BCC Staff Note 1: You’re reading the third in a five-part BCC Grace & Truth blog series on biblical counseling and depression. Few issues are more painful. God’s Word provides us with wisdom for addressing depression with compassion so we can care well and wisely. You can read Part One by Andy Farmer here and Part Two by Hayley Satrom here.
BCC Staff Note 2: This post by Dr. Kellemen was the first of several posts on his Changing Lives blog site at his RPM Ministries. Dr. Kellemen collated all of his posts into a free 24-page PDF that you can download at Depression, Medication, and Biblical Counseling. Dr. Kellemen has just added a new post in this series that you can find at Reflections on How Christians Make Decisions about Counseling.
The Battle with Depression
My friend, David Murray, recently shared an important blog post entitled, I’m Thinking about Going to the Doctor for Depression Meds.
David began his post with the following vignette.
“Someone recently told me that he had finally and reluctantly decided to go to the doctor about his painful and debilitating depression and ask about going on meds. I knew this person had tried every other spiritual and commonsense remedy but was simply not getting better.”
David then wrote:
“With his permission, here’s the advice I gave him plus another few points I’ve thought of since. Perhaps it will help others in a similar situation.”
A Mutual Desire for a Compassionate and Comprehensive Response
Knowing David, his writings, and his response in his post, I know it is David’s desire to provide a compassionate and comprehensive response to his struggling friend. David and I share that desire.
From the post and from knowing David, it seems to me that David had two primary audiences in mind:
- Any person debilitated by depression who also might feel guilt or shame over taking anti-depressant medication.
- Any organizations, churches, or individuals who might contribute to this shame and guilt through an “anti-medication mindset.”
Audience matters. So, I believe I “get” where David, was going. And there is much to appreciate in his post—especially David’s desire for a compassionate and comprehensive response.
How we respond to people struggling with depression and struggling to know whether or not they should take anti-depressants is a serious and vital issue. That’s why I am making the time to ponder what I believe a compassionate and comprehensive response might look like…
Toward a Compassionate Response
David began his response with these compassionate words.
“So sorry to hear you are still suffering in this way.”
Who among us would say anything less?
I might say more… I might gently probe what the depression has been like, especially of late. I might gently probe what the decision-making process about medication has been like—including any conflicted thoughts and feelings. Still, “So sorry to hear you are still suffering in this way,” would no doubt be a compassionate place to begin.
David then shares further counsel.
“But I’m very happy to hear that you are going to the doctor’s today. I know you are nervous but I wouldn’t worry about the visit—you will probably be just one of a dozen depressed people the doctor will see that week. He’s used to it. I’m glad you are willing to consider the meds.”
I could hear myself saying something similar, though I would not limit the potential treatments only to anti-depressants. I would encourage my friend to discuss openly with his doctor his physical symptoms, emotional moods, and potentially appropriate medical tests and medicinal treatments.
What Infuses Hope?
David then shares:
“The side-effects are usually minimal for most people and are often greatly exaggerated by opponents of medications.”
I think I understand David’s motivation in the first part of this sentence. He’s addressing someone who is apprehensive about psychotropic medications, and he wants to assure the person that they are safe and helpful.
However, the research does not support the statement that, “the side-effects are usually minimal for most people.” See Charles Hodges, MD, Good Mood Bad Mood and the extensive research he collates, as well as Saving Normal by psychiatrist, Allen Frances.
I believe it is compassionate to share honestly the research facts about potential side-effects and also about efficacy (effectiveness). I have seen far too many hurting people take psychotropic medications with unreasonable/unrealistic expectations. When side-effects do come and/or when moods do not improve, they can become hopeless…because of false hopes and unrealistic expectations about medication.
For those of you reading this post that have taken anti-depressants and experienced few side-effects along with improved moods, I truly thank the Lord. However, we must be careful not to extrapolate too much or too far from our individual experiences.
Sadly, the research indicates (and many personal testimonies concur) that for a significant percentage of people the side-effects can be significant and the effectiveness of anti-depressants can be insignificant.
