Grace Community Church pastor John MacArthur generated headlines and social media posts when he recently stated in a public forum that “the major noble lie is there is such a thing as mental illness. . . There’s no such thing as PTSD. There’s no such thing as OCD. There’s no such thing as ADHD. Those are noble lies to basically give the excuse to, at the end of the day, to medicate people.” MacArthur has doubled down on this view in a subsequent sermon and in a lengthy blog post in in which he refers to my specialty of medical practice, psychiatry, as a “formidable adversary to Scripture.”
As a Christian and a psychiatrist, I took notice.
It is tempting for psychiatrists like me simply to dismiss MacArthur’s criticisms of psychiatry as oversimplistic and wrong. To be clear, many of his claims are oversimplistic and wrong. In his recent blog post he dismisses the diagnoses of attention deficit/hyperactivity disorder (ADHD), bipolar disorder, schizophrenia, depression, and post-traumatic stress disorder (PTSD) and asserts that medications commonly prescribed for these conditions do more harm than good.
These are sweeping and controversial claims that require evidence, but for the most part MacArthur provides no evidence, instead selectively quoting psychiatry-skeptical journalists and researchers without any effort to understand the most recent scientific debates. To provide one example, among many: after questioning the diagnosis of bipolar disorder, MacArthur states that the drug lithium “left. . .patients worse than it had found them,” and then quotes from a nearly three-decade-old (1997) scientific review that questions lithium’s therapeutic benefit. He ignores, though, a number of more recent scientific reviews that demonstrate lithium’s efficacy for bipolar mania and for prevention of recurrence of mania. All to say: MacArthur has done little to engage psychiatric science and his readers and hearers should not assume that his scientific claims are trustworthy.
But focusing on MacArthur’s sloppy handling of the empirical scientific literature is beside the point. I suspect that MacArthur would not like psychiatry even if all of the treatments that we offer were remarkably effective with few harms or side-effects. This is because of his longstanding embrace of what we might call the “medical-moral divide,” which is embraced not only by MacArthur but by many in the evangelical Christian world.
MacArthur succinctly explains the medical-moral divide in his recent blog post. “The term ‘mental illness,’” he argues, “illegitimately assigns the status of a disease to human behavior that may be abnormal but not necessarily ‘phenomena independent of human motivation or will.’” Problems that people face, he argues, are often “not medical but moral. The mind is different from the brain. By scrutinizing the place of psychiatry and psychopharmacology among the sciences, and popular psychiatric diagnoses like ADHD, bipolar disorder, schizophrenia, depression, and PTSD, we shed light on the danger modern psychiatry has unleashed on our society by confusing the moral for the medical.”
The medical-moral divide provides an easy way to make sense of why people struggle. It also provides clear rules for who has the authority to help. Some problems—the ones that can be clearly linked to bodily problems—are medical. In his recent sermon, MacArthur names central nervous system infections, seizures, tumors, and traumatic brain injury as brain problems that are clearly medical and that warrant the intervention of clinicians. But other problems—the ones that cannot be clearly explained by bodily problems, and/or that are connected intricately to human action and motivation—are presumptively moral, not medical. In MacArthur’s view, clinicians have no legitimate authority in the realm of the moral. That is the pastor’s realm. Pastors should not treat clearly medical problems (like seizures) as moral problems. But in the same way, clinicians should not treat moral problems (like depression) as medical problems. To do so, at least in the context of psychiatry, is to foster a “dangerous dependency on drugs.”
To be fair, it is not only pastors like MacArthur who embrace the medical-moral divide. Advocates and clinicians in the mental health world do also. Sometimes, in an effort to decrease stigma and to assure people that living with a mental illness is not their fault, advocates will state that mental illness has nothing to do with character, weakness of will, or anything else that sounds moral in nature. In this way of thinking, mental illness has nothing to do with the choices that people make or with the patterns of these choices over the course of a life. It is just something that happens, possibly because of genetic or biochemical factors or possibly because of circumstances and events over which one has little or no control. More often, mental health clinicians and researchers simply find ways to ignore the dimension of the moral by labeling people’s unwanted experience and behavior as “symptoms,” aggregating those symptoms into diagnoses, and using technologies to treat the diagnoses, with the goal of treatment being symptom reduction.
