope that what really sticks in your mind is Psalm 23. Verse 4 brings a true perspective on all our woes, including a body that gets out of sync and mothers who can sometimes be difficult.

* * *

P.S. Here are some further thoughts, and something for further study for those so minded. Joseph Glenmullen, a research psychiatrist at Harvard, summarized hundreds of studies on the effects of psychiatric medications for anxiety and depression (Prozac Backlash, Simon & Schuster, 2000). He takes a balanced view, similar to the director of NIMH. He simply gives the research data. Research shows that most of the positive effect comes from placebo effect, not psychoactive ingredients. Perhaps two-thirds of those who take medications feel better because they expect the medication to make them feel better. In other words, even with a pill, the issue of one's faith plays a significant part.

How can you know whether you're getting a psychoactive bump in mood or a placebo bump? You can't. That's part of why paying primary attention to meaning and relationships puts medications in their proper place as second-tier items. A person getting a placebo bump will continue to feel better when off medications because the meaning and relationships in his or her life improve.

Glenmullen also gives details on the negative side effects that frequently arise and the frequency of drug ineffectiveness. People in these categories need not despair. Fruitful dealing with meaning and relationship issues always makes a difference in a person's life, even if they must live with lifelong tendencies towards depression and anxiety — which many wise and godly people in history have done. Even if there's no medication to make the tense-and-anxious reaction in your body go away, if the tense-and-anxious reactions in your relationships improve, then your life improves.

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  • Comment by  scott:

    "What Happens At The State Fair Stays At The State Fair" :-)

  • Comment by  LisaA:

    Except in my case, apparently. :)

  • Comment by  Christina:

    I will ask a question my discipler once raised that may help shed some logical light on the issue.

    When people have a chemical imbalance in their brain, why does that always lead them into the sin of despair and melancholy? Why don't chemical imbalances make them more susceptible to cheerfulness and joy? It seems that these chemical imbalances people are always speaking of lead to actions, attitudes and words that do not exalt Christ.

    In a counseling class, we went over a chapter in our book that was geared towards depression and I found the author's set of rules to be a little intimidating and without compassion. When it finally came to discussing the chapter in our group, my pastor's wife (with great wisdom) said that we wouldn't be studying that chapter in the group setting. Instead, we spent the evening studying the power of God.

    I'd be more than willing to email anyone that power of God study. It is filled with the hope of the gospel.

  • Comment by  rachael:

    As an adult daughter of a Christian woman who has been diagnosed with everything from schizophrenia to bipolar disorder to, at the age of 66, ADHD, I am crying tears of both thankfulness and sadness as I read this. I am thankful because it expresses so clearly what I have been unable to say to my mom each time she announces she has been "healed" by yet another drug with all its awful (unadvertised) side effect, and then watched her inevitably spiral downwards. I am sad because in the past I really was one of those who, because of what my mom was like on meds, rejected all of it and was one of those "just take five Bible verses and call me in the morning" people. I am not that way now, but my harsh, prideful attitude helped little and harmed much. And I am saddest of all still for my mom, who will listen only to "white coats" with Harvard degrees, and especially the Christian ones who have so totally rolled over and worshipped secular science, which denies even the existence of the sould, instead of the God who created both science and the soul. My prayer over the last few years has been that God would reenergize the Christian medical community and renew their commitment to the study and care for the whole person. Maybe this article, coming from an institution that hasn't always in the past expressed ideas in this area this way, is the begnning of that answer.

  • Comment by  Connie:

    "When people have a chemical imbalance in their brain, why does that always lead them into the sin of despair and melancholy? Why don't chemical imbalances make them more susceptible to cheerfulness and joy?"

    Guess what? When I was suffering from bipolar type two I DID have both. The highs were wonderful. I was joyous, full of energy, talkative, better than best. The problem with that was that what goes up must come down, and the lows were horrible.

    Thankfully for a period of time medication did help me. But I don't miss the point that good relationships with other believers and with the Lord Himself was a vital part of keeping me as well as possible.

    Thankfully, a year and a half ago the Lord totally healed my brain and I no longer have the high highs nor the low lows. My doctor released me from treatment since even he saw there was no need.

    But let me make it perfectly plain-for a time there was a need, and a very big need. I was on meds in obedience to God, while waiting for His timing to heal me.

    Treating true chemical imbalances-and the soul and spirit issues that result from them-is a complicated matter, and there are no quick and easy answers. It is wrong and cruel to say meds are never needed but it is equally incorrect to say they are ever the total answer either.

