Why did you write Descriptions and Prescriptions?
When it comes to issues of psychiatric diagnoses and medications it is too easy for Christians to go to one extreme or the other. That is, to either grant too much authority to psychiatric classifications and solutions for people’s problems as though Scripture is irrelevant for issues of mental distress. Or to dismiss them altogether as though medical science is irrelevant for issues of mental suffering in Christians. I wrote this book to present a nuanced “third way” between those two extremes that is grounded in Scripture, does justice to human beings as embodied souls, respects the role of scientific inquiry, and suggests compassionate and wise ways to minister to those who are struggling with mental illness in our churches.
How do you think your medical background and ministry training/experience contribute to the shape of this book?
My training and experience in both medicine and gospel ministry means that the book is first and foremost grounded in Scripture while also giving careful consideration to the medical research that contributes to the discussion. The book is marked by both biblical and scientific inquiry.
Who is your target audience?
My primary audience includes helpers and leaders in the church–pastors, vocational counselors working in a church setting, lay counselors, elders, deacons, small group leaders, and others involved in one another ministry. I trust the book will be helpful also for Christian psychiatrists, Christian psychologists, and Christian professional counselors.
What are the takeaways of your book?
For readers who come skewed to one extreme or the other regarding psychiatric classification and psychoactive medications, I hope they leave with a more balanced and nuanced approach. For readers who already have a more balanced approach, I hope they leave more clearly informed and equipped with biblical and scientific perspectives to undergird their ministry. Ultimately I want the perspectives of the book to provide helpers with guidelines for compassionate, wise, gospel-saturated care to those who are struggling with issues of mental health.
What imbalances have you seen in the way Christians think about psychiatric diagnoses and medications?
Regarding psychiatric diagnoses, I have encountered people who embrace a psychiatric label as an all-encompassing explanation for their struggles. Their diagnosis becomes the identity around which their lives orbit. They may seek only medical means of help and believe that biblical and pastoral realities are irrelevant to their problems. On the other hand I have seen people who resist a particular diagnosis when it might provide a helpful way to bring some clarity and order to their experience. These people may over-spiritualize their problems and resist appropriate medical interventions. Since God has made us both body and spirit creatures, it is important to consider both aspects of our personhood as we seek to understand the struggles of others.
What are some limitations and benefits of a psychiatric classification of people’s struggles?
The main limitation of a psychiatric classification is this: it is a description of the person’s experience but it is not an explanation for it. A diagnosis describes the person’s disordered thinking, emotion, and behavior but doesn’t tell you why the person is struggling in this particular way. The Diagnostic and Statistical Manual of Mental Disorders (the DSM) acknowledges this limitation. This means that a diagnosis becomes a starting point (not an endpoint) for careful inquiry, biblical understanding of this person as a body-soul image bearer, and ongoing pastoral ministry. At the same time, certain psychiatric diagnoses (for example, schizophrenia or bipolar disorder) alert us to patterns of severe suffering that may well require additional intervention, including medication.
How does Scripture give us a framework for understanding various forms of mental suffering?
Our starting point is Scripture because we cannot understand ourselves apart from God’s revelation to us. God created us as body-spirit image bearers who perfectly reflected His design for abundant and fruitful life (Gen 1:26-28; Gen 2:7). Body and soul worked seamlessly to honor and glorify God. The fall of Adam and Eve into sin affects us holistically—we are fallen, body and soul. Sin and suffering (physical and mental) become two ever-present realities for us as a result (Gen 3:16-19; Gen 6:3-7; Rom 5:12-21; Rom 8:22-23; 2 Cor 4:7-12).
