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Spiritual Wholeness

A New Vision of Human Flourishing—A Christian Approach to Mental Health with Duke University Psychiatrist & Theologian Warren Kinghorn

Episode Notes

Why do I struggle with mental health?

How do I respond to Christians who claim there's no such thing as mental illness?

What does my mental health diagnosis mean?

If you've asked any of these questions, you don't want to miss today's episode! Join me as I discuss these crucial topics with Duke University psychiatrist and theologian, Warren Kinghorn, a leading expert in integrating Christian faith and mental health.

Here’s what we cover:

  1. Does anxiety come from inside of me or outside of me? (7:22)
  2. The most important questions we must answer as human beings (11:03)
  3. What are the 7 benchmarks of mental health? (30:57)
  4. What is a Christian vision of flourishing? (34:27)
  5. Warren’s response to John MacArthur’s claims that there is no such thing as mental illness (41:08)
  6. How to think about diagnoses & what to look for in a clinician (46:23)

Find a full transcript and list of resources from this episode here.

Do you have questions for Dr. Alison?⁠ Leave them here.

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‍Thanks to our sponsors:

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Additional Resources:

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‍Related Episode:

  • Episode 45: Strong like Water—Finding the Freedom, Safety, & Compassion to Move through Hard Things & Experience True Flourishing with Aundi Kolber

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Music by Andy Luiten

Sound editing by Kelly Kramarik

© 2024 Alison Cook. ALL RIGHTS RESERVED. Please do not copy or share the contents of this webpage without permission from the author.

While Dr. Cook is a counselor, the content of this podcast and any of the products provided by Dr. Cook are not specific counseling advice nor are they a substitute for individual counseling. The content and products provided on this podcast are for informational purposes only.‍

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Transcript:

Alison: Hey everyone, and welcome back to this week's episode of The Best of You Podcast. I'm so glad you're here this week.

I'm so thrilled to introduce a brand new series called Therapists on Therapy, where I've invited some amazing thinkers and thought leaders at the intersection of faith and mental health to talk to us about current best practices in the field of mental health, as well as some specific areas of specialty that many of you have asked about–things you've struggled with in your own life or loved ones have struggled with. 

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I wanted to bring in some of the wisdom of the room to go deeper into some of these topics. And my goal is to equip us to understand how to advocate for ourselves, how to get the support and the help that we need. Life is hard. We are all facing a lot of challenges. I know so many of you, whether it's in your own life or whether you're parenting kids or whether you have friends or spouses who are going through hard challenges—You're trying to get to the root of the challenge that you're facing, and figure out the best way to get help through it. And in this series, I want to introduce you to some of the leading voices and the leading topics in the field of mental health so that together we can equip ourselves to become the best version of ourselves in partnership with God's spirit.

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If there is a specific topic you'd love for me to cover or a specific therapist you'd love for me to invite on for this series, please let me know. You can find me on Facebook or Instagram @DrAlisonCook and leave a comment for me under any post. I'll look for those there. You can also leave a review for the podcast. In that review, you can tell me a topic that you'd really love for us to cover during this episode. 

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Finally, you can send an email to info@dralisoncook.com and we'll get that there. And we're also going to link to The Best of You Podcast question form in the show notes. So wherever you're listening to this episode, go to the show notes and you'll see that link where you can leave a question for us. You might have a question for us that you want us to answer during this series, or you might want to let us know about a topic you'd really like for us to cover.

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To kick us off in this series,  I could not be more thrilled to have one of the world's foremost experts in the topic of Christian mental health,joining us for a conversation about what is mental health? How is it different from mental illness? How can we begin to move toward a picture of wholeness, a picture of health that applies to all of us?

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Every single one of us wants to be moving toward mental, emotional, and spiritual health. And what does that even look like, especially for those of us who are Christians who are seeking to follow Christ and incorporate our spiritual lives into our mental and emotional health?

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Dr. Warren Kinghorn is a psychiatrist and theological ethicist at Duke University. His work centers on the role of religious communities and caring for persons with mental health issues and how Christians in particular can engage in mental health practices. He is on faculty at Duke Divinity School, as well as on the faculty of the Department of Psychiatry at Duke University Medical Center. He is the co-director of the Theology, Medicine and Cultural Initiative at Duke Divinity School. And he practices psychiatry in the Durham VA medical center. Warren got his MD at Harvard university and his doctorate in theology at Duke university. He's brilliant. He understands the science of mental health, and he is a deep and faithful Christian.

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I loved this conversation with Warren Kinghorn. I'm always thrilled to find folks who are thinking on such deep levels about the intersection of Christianity and mental health. He has a brand new book out called Wayfaring: a Christian Approach to Mental Health Care. It's a fascinating, well-researched deep dive into the history of mental health in this country including some of the problems about how the field of mental health developed. It also includes a deep integration with Christian theology, spirituality, and practice. Please enjoy my conversation with Dr. Warren A. Kinghorn.