In this mechanistic way of thinking about human experience, it is remarkably easy to treat mental disorders without ever facing questions of moral decision-making. Psychiatric treatment becomes a closed loop of using medications and other technologies to decrease symptoms of disorders that are defined by symptoms. In that way, it’s disturbingly easy for a psychiatrist to treat someone for a mental illness without ever learning very much about the details of their life.
Most clinicians, most pastors, and most people, however, know that things are rarely that simple. Mind, body, thought, feeling, emotion, and action are all inextricably linked and all tied up with each other. Mental health problems like depression and anxiety have to do with the body and may in some cases even originate from conditions of the body. At the same time, though, they are often related to the choices that people make over time and the patterns of how they engage in the world. Some choices and patterns of living tend to perpetuate and exacerbate problems over time. Other choices and patterns of living tend to ameliorate problems over time.
Nothing is ever certain. Someone can be doing everything that they can do, and more, and still not feel any better. It is therefore critically important not to blame people for their unwanted experiences and to intensify shame and stigma by telling them, as MacArthur does in his sermon, to “get a grip on your life.” But neither is it helpful to lead people to think that they have no capacity to act meaningfully in response to their problems. How we engage in relationships or isolate, accept unwanted experience or avoid it, manage shame or deflect it, seek help or refuse it, are all going to affect how the experience of any mental health challenge unfolds over time. Mental health problems are not only moral problems, but they have an inextricably moral dimension because they are affected by how we respond to challenges and how we act toward purposes and goals that we understand (perhaps mistakenly) to be good. It is not tenable to think about most forms of psychological suffering without thinking about the way that someone engages and lives their life and about the norms and practices of the communities in which they live.
But mental health problems are also medical problems, in the sense that the logic and practices of psychiatry, psychology, and the other mental health care disciplines are deeply helpful for understanding them and for illuminating helpful paths forward. Mental health work is moral guidance and care, just as it is medical guidance and care. Good clinicians must be wise and knowledgeable. (For that matter, as any primary care clinician knows who treats patients with diabetes, hypertension, low back pain, or a host of other chronic medical conditions, a great deal of medical guidance is also moral guidance. It might be known as behavioral counseling or health education, but it is still moral guidance.)
Does this mean that MacArthur is right and that psychiatrists and other mental health clinicians should get out of the way and leave counseling to pastors and to ordained biblical counselors? That would be a profound mistake. Practically, it would mean forgoing the wisdom and experience of many skilled clinicians who have spent years learning how to help people in distress. Biblically, it would be a denial of the way that the whole church is called to minister to the needs of those among it. In Romans 12, Paul reminds Christians that we are “members one of another” (12:5). Some Christians have ministries of prophecy, service, teaching and leadership, and must exercise those well. Others have ministries of mercy and paraklesis (12:8), from the Greek verb parakaleo, a term that is expansive enough to be translated as encouragement, consolation, exhortation, strengthening, and comfort in its many uses in the New Testament. The exercise of ministries such as paraklesis is in Romans 12 clearly not restricted to the ordained pastors of the church. It is exercised by the whole church, the body of Christ operating as a corporate body in which individual members play important roles in the body’s edification and sustenance.
Christians who live with mental health challenges deserve better than pastors and clinicians who embrace the medical-moral divide and who use that divide to stake out their professional turf. Rather, the church needs pastors and clinicians who are willing to exercise their office faithfully, who will use their wisdom and skill to encourage and edify those who are struggling, and who will remember that those in their care are not malfunctioning machines but rather wayfarers who are on a journey to God. Pastors and biblical counselors have an important role to play, but so do psychiatrists and other mental health clinicians.
As a psychiatrist I have learned to prescribe medications for mental health problems, and I seek to do that in a way that facilitates rather than hinders my patients’ capacities to form healthy relationships, to act for meaningful purposes and goals, and to understand their life as a journey. I have also learned, however imperfectly, how to talk with trauma survivors about their most painful experiences, how to help those who are seriously considering suicide to stay safe, how to encourage those who are addicted to substances to seek appropriate help, and more. All of these are forms of moral guidance, but they are practices and skills that I have learned as a medical practitioner. In all of them, I would like to think that I am participating in a small way in the church’s ministry of paraklesis.