There is no doubt that our cognition, our affections, and our will to act must and do reference the living God—we are by nature worshippers, according to Paul in Romans 1. The human heart is always active (Gen 6:5; Exod 25:2; Lev 19:17; Deut 6:5; Prov 13:12; Prov 14:13; Ezek 36:26-27; Matt 15:10-20; Luke 6:43-45; Eph 6:6; Heb 4:12). So while mental illness is suffering, it is also demonstrative of an active posture before the Lord—we remain image-bearers, after all! Our thoughts, emotions, and actions reveal an orientation toward or away from him, moment by moment. To ask, as Scripture urges us, “What does the call to love God and others look like in the midst of your suffering?” is a profoundly humanizing question.
At the same time we must recognize the mystery involved in the interface of body (brain) and spirit. Scripture doesn’t slice and dice people into bodies and spirits per se, but approaches God’s people holistically as saints who need confirmation of their identity in Christ, sufferers who need the consolation of God, and sinners who need loving correction of their wayward ways. Ministry to anyone with a psychiatric diagnosis always involves these elements in various measures (1 Cor 1:1-9; 1 Thess 5:14).
How does Scripture guide our thinking about the use or non-use of psychoactive medications?
Clearly, Scripture does not provide explicit instruction about the use or non-use of medication. However it provides a wise and balanced framework for considering such questions. For example, here are several biblical perspectives that offer guidance: (1) Relief of suffering and growth in Christian character in the midst of suffering are both important; (2) Medications are a gift of God’s common grace and medications (like any gift of God) can be used idolatrously; (3) Motives are important—a person can have wrong motives for wanting to take medication and a person can have wrong motives for not wanting to take medication; (4) Attention to the interplay between the spiritual and somatic aspects of the person’s experience is important. In the end, the use or non-use of medications is not a “right or wrong” issue but a “wisdom” issue. We ask, “What seems wisest for this particular person with this particular constellation of struggles and strengths at this particular time?”
If the local church embraced the ideas in your book, what would change?
My hope is that leaders in the church would have increasing confidence to pursue those in their congregations who are struggling with mental health issues. And that they would do so in a balanced way, being attentive to both spiritual and bodily aspects of these struggles. I want them to have a growing conviction that Scripture speaks broadly and deeply to the disordered thoughts, emotions, and behaviors associated with psychiatric diagnostic categories, and that Scripture provides fundamental ways of understanding people that are much more full-orbed than a diagnosis can capture. At the end of the day my goal would be a restoration of the local church as the central locus of care for those who are troubled, while recognizing there are times when we must wisely partner with those in the medical community.
How can leaders in the church become better equipped to minister wisely to those diagnosed with psychiatric disorders?
The most fundamental starting point is to listen deeply to people and to Scripture. Both are critical. Listening to people’s stories without an accompanying biblical perspective will result in truncated, imbalanced ministry. Listening to Scripture without listening to people’s experiences will also result in short-sighted and imbalanced ministry. Always ask, “How does Scripture provide clarity and coherence to this person’s struggle as a body-soul image bearer?” But do so, making sure that you have sought to understand the struggler’s experience as well as possible.
Can you tell a story that illustrates the balanced approach you are advocating in the book?
I knew a man in my former church who struggled with paranoid schizophrenia. Despite the use of multiple medications, he continued to have bouts where accusatory voices filled his head, telling him that he was worthless and that he ought to kill himself. What did he need? Fine-tuning of his medications? Certainly that was something important to pursue, given the complexity of his psychoactive medical treatment. But I think what he also (and perhaps especially) needed at those times was a friend. A friend who would listen with compassion and patience. A friend who would take seriously the impact of those demeaning and frightening voices in his head. A friend to remind him of God’s favor, care, and presence in his experience of isolation, confusion, and loneliness. A friend who would pray for him and read the Psalms with him. A friend who would highlight that, in Jesus, nothing could separate him from the love of the Father (Romans 8:38-39). A friend who expected both personal and corporate benefit from having this man as a part of the body (1 Corinthians 12:21-26). You can be that friend. I can be that friend. And that’s apart from having any particular medical expertise with schizophrenia (which of course he needs as well). There’s the balance: by all means seek psychiatric input/medication when it seems justified but approach the person with biblical categories in mind, confident that God speaks into the experience of suffering.More info here
Discover a biblical and scientific framework for grappling with the role of psychiatric medicine in the lives of Christians. Draw on the experience and wisdom found here to equip wise and compassionate communities of counselors, helpers, families, friends and churches. This compact and thoughtful resource provides a wise, balanced approach toward dealing with mental health issues.