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Warren, I am so thrilled to have this conversation with you today. You are bringing such an important integration to light with this book, Wayfaring: a Christian Approach to Mental Health Care. One of the things I love, you argue that in light of the gospel, we see that mental health care at its best is not about fixing broken machines, but rather about attending and guiding wayfarers who are loved by God, who are on a journey to God, and who are invited by God's grace to freedom, wonder, rest, and loving relationship with God and others.

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I just, I loved that. That's the whole thesis of this book. We are not problems to be fixed. We are humans to be invited into a loving experience with God and with each other. And as a psychiatrist, as a Christian, there's a whole lot underneath that. I guess I wanted to start in the book, you spend a lot of time at the beginning talking about this medical model that psychiatry-to-date has really been a part of. What is that? What do we mean by that? And what are some of the issues with that, that you're trying to address in this book?

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Warren: First of all, Alison, thank you for having me on, and you so beautifully stated the central themes of the book. I do think that the medical model is tricky when we think as people of faith about flourishing and about mental health. I'm a psychiatrist, which means I'm a physician. I went to medical school, and I'm trained in medicine.

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I do believe in the goodness of medicine and of psychiatry, and there's ways in which thinking medically can actually lead us on the wrong track. There's a long history within modern medicine and also within psychiatry of thinking about the human being as a kind of machine, about the body as a complex machine, about the brain as a machine, about the mind even as a machine.

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And when things aren't going well, we sometimes think what's wrong is that the machine is somehow broken. There's something wrong in either neural circuits or in the brain or in the endocrine system. And we need to find what's wrong with the machine and find ways to fix the machine and to set it right again.

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But humans aren't machines. We're creatures and we're organisms. One of the things that I talk about in the book is the specific way that this machine way of thinking can show up in psychiatry. It's not always specifically related to thinking about the body being broken, but it has to do with how we organize our experience.

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So I'm a psychiatrist in the VA system. I see veterans and I'm really proud and honored to do that, but as a psychiatrist, when people come to me, they come with what we might consider unwanted experience or behavior. They're not doing well. They're having emotions they don't want to have. Their relationships are not going well. 

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In my clinic room, I listen to that and I say, oh, I now understand what's happening with you. These are symptoms. I rename the unwanted experience as symptoms. So the symptom might be lack of sleep or lack of interest in pleasurable activities. And then I aggregate those symptoms into diagnoses. 

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A certain number of symptoms over a certain period of time in psychiatry becomes a diagnosis, like major depressive disorder or ADHD or bipolar disorder. And then I can reach into my toolbox of evidence-based treatments and pull out treatments for this diagnosis. That could be a medication. It could be a referral for a form of talk therapy. It could be another kind of treatment. 

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I send the patient on, and then the patient comes back to see me a week or two or three or four weeks later, and I say how are things going? And in the medical model, if the patient comes back and they say my symptoms are improved, and I say great, the treatment's working and we're going to keep going with that–now there's a lot of good about that way of thinking. I want my patients to be in less distress. I want their symptoms to improve. 

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That way of thinking about mental health as symptoms that need to be improved, is one way of thinking about how we can develop new forms of therapy, but there's a lot that's left out with that as well. One thing that happens when we think about mental illness as this collection of symptoms that has to do with something that's broken in the body as a machine, is that it tends to focus attention on the inside. 

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We think that mental health problems are things that are inside us. They're internal to us. They're our unique problems. And we may not always focus on the relationships that we're part of, the communities that we live in, the broader culture that we live in. Another problem is that the focus of treatment is often on symptom reduction. So if I can prescribe a medication that is focused on symptoms and a patient says they're doing better, I think great, I'm doing my job as a psychiatrist. 

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What if that reduction of symptoms actually isn't helping the person to live more fully and wholly in the world and to experience a kind of fullness of life? Am I really doing my job? 

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People often think that the problem is that their brains are broken or their bodies are broken, and that leads people to think about biological treatments like medications as the first line of treatment. When maybe that shouldn't be the first line treatment–maybe talk therapy or other things should be first. 

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I think another problem is that that way of thinking often doesn't address the kinds of questions that we most need to answer for ourselves and with each other as human beings, which is, who am I? Do I matter? Am I loved? And what communities do I belong to or not? These are deeper questions that often can get ignored if we focus on this kind of mechanistic view of mental health treatment as managing symptoms.

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Alison: It's so profound what you're saying, especially from within the medical community. I know as an early therapist, training in a clinical psychology program, to your point, I remember a client specifically who was telling me all about her anxiety. She couldn't sleep, all the symptoms you're describing, that would classify as some sort of generalized anxiety disorder or specific anxiety disorder. 