I want to give hope—but not false hope. I want to encourage people to make an informed decision. That, to me, is compassionate.
Are You an Opponent of Medication?
Perhaps you are wondering if I am among those who greatly exaggerate side-effects because I am an opponent of medication.
No. I am not.
Nor is the biblical counseling movement. In the first Biblical Counseling Coalition book, Christ-Centered Biblical Counseling, a NANC (now ACBC) Fellow shared his testimony about having made the decision to take anti-depressant medication. None of the leading biblical counseling groups such as the BCC, NANC/ACBC, CCEF, or ABC are “opponents of medication.” Biblical counselors are proponents of compassionately encouraging people to make informed decisions about comprehensive care.
On a church level, I have pastored three churches and been an elder or lay leader at several others. I have not seen church members discouraging people from considering anti-depressants or shaming people for taking them. I can’t extrapolate my experience to others. I know it happens in some churches. That is sad.
What Potential Audience Do I Most Need to Be Concerned About?
This leads to an important question we must consider:
“What potential audience do I most need to be concerned about when I respond to someone thinking about taking psychotropic meds?”
I assume that as David penned his post, he was picturing a gathering dark cloud of opponents—counseling organizations, churches, or individual that are anti-medication.
I picture a very different audience. I picture an audience that minimizes matters of the soul, or even denies matters of the soul. The consistent message that concerns me is the one coming from the world to the church: “We are only bodies.” This materialistic worldview is “anti-soul” with the result that all hope is placed in biological cures. The result is tragic, as Dr. Frances notes: the under-treatment of the truly ill and the overtreatment of the basically well.
I’m not saying David believes the body-only, materialistic view. I know he does not.
I am saying that our perceived audience makes a huge difference. And the perceived threat makes a huge difference. Is the greatest threat from some people in the church who are opponents of psychotropic meds? Or, is the greatest threat from the world and its materialistic worldview?
David was giving person-specific counsel. Perhaps in this person’s case, David perceived that the greatest threat was from anti-meds folks. I respect that.
But David said he wanted his post to help others also. I applaud that. So, my question is, “Which ‘voices’ are most prevalent? The voices of the anti-medication folks? Or, the voices of the world’s anti-soul folks?”
At the very least, wouldn’t compassionate counsel respond to both voices, saying something like:
“I applaud you for going to a doctor, talking openly about your symptoms, discussing possible physical causes for your moods, and whether anti-depressant medication could be appropriate in your situation. When you go, I would encourage you to ask your doctor some specific questions about potential side-effects of anti-depressants—so you can make an informed decision and so you can be prepared if they occur. I’d also encourage you to ask your doctor about what expectations you might want to have about the likely effectiveness of anti-depressants in helping you with your moods.”
I would not add, “The side-effects are often minimized and the effectiveness greatly exaggerated by those with a materialistic worldview and those who benefit greatly from the sale of psychotropic medications like the medical-pharmacological-industrial-complex.” Just as I would not add that side-effects “are often exaggerated by opponents of medications.”
There would be an appropriate time for this important worldview conversation. However, when talking with a depressed friend, I would want to avoid pejorative statements about philosophical opponents.
Toward a Comprehensive Response
There are many indications in David’s post that he is concerned with a comprehensive response to depression. David notes that this person had tried “every other spiritual and commonsense remedy.” David also addresses practical issues about TV watching, exercising, eating and sleeping well, resting, therapy, talking with a pastor, maintaining Christian fellowship, Bible reading, and prayer. David discusses biblical themes like hope, suffering, God’s sovereignty, and sanctification.
There is no doubt that David wants to encourage a comprehensive approach to addressing struggles with depression. So do I.
Yet, there is a major area of counsel where David and I would part company. David says to his friend:
“Given what you’ve told me about your state of mind, you should ask your doctor about ongoing counseling, preferably from someone with expertise in CBT (Cognitive Behavior Therapy). That will help you re-train your mind/thinking patterns for long-term recovery. If it was a Christian counselor, that would be even better, but make sure they are trained in CBT.”