“Michael Emlet has nailed it! Finally, we have a medically informed and biblically wise approach regarding what we really know and don’t know about psychiatric diagnoses and medications. We need this holistic aim in ministering to spiritual, emotional, and biological care for those who are suffering. This book is both fascinating and succinct and I will be recommending it often.” – Aimee Byrd, author of Housewife Theologian, Theological Fitness, and No Little Women
“I have found nowhere in all my training or reading a more helpful tool for me as a pastor to undertand the complexities of psychiatric diagnoses and medicinal prescriptive practices from a Scriptural perspective.” – Joseph Novenson, Senior Teaching Pastor, Lookout Mountain Presbyterian Church, TN
“Wisdom is the ability to take complex human experiences and untangle the knots. The painful human struggles that are given psychiatric labels and psychoactive medications perplex us all. Mike Emlet untangles the knots. He offers a lucid and humble understanding that will make you think. He commends practical and gracious ways forward that will help you care.” – David Powlison, Executive Director, CCEF
“The relationship between the spheres of the medical and the spiritual in pastoral care can be an extremely tricky one to navigate especially for pastors with no medical training. That is why this clear and concise book by Mike Emlet is so important. Mike brings his medical expertise and his experience of Christian ministry to bear upon a field that will inevitably cross the path of many Christians. This is a small book but one that should be on the shelf of all those involved in pastoral care.” – Carl Trueman, Professor of Church History, Westminster Theological Seminary
Publisher: New Growth Press
Publication Year: 2017
What do you think when someone you know is diagnosed with a psychiatric disorder? Or has started to take a psychoactive medication? Do you say to yourself, “Finally, he is getting the help he really needs!” Or do you feel skeptical about either the diagnosis or the solution (or both), and wonder if what the person really needs is simply to trust in Jesus more?
It doesn’t take too many conversations in the church to realize that there are widely divergent views regarding the diagnosis and treatment of mental health issues. Like many, you may find yourself falling into one of two camps. Let me call this the Goldilocks Principle. What do I mean?
You may be someone who is “too cold” toward psychiatric diagnoses. Perhaps you’re highly suspicious of using these labels. You believe that they are secular understandings of the person that compete with biblical categories and solutions. At best you don’t think they’re helpful, and at worst you believe they are harmful and dehumanizing.
Or perhaps you are “too warm” toward psychiatric diagnoses. You may embrace them as nearly all-encompassing explanations of the person’s struggle. You may gravitate toward medical solutions and diminish the relevance of the biblical story for these particular problems. But is there a third way, a balance between these two extreme tendencies?
Similarly, you may be “too cold” toward psychoactive medications. You’re extremely wary of ever using them. If you’re honest, you believe that Christians really wouldn’t have to take psychiatric medication if their faith were robust enough. And what about those side effects—why risk it? Or you may be among those who are “too warm” toward psychoactive medications. If a Christian has no problem using Tylenol for a headache, why shouldn’t she use an antidepressant when she is depressed? And about those side effects—they are invariably worth the benefit. But is there a third way, a balance between these two extreme tendencies?
That is one major goal I had in writing Descriptions and Prescriptions: A Biblical View of Psychiatric Diagnoses and Medications: to help you move from either extreme—too cold or too hot—toward a view of psychiatric diagnoses and medications that is hopefully “just right.” Perhaps you don’t tend toward one of these extremes but you are looking for the biblical and scientific framework that allows you to maintain that third-way position. That’s exactly what I hope this material will do. I want to take seriously what help psychiatric categories and medications provide but also recognize their limitations.