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But as she told me her story, it turned out that her parents had kicked her out of the house at the age of 12, and that she was living by herself. She was 18 and having to support younger siblings. And I thought, of course you're anxious. Of course you're anxious. I write about this in The Best of You. As a human being, versus a therapist, the human being in me is saying, you need support. This is a community issue. The anxiety is not inside of you. 

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And that's what you're teasing out here. Seeing patients and then trying to figure out, what is actually the most helpful to this person in this situation? Is it a medical diagnosis that we treat with medication, or do we look at the whole context of this story? 

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Warren: And to be clear, when somebody comes in and they're really struggling with anxiety, they deserve and need care and help, and there's help for them. And that help may well be in medication. So medications can be very helpful as well as other kinds of treatment. But I think that it's important to think, what kind of picture are we looking at?

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Anxiety is a great example, but when I teach medical students and residents at Duke and my work as an academic psychiatrist, I often encourage them to think of what's happening with the patients for whom they care in two different ways. In my experience, it's really hard to keep these two things together at the same time.

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So this is a little bit simplistic, but I write about this in the book. One of them is what we might consider the “inside out" model of mental health problems, which is this basic idea that if I'm in distress, if I have anxiety, for example, then the problem starts from within me. It either starts from my genes or my neurotransmitters or my serotonin levels or maybe something deep inside my personality.

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Then that shows up in my relationships and in my community and in the way that I live my life. But the problem is on the inside. And it starts on the inside, and therefore I need to fix what's on the inside. Maybe things on the outside will get better. I encourage my trainees to think, what if we actually invert the view?

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What if we think of the primary problem not as something that starts on the inside of someone; maybe it starts in relationships or starts in the way that a community lives together or a school or a class or a church, or what if it has to do with our culture and being a place that there's so much uncertainty and fear and polarization?

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What if the anxiety that we feel is not something that starts from the inside, and shows up from the outside? It's something that's a reaction to very real challenges and stressors and trials that are happening all around us, and then it shows up on the inside of our experience, but also it marks itself in our bodies. We get tense; we start to have fight or flight responses. There's ways in which that affects us. 

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What if mental health problems are not problems on the inside but rather fundamentally problems of community and culture and relationship that then show up on the inside? How we respond isn't going to be like, how do I fix myself? It's going to be, how do I acknowledge what's happening around me and think about what that means?

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Alison: I love that. I want to pause here for a second. I love what you're saying. It resonates with my experience with clients. What does that mean then for how we approach care, if we're going to take into account the whole context? I know one of the things you talk about in the book is shame.

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That locating the disorder “inside the person” can really evoke shame. I'm imagining one of the ways this outside-in model is saying, this is a systemic issue. It's not your fault. Let's try to get to the root. I don't want to put words in your mouth, but how does it change how we approach our suffering and our clients who are suffering?

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Warren: Yeah, in part it has to do with not thinking that our struggles and our suffering are something that only has to do with us as individuals. We all become who we are in-relationship. We have an ongoing need for relationships, even if we don't necessarily always see that or acknowledge that or feel that in the same way.

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We experience it differently, but the way that we are together as human beings is really important. Much of our distress is a response, is a reaction, to very real things that are happening around us–to trauma, to stress, to violence. So the communities can either be accepting and loving or not.

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There's all sorts of ways in which we can respond. Social media, the way that we've become both polarized on social media and we're always thinking about, I'm not measuring up to others. My experience is that shame is a deeply important dynamic within a lot of mental health problems that's actually not talked about in that way, maybe as much as it should be.

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I think most broadly, and I love the work of Brené Brown on this, I love the work in the Christian world of Curt Thompson on this, but I think of shame as a kind of response that has to do with two ways of thinking. One is that I am not _______ enough, where the blank is whatever I perceive to be absolutely necessary to belong to a community that I really either want or need to belong to.

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I teach at a university, so that blank might be I'm not smart enough, I'm not well-read enough, I'm not social enough, I'm not orthodox enough, I'm not progressive enough, I'm not, all sorts of other things. That's the first thing. And the second, that because I am not _____ enough, when other people actually realize that, they will exclude me, and I'll no longer be welcome in this community.

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Shame is that fear that we are actually not enough for our communities and we're going to be excluded by them. And the natural response to shame, and we all feel shame at different parts of our lives and over the course of our lives, there's some unhealthy responses.

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We can try to block it out, and that doesn't help very much. We can try to numb our emotions through pleasure seeking behavior or substances or sex or lots of other things. We can shift it off by deflecting the responsibility to other people, which may be actually truthful in a way, but it doesn't necessarily help to deal with the dynamic.