  • Comment by  BDB:

    Christina (#1) wrote:

    >>Why don't chemical imbalances make them more susceptible to cheerfulness and joy? <<

    I think it can, but the other people around them are OK with that.  They can be fun to be around, but they might not be able to focus enough to manage their affairs.  It's easier for friends and family to be willing keep them organized if they're fun to be around.

    Similarly, there are drunks who become violent and dangerous.  There are also alcoholics who become funny and cheerful.  The latter is still using a chemical to deal with their life.  That's still not healthy.  But it doesn't frighten the people around them.

    I do know a few people on lithium, and it does seem to moderate their bipolar tendencies.

    At the same time, I've read a lot of biographies of giants of the faith.  Pretty much all of them grow their faith through suffering.  Much of the therapeutic community seems to believe that all suffering is bad.  It's not.  Suffering is sometimes necessary to the development of godly character.  Why else would books like Lamentations and Ecclesiastes be included in the Bible?

    I remain deeply concerned that antidepressants are being heavily over-prescribed in North America.  I do know people who've been on Paxil and other drugs.  One of the side effects with a few of them is that it seemed to erase their conscience.  The things they would do...a normal person would be ashamed of.  It didn't bother them at all.  No sense of urgency to get their work done.

    I think there's a lot we don't understand about antidepressants, and that scares me as much or more than mental illness.

  • Comment by  HoytRoberson:

    Christina,

    Most people with chemical imbalances are not "right," and usually when our bodies aren't functioning properly, we don't become happier. Does cancer make someone brighter? Why should a brain imbalance?

    But it isn't true that chemical imbalances always make people depressed. Sometimes it makes them irritable (much like having the flu might), or in some cases, it makes them manic.

    Unfortunately, even if they are manic, the "better feeling" isn't usually productive in its effects.

    And so, chemical imbalances cause various reactions in people because their bodies aren't functioning properly. And when we're sick, the illness seldom makes us productively feel better.

  • Comment by  Mike:

    The "Get Smart!" segment struck a chord with me. See, my ex-wife and I were mismatched along several axes. She was athletic, I wasn't; I was an intellectual, she wasn't; we had different family backgrounds - basically, we just didn't have a lot in common as far as interests. It really became a problem later.

    So, I think the listener really needs to look hard at her discomfort with the intellectual mismatch. It sounded to me like she's very happy with her beau as far as the emotional connection. That oftentimes is the hardest thing for a woman to get from a man. However, like you folks said, it's been three years - and he hasn't made a shift in her direction on the intellectual axis. If it hasn't happened yet, it's probably not going to. It could be that he's just not wired that way; after all, not everyone has the same gifts. (In my case, my ex expecting me to be athletic just wasn't in the cards.)

    She might be holding on, though, thinking that "nobody's perfect" and she's not wanting to give up on someone with whom she has a good emotional connection and who's such a great match in so many other ways. (This is where you get into the whole "list of stuff I have to have" argument, which can really muddy the water.)

    It basically leaves the young lady with two choices: Either she learns to live with him as he is, valuing his differences, or she decides that this is a gamebreaker and cuts bait. If it really bothers her that his intellectual pursuits are limited, then it's not likely to get any better after 10 years of marriage, unless she can just accept that this is one area of her life that he won't be able to share. Maybe she has a brainy girlfriend with whom she can discuss weighty matters.

    Anyway, just some rambling thoughts from someone who married a person with differing interests.

  • Comment by  Jo:

    A clarification from me too: There's a lot I agree with in the articles, and in this post too.  I still think there are important issues that haven't been addressed, and there are places where I disagree or would be cautious at least, but perhaps those things weren't the point of this series.  Topics for another time, maybe.

    To Christina, though:

    "Why don't chemical imbalances make them more susceptible to cheerfulness and joy?"

    Actually, mania leads to extremely elevated mood, hyperactivity, high energy etc - virtually the opposite of depression.  That's not 'cheerfulness and joy' in the positive sense, but as you say:

    "It seems that these chemical imbalances people are always speaking of lead to actions, attitudes and words that do not exalt Christ."

    Obviously an imbalance is not a good thing.  The balance is what God intended, therefore an imbalance of any kind will not exalt Christ.  It doesn't mean these conditions aren't real, in fact it can be clearly shown on brain scans that they are.

  • Comment by  Leeandra:

    @Christina--chemical imbalances in the brain CAN produce definite feelings of inordinate cheerfulness and joy just as they can produce feelings of despondency.  The former is called mania, the latter is called depression, and people can (and do) continue to exult Christ in BOTH these states.  See Christopher Smart's poem "Jubliate Agno," written while confined to a madhouse for what we'd now call bipolar mania, or the "terrible sonnets" of Gerard Manley Hopkins, who spent most of his adult life suffering from what we'd now call clinical depression.  