There is no doubt that many people suffer greatly with emotions and patterns of thinking that bring grave hardship to them and to their loved ones. The pressing issue is how best to know and understand their struggles. And then, having understood, how best to provide compassionate and wise help. After all, we are called to “bear one another’s burdens and so fulfill the law of Christ” (Galatians 6:2). Psychiatric diagnostic classification and psychoactive medications provide a way to understand and help those who are burdened in particular ways. This book assesses the limitations and benefits of understanding and helping people using that lens.
I have written this resource primarily for helpers in the church—pastors, counselors, elders, deacons, youth workers, men’s and women’s ministry coordinators, small group leaders, and other wise people who may not have a formal title or ministry job description but are actively engaged as intentional friends in one-another ministry. You are on the front lines of pastoral care and, no doubt, you have cared for and will continue to minister to people who struggle with mental anguish, who are diagnosed with psychiatric disorders, and who may be using or have questions about psychoactive medications.
This resource is in no way meant to be a comprehensive guide to helping those diagnosed with a mental illness, nor will it discuss the multifaceted approaches that exist for helping those who are suffering in this way. I simply want to provide a foundational biblical framework for understanding psychiatric diagnoses and the use of psychoactive medications. Ultimately, I want this book to help you to think wisely and compassionately about these struggles so that you are just a bit more equipped for this important work of burden-bearing and counseling.
(Adapted from Michael R. Emlet, Descriptions and Prescriptions: A Biblical Perspective on Psychiatric Diagnoses and Medications [Greensboro, NC: New Growth Press, 2017],
Alasdair Groves and Mike Emlet sit down and talk about some of the best aspects of psychology.
As Christians, it can be hard to know what to think about the diagnoses the mental health world uses to describe troubled people. Are they useless because they are based on a secular view of mankind? Or are they helpful because they offer researched and detailed descriptions of common problems? Dr. Emlet offers a biblically informed perspective for our ministry that helps us to be neither “too cold” nor “too warm” toward these classifications.Download Additional Resource
In this podcast, Dr. John Applegate, a board certified psychiatrist who currently practices in Philadelphia, shares how he balances living in the two worlds of Biblical Counseling and Psychiatry. Dr. Applegate addresses some of the typical questions that Christians face when approaching the topic of medication.
Dr. John Applegate
Have you ever met an elder in a Presbyterian church who is also a practicing psychiatrist and a self-confessed CCEF addict? In this podcast, Dr. John Applegate, a board certified psychiatrist who currently practices in Philadelphia, shares how he balances living in the two worlds of Biblical Counseling and Psychiatry.
Dr. John Applegate
It’s the year 2063. A New Yorker article titled “The Last Normal Person in the United States” highlights the life of a certain E. Piphany. As far as experts know, she is the last living person not found to be diagnosable by the recently released DSM-9. Amazingly, she alone does not fall into one of the 5,146 conditions currently described in the DSM.1 Which, ironically, makes her quite abnormal . . .
OK, I admit I’m being a bit snarky. No one, least of all thoughtful and caring psychiatrists, wants the trend of multiplying diagnoses to continue to this hypothetical endpoint. In fact, the fifth edition of the DSM unveiled last week contains a few less diagnoses than its predecessor. But the release of the DSM-5 after more than a decade of debates and revisions still pushes us to ask hard questions.
Even insiders within the psychiatric community have raised concerns about over-diagnosis and the way we classify mental disorders. See for example the recently released Saving Normal, by Dr. Allen Frances, who chaired the Task Force that created the DSM-IV. The subtitle says it all: “an insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life.”
What I hope to do in this post is to briefly orient readers on how to think about psychiatric diagnoses and what role they should, and should not play, in biblical counseling.
DSM categories are descriptions not explanations
It’s important to remember that psychiatric diagnoses are descriptions of a struggling person’s thoughts, emotions, and behaviors; they are not explanations for them. They tell you what but not why. The DSM admits that. So what’s the problem? What’s wrong with giving a name to a set of symptoms? Isn’t that generally how the diagnostic system has historically evolved?