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My favorite way of coping with shame over the years has been to work harder, to keep going, stay busy, keep achieving, so that I can convince myself and others that I am enough to be here, in whatever place this is. And that doesn't work well either. That's how people in mid-career, like I am, often get burnt out because they have worked harder and you cannot outrun shame forever.

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In the Christian world, the response to shame and I think even therapists would say this, is to accept it. To accept its reality, and to allow ourselves to take the risk to be vulnerable with ourselves and in relationships and in those communities. To realize that those shame-thoughts that we think we're going to be excluded may actually not be the case. To take the risk of showing up in vulnerable relationships. 

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As Christians, I think we have this incredible promise that no matter who we are, no matter what we've done, no matter how we've achieved or not, that God knows us and loves us and holds us and sees us as part of God's good creation. And that's such an incredible gift to us, because we come into this world loved, and nothing can ever take that away.

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Alison: I love that. It's beautiful that we have that resource as part of that shame resilience. What you would say to someone who is struggling with shame or is struggling with anxiety and has really felt like, “oh, this is something broken inside of me”. What would you say to that listener?

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Warren: To someone who's either struggling with shame, or with anxiety, or with anything else and thinks, oh the problem's me, then I think one is, don't try to fix it yourself. Bring that experience honestly to someone else, and for some people maybe that's not a professional. Maybe it's a trusted friend or a mentor. Maybe it's a pastor. There are lots of people who I think could help, but do consider bringing that into a relationship with a therapist and being open and honest about that.

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Frankly, when we're trapped in ways of thinking and feeling that have gone on for a while, and we think the problem is within us, it's almost impossible to talk ourselves out of that easily. Having someone else reflect our experience back to us to say, hey I hear what you're saying. Is this right? Maybe what you're feeling makes sense in a certain context of your relationships. 

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But also, being willing to talk about our experience with someone else in a way that makes us actually take some risks and feel vulnerable, that someone else is listening. The experience of speaking to someone else and having them reflect our experience back to us in a way that's loving, that's not immediately met with judgment, that allows a space to hold, that is itself freeing. 

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That itself is a treatment for shame, because it's no longer ours to bear alone. It's to be brought before others, and I think the way in which we can bring our shame, our anxiety, our fears, our experience that we don't want anybody else to know about, that's the path of healing.

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Alison: Yeah. To your point, it's such a paradox. So much of our pain, all the things that we struggle with, happen in the context of relationships. They're also healed in the context of relationships.

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Warren: That's right. That's right.

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Alison: There's this beautiful quote that you have about emotions that I wanted to ask you about. We talk a lot about emotions on the podcast. A lot of my listeners, including myself, have received messages from faith communities about emotions being bad or emotions being wrong. You're not supposed to have certain emotions. 

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We talk a lot on the podcast about honoring emotions as cues. You have this incredible quote, you look at emotions as “powerful signs of love that can orient the journey of the wayfarer”. Talk to us a little bit about that. What do you mean when you say emotions are signs of love that can orient us on our journey? That's powerful.

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Warren: Yes. In a lot of the book, I draw on the thoughts of St. Thomas Aquinas, who was a philosopher and theologian who lived and wrote in the 13th century. A lot of people now would say, how could a 13th century thinker possibly be helpful for thinking about modern mental health care? But I try in the book to unpack how I think Aquinas is helpful.

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Aquinas was a Christian philosopher and theologian. He was himself someone who had a deep spiritual worship life and his central image of the human being was of the human being as a wayfarer, as a pilgrim, someone who's on a journey to God. So our lives are those of people on a journey, and we find our fulfillment in God.

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That's the vision that Aquinas gives to us. But one of the things that he was really emphasizing is that emotions (he would have said “passions”) are part of the good embodied human nature that God has given to us. It's good that we're feeling, passionate creatures. That's part of who we are and actually, when they're rightly ordered, that all the emotions actually are good for us.

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And Aquinas believed that we by nature are lovers. We can't not be lovers, because we're always loving those things that we think will either be good for us, or that are beautiful, or that will in some way lead us further on the journey. We're always drawn in love to people or things that we believe are life-giving and good for us.

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So it's not like we have a choice about that. We are lovers. Then all the other positive emotions take their form of helping us on that journey into our loves. Aquinas has this incredibly beautiful vision of us, drawn to someone or something in love.

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We have this desire to be close to that person or that thing. It's obviously very different in different contexts, and that when we find ourselves attaining union with, say, someone that we have not seen in a while and we love, and we're finally with that person, we feel a deep sense of delight and joy.

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Our lives are in this constant cycle of love and desire and delight and that helps to lead us on the journey. But then the negative emotions, or what we might think of as the unpleasant emotions, are also actually there for us. They're there to help us when we perceive something blocking our loves, or something that gets in the way of what's good for us or in the way of what will lead us into what's good and true. Then, we feel an aversion to that thing.