    The thing people must remember is the difference between depression and despair.  Depression can often lead to despair, but it's not a given.  

    Good books on this exact subject (I'm surprised no one has mentioned them yet) are Viktor Frankl's "Man's Search for Meaning," "The Will to Meaning," "Man's Search for Ultimate Meaning," and "The Doctor and the Soul."

  • Comment by  Jethro:

    Dr Powlison cites a few studies in his response and then heads straight to his predetermined conclusion - which he is refreshingly honest about.  

    Conspicuously absent however is a three way outcome comparison between regular counseling, biblical counseling and no counseling across the medication/no medication/placebo sub-groups.  

    I'm not sure if there is such a study or not, but perhaps Dr Powlison can address this and let us know the relative success of the different counseling models both alone and combined with medication?  

  • Comment by  Lynne:

    Ted,

    Thanks so much for including research and the NIMH director's words about medication.  

    When I work with parents and adults, I often tell them the purpose of medication is to control or minimize the symptoms, we review common side effects, then we talk about how the medications help us regulate the emotionality so we can work on the thoughts and behaviors we picked up along the way, things meds don't fix.  

    For example, a child can take a stimulant for ADHD.  This will likely help them sustain attention longer.  It will not fix the other symptoms that often come with ADHD (poor social skills, poor study habits, poor organizational skills).  Nor will they suddenly recall the information they did not pay attention to and learn.  

    Research also shows that for mild to moderate depression, Cognitive-behavioral therapy works a little slower the anti-depressant meds initially, but the gains hold up far longer.  This is because you're working with peoples thoughts and behaviors.  

    Rachel,

    I appreciate you sharing your story and the impact your mom's mental illness has had on her and you.  My  prayers are with you.  I have so much respect you sharing how your opinions have shifted over time and some of the events that have shaped them.

  • Comment by  cn:

    I'm I the only one who can't find episode 32 on itunes??

  • Comment by  AmirLarijani:

    I fully agree with Powlison.

    Medications are useful in terms of taking the edge off symptoms. That can be helpful to both counselor and client.

    If you are dealing with someone who is bipolar, medications can mean the difference between having a client you can work with, versus someone who is too irrational to reason with, or--worse--commits suicide.

    If you are dealing with a nasty depression, medications can help blunt the symptoms enough to help you see reality more clearly.

    Meds aren't everything, but they certainly can augment the process.

    Some people would contend that mental illness is the result of sin, and it may be in many cases. I know some friends who are bipolar, and a lot of their woes stem from post-abortion guilt. (Note: All bipolar sufferers do not fall into this category, but some do.)

    I would also contend that some people have predispositions to mood swings that can become exacerbated by hormonal factors, substantial life events, and--yes--even sin.

    For them, meds are hardly a panacea. Not by a long shot. But they can help blunt the damage and make it more possible to deal with a more rational client/patient.

  • Comment by  Anna:

    "How you're relating to God and how you're relating to [others] are not controlled by your body, but by your heart."

    My experience, and that of many other depressed people I know, is in direct contradiction to this statement. From my response to the first blog post:

    'When I'm in a deep depression, I can't focus long enough to read the Bible. Irrational guilt and self-condemnation make me feel unworthy to pray. Memorizing comforting Scriptures is impossible when my mind is so foggy I literally can't remember what I ate for breakfast. Fellowship with other Christians can be a source of deep comfort, but only if I can force myself to leave the house and seek out people to spend time with.

    I can (and do) pray for strength to withstand the compulsion to pull out my hair and pick holes in my skin -- but it falls short when the fixation begins, because the disease is by definition COMPULSIVE. All of my attention is focused on this behavior and I can't even remember that I'm supposed to pray, much less follow through. The symptoms of these diseases can themselves block the "cures" some Christians recommend.'

    I have spent hundreds if not thousands of hours in the past decade praying for forgiveness, strength, the fruits of the spirit, more love for my neighbor, and healing from my depression and trich. I've read the Bible cover-to-cover twice and studied large portions of it in-depth. I've participated in a number of Bible studies and Christian ministries. I've served my church and community as much as I am able. I pray and worship daily, even when tears are pouring down my face and I can't even get out of bed. I certainly don't lack in self-discipline; I graduated from college a year early, summa cum laude, while battling this disease without medical or psychological help because I was convinced that it was my own fault and I just needed to pray harder.

    I'm still depressed, but now I'm medicated and functioning. Would anyone like to tell me what I'm doing wrong or where my faith is lacking?

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