The problem is this: giving a summary label to a set of symptoms gives the appearance of explanation, particularly in our medicalized culture. It suggests that each diagnosis is a discrete and largely brain-determined entity, and there is simply little evidence for that except in the major psychiatric categories of schizophrenia, bipolar disorder, and severe depression. Even in these entities, we must realize the complex interaction of multiple factors.
Knowing that these categories are primarily descriptive (and not definitive explanations) should reduce any intimidation biblical counselors might feel about them. Don’t be scared off by a diagnosis! Don’t assume that you can’t provide what the person really needs. It may be important in certain cases to involve others, including psychiatrists, in the care of your counselees. But you can do the hard work of pressing beyond the symptoms to explore a variety of potential contributors to the person’s struggle. Spiritual, physical, relational, situational, and cultural factors are all important to probe and address. Doing so will help prevent the uniqueness of individuals from being swallowed up by a clinical description.
Descriptions can be helpful
On the other hand, do not simply dismiss the diagnostic entities in the DSM as invalid. Realize that they describe a subset of people who are struggling in real ways. Don’t allow a critique of the DSM to become a critique of the suffering people described in its pages! Rather, listen and learn—from your counselees—and from those in the psychiatric community who are “case-wise” and have devoted their lives to helping people who struggle in very particular ways.
But then, prayerfully seek to interpret people’s lives through the pages of Scripture. If it’s true that Jesus comes to make his blessings known “far as the curse is found,” then we need to wrestle with what the outworking of redemption looks like in concrete ways in the lives of those who struggle with psychiatric problems.
The current description-based system of psychiatric classification seems to be here to stay, at least for the foreseeable future. The DSM-5 gives no epiphanies from the secular mental health community, which is still at loggerheads regarding how best to classify psychiatric problems. We Christians must remain intent on faithfully and creatively bringing the riches of redemption in Christ to the people before us, whether diagnosable or not.
1 Diagnostic and Statistical Manual of Mental Disorders. This is the official diagnostic manual used by mental health professionals and published by the American Psychiatric Association.
A friend sent me a copy of Jon Ronson’s book, The Psychopath Test: A Journey through the Madness Industry. He just wanted my opinion of the book, I think. (But it did remind me of another friend who gave me a six-pack of Tic-Tacs for my birthday.)
The book is a very interesting journey. By page 97, you finally get to the 20 items of the psychopath test. By page 168, you are screening most of the people you know according to these items—I identified at least two, no active pastors (the one I considered had retired), no CCEF colleagues, but I was certainly looking forward to identifying many more with my new found knowledge. By page 211, I realized that I had just fallen prey to that diagnostic fever you get when you learn a new way to identify behavior and are suddenly on the prowl for it everywhere. By the end of the book I came back to sanity: there are some truly nasty people out there who are devoid of compassion, but there are not very many, and I do not have to keep looking for them.
Psychopaths, also known as sociopaths, are described as charming, manipulative, and lacking conscience, empathy, guilt and remorse. The well-known ones are men. The checklist, which is not officially sanctioned in modern psychiatry, also includes need for stimulation and proneness to boredom, pathological lying, shallow emotions, promiscuous sexual behavior, unrealistic goals, inveterate blaming, and unstable relationships. Among the most eerie descriptions is that they have no warm emotions but study the emotional responses of others so they can use those emotions to their advantage. Now you are probably thinking about some people you know too.
No empathy and compassion
It is the matter of empathy and compassion that raises a question for biblical counselors. Psychopaths do register very little empathy and compassion as measured by amygdala functioning (the amygdala is an area of the brain that seems to be involved in emotions). Does this mean that someone can be neurologically wired to be unmoved by the pain and suffering of other people? And does this mean they are unable to change?