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If we find an obstacle that's coming toward us quickly, then we feel fear because we feel the need to get away. If we find ourselves oppressed and trapped by something that we don't feel like we can escape, Aquinas says our natural response then would be a kind of sadness. And maybe if we feel like we can actually escape, a sense of anger. 

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What Aquinas does is he encourages us, and I think he's speaking as a Christian here, not to see our emotions as these like unwanted things that happen in our bodies that we want to get rid of in whatever way, but to attend to how the emotions are in some ways signs of whom and what we love.

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If I'm feeling anxious about something, rather than seeing oh, I'm anxious, that anxiety needs to go away. What is my anxiety telling me? Maybe what I'm worried about is getting in the way of a pursuit toward what I love? Maybe it's that I'm in an academic program and I really want to finish and I'm anxious about a test and I'm worried that the test is going to get in the way.

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In some ways, even though I don't like that anxiety, it's a sign of what I'm being drawn toward. It's a sign of what I love. Thinking about our emotions in that way allows for a kind of freedom and a kind of celebration that even our negative emotions can in some ways be oriented toward the good and become things that we can accept and embrace as beautiful.

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Alison: Yeah. I love that as opposed to problems to solve. It’s part of this beautiful complexity that makes us human, makes us bearers of God's image. There's complexity to who we are. When we reduce all that complexity to a symptom to be solved, we miss out. So that leads me to the question then. What then is the goal? I think about this a lot. What is the goal of this healing journey, of this wayfaring journey? As we're talking, I don't think the goal is to eradicate some painful emotions or even emotions we don't like. I don't think the goal can be to eradicate all of the hard things because relationships are hard. In even the healthiest relationships, relational challenges surface. So sometimes I find myself asking, what is the goal of all of this, as we think about what it means to be human, as we think about what it means to flourish, as we think about mental health?

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Warren: Yeah. It's a great question because one of the curious paradoxes of mental health care is that we talk a lot about mental illness or mental disorder. We talk about mental health as a broad concept, but most people don't actually, in the clinical world, define what mental health is. We define disorders, but we don't define what we actually mean by mental health.

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I think there's a number of reasons for that, in part because when you really begin to try to pin down what mental health is, you start getting into these personal moral questions about what it means to live a good human life. And in the world of mental health, we're always a little bit leery of being too directive about that. 

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I talk about this in one of the chapters of the book–there are some areas of consensus about what mental health is in the broader world of mental health care, boiling down to these seven different things:

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One, mental health has to do with the security of our bodies and of our persons. It's hard to be mentally healthy in the midst of an abusive or traumatic relationship. Mental health does entail at least the capacity for a positive regard for ourselves and for our lives. The capacity for a full range of emotions, the capacity to feel sad when there's sad things that are happening, or angry when there's injustice happening. 

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The capacity to find meaning, the capacity for purposeful and engaging activity, the capacity for intimate and fulfilling interpersonal relationships, and then this general concept of the ability to respond flexibly and creatively to challenges.

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So mental health has to do with flexibility, with capacity, with ability to engage in relationships. When we talk about mental health in the broader world of psychiatry and mental health,I think we're aiming at something in that area. Christians can take it a step further and can say yes to all those things. All those things are good. We want to embrace all those things. 

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Certainly as a psychiatrist, I want to embrace those things for my patients and for myself. But Christians are going to say yes, but if any of those things are pursued as if that is the highest goal of our life, like if you live only for security, or if you live only for particular kinds of relationship, or if you live only for positive emotion, you're going to end up getting sidetracked because you're going to make those things your highest good.

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They're going to become a kind of god for you, and you're going to pursue those. Again, I'm drawing from Thomas Aquinas here. He'd say that anything that we pursue as our highest good is going to end up disappointing us. Christians believe that only when we pursue God as our highest good, when we're constantly allowing ourselves to be drawn in love for God and for God's creatures and for the world around us and for ourselves, can we really fully know the kind of fullness of life that God has for us.

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I want to embrace all these things that are said in modern mental health care, but also to say for Christians, we can think in a broader range because we believe that we're creatures of a God who loves us and who wants us to be in union with him. And that's really important.

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Alison: That is so interesting what you're saying. A couple of thoughts come to mind. There's a way in which science can give us those baseline categories that are important and valid. You can also see in the growth of the self-help and wellness space, how those can become gods. Sometimes I'm like, oh my goodness, I could spend my whole life pursuing those, and it almost feels exhausting to me. And yet they are important. We need to have resilience. We need to have the capacity for emotions–I won't repeat the whole list, but we need to have the capacity for all of those things. 

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And yet it's almost exponentially magnified when we bring the spiritual/theological dimension into it. What does that vision look like when we magnify those baseline goals of mental health and infuse them with the power of the Holy Spirit? What does that picture look like?