It appears to me that in David’s mind CBT (Cognitive-Behavioral Therapy) would be comprehensive therapy. I disagree.
Secular CBT Is Not Comprehensive
I was surprised by David’s encouragement to his Christian friend to see someone, even a non-Christian, with expertise in CBT. Granted, David did say that a Christian counselor practicing CBT would be “even better,” but there is clearly a recommendation to consider seeing a non-Christian counselor practicing CBT.
This seems inconsistent for David, who recently authored the book, Jesus on Every Page. David has a passion for a Christ-centered, gospel-saturated, grace-based approach to everything in Scripture and everything in life. So do I.
The non-Christian practicing CBT is not going to be concerned about gospel-saturated living, Christ-centered thinking, or a grace-based relationship to Christ. His belief system, by very definition, is going to be, at best a-Christ—without Christ. Theologically, it would be even worse—anti-Christ.
I understand common grace. I understand that the image of God is depraved, but not eradicated, in the non-Christian. I also understand, and I know David does, that the fallen mind is not Jesus-shaped.
When a depressed friend, counselee, or church member comes to me, and I want to point them toward comprehensive care, I am not going to point them toward a non-Christ counselor (not just “non-Christian” but “non-Christ”). That non-Christ counselor cannot offer comprehensive care. How can care be comprehensive when Christ’s gospel of grace is not the center of that care?
Christian CBT Is Not Comprehensive
I also do not believe that “Christian CBT” is comprehensive. Admittedly, I do not how David is defining “Christian CBT.” But let’s take the phrase “Christian CBT” at face value.
It is a Christian whose therapy model focuses on cognitive and behavioral matters. Even apart from issues relative to integration or non-integration of secular concepts, CBT is far from comprehensive.
We are not only cognitive beings and behavioral beings. We are, at the very least:
- Everlasting Beings: Created by God to live through and for God by grace.
- Socially Embedded Beings: God designed us to be embedded in, impacted by, and influenced by our cultural, social setting.
- Embodied Beings: God designed us as complex mind-body, soul-body beings.
- Emotional Beings: God designed us to feel and experience life deeply.
- Volitional Beings: God designed us with the capacity for behaviors and also with the capacity for motivation—purposeful behavior.
- Rational Beings: God designed us with the capacity to think in stories, images, and beliefs and we can do so either wisely or foolishly.
- Relational Self-Aware Beings: God designed us with the capacity for self-awareness, which as Christians means that our identity is in Christ.
- Relational Social Beings: God designed us so that it is not good for us to be alone and so that we could mutually love one another sacrificially.
- Relational Spiritual Beings: God designed us so that the holy of holies of our soul is our capacity for relationship with God. We are worshipping beings.
Even in this brief summary of comprehensive care, it is evident how incomplete, inadequate, partial, and insufficient “Christian CBT” is.
So, rather than giving counsel that tells my depressed Christian friend to ask his doctor for a referral to a non-Christian counselor or a Christian counselor who practices CBT, I would say something like:
“Given what you’ve shared with me about the state of your body and soul, in addition to seeing your doctor, I would encourage you to connect regularly with an equipped, compassionate biblical counselor who practices comprehensive, Christ-centered, gospel-based, grace-focused biblical soul care. As you meet with this Jesus-focused counselor, I’d encourage you also to embed yourself in your local church—in the Body of Christ. You are hurting right now, and Christ does not want any of His children suffering alone…”
My prayer for my friend would be that he find Jesus-care—care from Jesus, from a Jesus-like counselor, and a Jesus-like church as he decides if anti-depressants would be a part of that compassionate, comprehensive care. My prayer would be that he find a Jesus-like counselor—one who is full of grace and truth, one who is richly, robustly, relational, one who cares compassionately and comprehensively.
Join the Conversation
A friend says to you, “I’m thinking about going to the doctor for depression meds.” What would your compassionate, comprehensive response sound like?