Here is a proposition to consider: compassion and empathy—the ability to enter into a person’s world and be moved by it—are unequally distributed throughout the population. Some people are good at it, others are not so good. I know people who are moved, even disrupted, by the day’s news stories and often pray for people they have never met. And I know others, who are barely moved, even by tearful pleas for engagement from loved ones. The range is broad, even in the non-psychopath population.
Is there hope?
Can those who, by nature, are less emotional, less empathic and less compassionate grow in such things? After all, some physical impairments never improve, and we do not expect them to. For example, we do not expect someone with a damaged spinal cord to be healed, even if the person has a growing relationship with Christ. But that’s okay because God does not say we must walk. He does, however, call us to grow in compassion (e.g., Col. 3:12) and with any calling he provides grace to fulfill it.
So the answer is clear: constitutionally passionless people can grow in compassion (though they might never be as proficient as some would like). They might never have strong emotional responses to the joys or miseries of others, but they can learn how to rejoice with those who rejoice and mourn with those who mourn. The criteria is not how brilliant they are in their compassion; it is their humility and willingness to grow that is important. If there are neurological predispositions, they set limitations but these limitations are malleable.
The “up side” of the fear of man
There is one other theme in the book that interests us. Ronson, at times, wonders if there is an inner psychopath in him, and leaves readers wondering about themselves. That is: Am I a psychopath? Ronson rejects the diagnosis for himself because he is so prone to anxiety. To be more specific, he cares what people think of him. This means that we have finally found something good about the fear of man! Though we want to do battle with it, be encouraged that, as long as the fear of man is palpable in our life, we are not closet psychopaths.
CCEF likes science. Of course, everyone likes science—there is no news in that.
To be more specific, we like the disciplines that carefully observe human behavior. These include anthropology, medicine, psychiatry, sociology, literature, history, psychology…and another dozen or so. If someone is looking closely and carefully at people, we are interested.
But closely and carefully are the operative words here. All science is not equal. Good science precludes a rush to judgment. It takes time and requires humility.
Arrogant science, humble science
Scientists, as they mature, are increasingly discriminating about their science. Here is one expression of that maturity: the more audacious the claim, the more suspicious we become. For example, did you know that the gene for mania was discovered about twenty years ago? It was announced on the nightly news with fanfare. The problem was that no one was ever able to replicate the study. All of the sciences, especially those that consider human beings, need other careful observers to verify their claims. This means that a mature scientist will have a wait-and-see approach to most research, at least until careful reviews can be made of a number of similar studies. Even then, we know that careful reviewers can come to different conclusions.
Alfred Adler said it well; the science of human nature compels us to modesty.
Qualitative science, quantitative science
Scientists, as they mature, also notice that there are many ways of doing careful observations. Research can use surveys, analysis of a recorded conversation, psychological tests, outcome measures, EEG changes and many other methods. One way to organize these approaches has been to place them on a continuum from qualitative to quantitative. Qualitative studies focus on a few individuals and look in depth. Quantitative studies look at one particular dimension across a large number of people and try to discover general trends.
While both kinds of studies are useful, I would suggest that counselors who focus more on overt behavior, such as behaviorists or cognitive-behaviorists, are drawn to the quantitative studies. Those who believe that there is a lot going on within the person, such as the psychodynamic approaches, tend to prefer the qualitative studies. CCEF, I think, seems to prefer the qualitative approaches that carefully describe a single subject’s experience because it suits our understanding of human nature, though we appreciate many other means of observation.
Not anti-science, science in context
CCEF is occasionally identified as anti-science, especially psychological science, but this is not the case.
We are interested in careful and modest science. When we find it, we work to understand it as part of a larger reality. By that I mean, once we have a reliable observation, we want to “retell” that observation in light of Scripture. [i] We believe this does not diminish the value of useful scientific observation but instead places it in a richer and more meaningful context.
[i] Our 2011 conference on psychiatric disorders would be an example of this retelling.