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Warren: Yeah, what does a Christian vision of living fully and wholly and look like? And how does that relate to the way that we talk in mental health care? I might start by saying that we are creatures of a God who loves us and who knows us and who wants us to be drawn into God's life and so we start there.

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Christians believe that God loves us and therefore we're able to love God. And I would say that it's God's love for us that is first. In God's grace for us, that then allows us to love God, to love ourselves, to love our bodies, to love our experience, to love the natural world around us, to love other human beings, even those who are enemies, to love all things, and we love it in the love of God. 

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We find ourselves as Christians loved by God, and able, in God's love, to love God, and ourselves, and our experience, and others in return. Our lives become, what does it mean to become deeper lovers of God and of all that God is and all around us? I think Christians believe that we are God's good creatures, that God knows us and loves us. 

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We believe that we're made in God's image, which I talk about in the book, there's a lot of wrong ways to interpret the image of God, but I interpret it as us having a kind of connection with God. A way of being part of God's life that can never be taken away. Christians believe that in grace, we're invited to participate in the very life of Jesus. We find ourselves in the Christian life loved by God, drawn by God into God's life, and invited to participate in Jesus’ life and in the life of the church. 

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That means that we become more and more able to love as Jesus loved. We become more and more able to give and to extend mercy as Jesus did. We become able to find, when we suffer, that we're in some ways joined by Jesus. Not alone, but able in some ways to be able to find ourselves in solidarity with Jesus and his suffering and Jesus in ours.

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We're able to know that death and suffering and sickness is not the last word, because we are part of a life who's overcome death and who is now raised and ascended and so we don't have to fear. In all these ways, being drawn in love toward God into Jesus' life, again, this is not something that you can talk about in modern psychology, but it is something that Christians can and should, I think, embrace as part of what it means to find fullness of life in Christ.

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Alison: I love that. I think about that as someone who straddles both worlds. Sometimes I'll find a client in my mind. I'm like, oh, this is almost pastoral. They need spiritual encouragement here. And then sometimes with clients, as I'm sure with you, you find, oh, we need to learn some skills here about emotional regulation. We need to learn some skills here about calming the nervous system. We need to learn some skills here about buoying up some resilience. We need to do some naming here of relational patterns that are toxic, that are hurting the person. So there's this psycho-educational intervention or psychological intervention.

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And then almost as often, even sometimes in one session, there's alongside of it, this deep spiritual grounding of, you are not alone. In all of this, every step of the way matters to God. If you leave here and you continue to have these anxiety attacks, God is with you in that.It's such a different picture: you're not alone in it. Every piece of the process matters. Even as you're learning these new skills, even as you're learning to enter into psychological healing, you're simultaneously being buoyed up by the spirit of God. It's hard to describe if you don't straddle both worlds as I think you and I both do.

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Warren: Yes, and you're mentioning the Holy Spirit–the Holy Spirit helps us in the process. The Holy Spirit is around us and preparing our hearts and our lives for these capacities to be drawn more deeply into love of God. So I think that's really important. It's all important. The kind of things that psychologists talk about everywhere, emotion regulation and and resilience and post traumatic growth. And all of these are goods. 

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To someone who's really struggling to find ways to live in the midst of overwhelming emotion or maybe thoughts of self-harm or other things, then the kind of things in the mental health world can offer to help people find freedom and to find ways to live with that, that's good and that's part of the journey and that's what's needed right then. 

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We don't need to be always going to these broader theological concepts all the time. Sometimes what people need is to find ways to care for their bodies at a particular point in time or to stay safe at a particular point in time and that's what's needed for the journey.

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Alison: Yeah, it's really the both-and.

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You mentioned that you had some thoughts on what John MacArthur said recently, I know it created a lot of buzz and a lot of firestorm. I don't want to talk so much about him per se, but I am curious about this, the persistence of. of that type of thinking in some Christian circles. How would you respond to that kind of a broad brushstroke of, "there is no such thing as a mental illness"?

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Warren: Yeah, John MacArthur created headlines recently by calling a lot of different psychiatric diagnoses, including ADHD and PTSD and bipolar disorder and depression, he called them noble lies, and he then later wrote a blog post on his church website, I'm forgetting exactly what it is, he called them noble lies and he called psychiatry a formidable obstacle to scripture or something like that. 

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I think that where MacArthur's coming from, he's been saying this kind of thing a long time, and he's by no means alone in the Christian world. He's worried about ways of thinking about mental health where people go to a clinician and they say, I'm having these experiences and the psychiatrist prescribes medication and they never talk about what's happening in a person's life or anything else. So in a way, I don't like that form of mental health care either.

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The problem is, that's not what most mental health care is. I think it was dramatically over-simplistic and wrong for MacArthur to say that. He questioned the existence of these diagnoses, but I think it's very important that we not question the experience that brings people into the clinic that ends up getting named as these diagnoses. 

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PTSD is real in people's experience and ADHD is real and bipolar disorder is real. Of course, these diagnoses are real. The central problem with MacArthur's perspective is that he's trapped in what I would call the “moral medical divide”, where he basically says our experience is different. When the body's sick, then that's a medical problem.

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So if someone's having a seizure or a meningitis, that's a medical problem, and doctors need to get involved in it, but when it's anything that has to do with human choice or action or motivation, it's no longer a medical problem. It's a moral problem. And in his perspective, it's the pastor that has authority over moral problems.

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Just as pastors shouldn't try to treat seizures, neither should clinicians try to treat depression, because he sees depression as a moral problem. And I think that's profoundly over-simplistic. Because anyone who either has experienced mental health challenges or who cares for people with mental health challenges knows that our experiences are embodied.

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They have to do with how our bodies work. The knowledge and practices of medicine and psychology and mental health care disciplines can be really helpful. But also, how we live with mental health challenges is part and parcel of how we live and how we respond to our experience and how we seek connection or not.

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How we act in response to our experience is really important and how we live through mental health challenges. We have to acknowledge that mental health care is a kind of moral guidance, you might say, and that it's a way of encouraging people to think about themselves in certain ways and to live in certain ways and to think about certain kinds of choices rather than others and certain kinds of things rather than others.

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It's also medical guidance that draws on the knowledge and practices of medicine and psychology and the mental health care disciplines. It's both. And I think it's important to acknowledge that it's both. I think where MacArthur goes wrong is also this idea that only pastors should be involved in moral guidance.

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My opinion is that it's practically not helpful, because there's a lot of people out there who have a long experience with helping people in distress to be in a better place or in the mental health disciplines. But also, I think about Romans 12, where Paul talks about the number of different gifts that are given to members of the body. There are gifts like leadership and preaching and teaching. But there's also the gift of mercy and an interesting gift called paraklesis, which is often translated as encouragement or exhortation.

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The Greek word parakaleo means either to encourage, to comfort, to exhort to console and it's used a lot in the New Testament. As a psychiatrist, a Christian psychiatrist, when I'm working with Christians, I'm in some ways bringing in my practice as a psychiatrist, something that can help with this spiritual gift of paraklesis.

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It is really important to think about that kind of care, not only as the pastor doing that. All the pastors do have a really important role, but also others of us who have particular forms of training are able to be involved as well. I respect some of what I think MacArthur is trying to aim at, but I think the way his critique is framed is profoundly over-simplistic.

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Alison: Yeah. I appreciate you speaking to that. I think for those of us in the community, yes, we see issues. There are some issues. As you're describing in Wayfarer, there are issues within the way that mental health is being addressed. It works itself out in the field of psychiatry, in the field of psychology. We're not blind to that. And also, it's not that simple. There's so much, even, you and I could go round and round about, oh, do I like the DSM 5 or don't I? Do I think there's a place for diagnosis? 

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Sometimes I find it very helpful to categorize a cluster of symptoms and put a name on it so I know what I'm dealing with. That's not the end game for most of us. I would argue for most of us practicing, it's very hopeful to give you a directional aim in which to begin the work of healing. There's so much more to it.

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Warren: Yeah, I've thought a lot about the DSM, and obviously I work with the DSM a lot as a psychiatrist and the DSM is an important document, but I think it's important to think about what it does well, and what it doesn't do well. At its best, the DSM is a guide, a list of diagnoses with particular definitions that psychiatrists mostly and psychologists and other clinicians have. over decades, put together, that helps to facilitate the work that we do.

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It's at best what the DSM IV called “a helpful guide to clinical practice” and it's informed by science. But it's also informed by the professional interests of people, psychiatrists, it's informed by a lot of complicated debates about what should be included and shouldn't. And it's not like it's dropped from heaven on tablets of stone.

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It's put together by people, but they're typically put together by people that are doing the best they can to try to think about what we see in clinical practice. There's often a concern in the general public that if something shows up in the DSM, that therefore it's being claimed exclusively by psychiatrists as a mental illness.

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There's often talk about the overdiagnosis problem. Most recently in the DSM 5 TR, “prolonged grief disorder” was introduced as a mental disorder. And there's been a lot of debate about that, including Christian circles, of, should we be medicalizing grief?

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And my position on that is that grief is a sign of love. It's a natural process. It's also the case that sometimes people can get stuck in grief in ways that can be really harmful. They can be having thoughts of suicide. They can be distancing from all forms of relationship. There's things that, especially grief therapists, can offer that might be really helpful in helping people through. 

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So it's not the fact that something shows up as a diagnosis that's the central problem. It's if people then respond to that diagnosis in ways that are mechanistic and impersonal rather than with the journey of the wayfarer in mind. So it's not diagnosis, it's how we respond to the diagnoses and how we live with diagnoses that really matters.

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Alison: It's a naming tool. I look at it as a naming tool. It helps us give a name to something, which we need to practically get at it. But then what we do with it, as you said, then you bring in, I love your vision of the Wayfarer. Okay. This is a spot on your map. In this part of the map, this is the name of the place at which you've arrived.

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You've arrived at the field of anxiety. Or you've arrived at the field of PTSD. This is what we're going to call it. It's a tough spot. It's not your destination. It's not who you are, but we can give that name to it, which will then help us figure out how to help you find your way through it and even out of it and into a different place.

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And maybe some of that will be using medicine. To help you see clearly again, some of that will be unpacking your story. My sense is that most of us working in the field understand that, but it does become really inflammatory when folks grab sound bites or reductive ways of viewing some of the work that we do. I appreciate you speaking to that. I think it's important.

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Warren: Yeah. I tell my trainees at Duke that a good psychiatric diagnosis is one that leads to a helpful pathway forward. And an unhelpful diagnosis is one that doesn't lead to a helpful pathway forward, even if it actually meets the criteria in the DSM. One clinical example, I won't go into any identified detail, but I had a patient a couple years ago, this is one example.

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The diagnosis of borderline personality disorder is often assigned reluctantly because they're concerned that it will lead to stigma. And I actually don't personally share that, but I think that's something that often is seen. I had a patient that came in a couple years ago who had a whole list of diagnoses when he came to see me.

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One of which is bipolar disorder, another of which was PTSD. There was an anxiety disorder diagnosis, and we talked about his experience. And one of the things that had been frustrating to him was he cycled through medication, after medication. It was mostly focused on treatment of bipolar disorder, and he wasn't actually getting better.

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He was feeling maybe less emotionally reactive, but he wasn't really getting to where he wanted to be. We talked through, “I wonder if you've considered this diagnosis of borderline personality disorder”. And we talked through in very general ways, like what kinds of life experiences often accompany that diagnosis, and what kinds of experiences people have when they live with borderline personality disorder.

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For him, It was really helpful and he wrote me a week later, and he said, “I've been reading about that diagnosis and it matches my experience so well”. For him then, it was a pathway, not to get him off of all medications, but it was a pivot from thinking about medications as the primary solution to his problems toward thinking about DBT and trauma-focused psychotherapy as the place where he would most want to invest.

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It shifted the way that we thought about treatment, and in that way, borderline personality disorder was a helpful way of naming his experience that helped to lead him to a health pathway forward. Diagnosis can be really helpful and important in that.

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Alison: Yeah, it's all how you use it. I love that nuance. I want the listener sticking with us through this conversation to hear, this is what you want to look for in someone who is providing care to you, someone who will help you find a well fitting name. I talk about that in my last book. What's a well fitting name? Not to pigeonhole me there, but to your point, to help me open up a path toward greater healing, greater understanding? The truth sets us free in that sense toward greater freedom. I love that. That's beautiful.

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Warren: I think you want somebody who's not going to be coming in as an expert saying, oh this is what you need and I'm going to prescribe this. But rather somebody who can come alongside you, who can look the other way at the world along with you and can say, what journey are you on? And what's needed right now?

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Alison: That's right. I love that. Thank you so much, Warren, for sharing your expertise, your wisdom. You have so much on your plate. You're doing so many things. Tell us where folks can find your work, especially your new book Wayfaring. It's called Wayfaring: A Christian Approach to Mental Health Care. It's an incredible deep dive into the realm of this integrative space that we talk about all the time on the podcast, Christian mental health. Where can people find the book and where can they find more about you?

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Warren: Yeah, thank you. The book can be found in pretty much any online outlet or bookstore. It's published by Erdman's Publishing and it came out in 2024. I'm easily searchable online and a number of my works are found by searching for my name and you can find some things that I've written online.

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I'd also invite anyone who's interested to learn more about our Theology, Medicine and Culture Initiative at Duke Divinity School. I have this unique experience at a faculty role at Duke where I teach in the medical school, but I also teach in the divinity school. And we actually invite mental health clinicians and and other clinicians to come and study with us in a seminary, in a program of Christian learning and formation. 

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Anybody who's interested in that could easily find us online at the Duke Divinity School Theology, Medicine, and Culture Initiative.

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Alison: I will be looking that up personally. That is very exciting. That sounds really cool. Thank you so much for your time and for all the work that you're putting into bringing so much goodness into the world. I know sometimes it's a unique journey as clinicians and as folks working in the field and I appreciate all that you're doing.

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Warren: Thank you, Alison. Thank you for having me on podcast and I'm really honored to speak with you. Thank you.

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