A Current Discussion…
There have been discussions recently in the modern biblical counseling world about whether or not it might be legitimate, at times, for a biblical counselor to refer a person to a psychiatrist. For one such discussion, you can see this Twitter/X thread:
A Personal Open Letter for ACBC Members.
An Historical Analysis…
If you’ve ever read my writings, then you know that I love church history. And, you also know that I love to collate church history—to see how it speaks into current discussions/debates.
So, here are five examples from the history of the modern biblical counseling movement where prominent leaders—such as David Powlison, Mike Emlet, and others—address whether biblical counselors should ever refer counselees to psychiatrists, and what our overall perspective on psychiatry should be.
History Lesson #1: David Powlison on the Biblical Counseling Movement Always Having Affirmed Psychiatry
In A Letter to the Editor, in the Journal of Biblical Counseling 16:2, 1998, David Powlison acknowledges the long history of biblical counselors affirming the role of psychiatry.
“Those ways where psychiatry is the most medical-scientific or the most custodial have always been affirmed as relative goods by biblical counselors; here psychiatry is an honorable profession.”
History Lesson #2: Mike Emlet on When Should a Pastor Recommend a Psychiatrist?
In an April 17, 2016 CCEF video, Mike Emlet addressed the specific question, When Should a Pastor Recommend a Psychiatrist? I listened to the video and created the following transcript.
01: When should a pastor recommend a psychiatrist? There probably are two extremes. Some people would say, “As a pastor, I never refer to a psychiatrist.” At the other end of the spectrum, maybe those who would be referring very quickly outside the church for additional help.
:25: So I think there’s a middle way, a wise way, and some things that would come to mind, in terms of getting help from a psychiatrist or seeking a referral, if you have someone who has very bizarre, erratic thinking and behavior that might be characteristic of psychosis, that’s something that you want to get additional input on.
:52: Someone that is very suicidal, you also may want to get help within the church for, but depending on how dangerous the person truly is to him or herself, you may want to get a physician involved. There may be a benefit to being on medication, at least to getting that evaluation would be important.
1:22: And then there maybe people who despite there wholehearted reception to biblical counsel continue to struggle in very severe ways, maybe in very severe depression, or very severe anxiety, or obsessions and compulsions might be a few areas. So they’re taking it in, they seem to be embracing biblical counsel, but they’re not changing, they’re still struggling. That may be, although you can’t prove it, that maybe a marker for some more biological weighting to their struggle. So it may be beneficial to seek medical input at that point, just to see would there be any potential benefit to the use of medication, even for a shorter time.
2:09: So I think there are a number of reasons why a pastor might want to consider a referral to a physician psychiatrist.
History Lesson #3: David Powlison on Pursuing Psychiatry as a Vocation
In a CCEF video Q&A from July 30, 2016, David Powlison addresses the question, Is it possible to pursue psychiatry as a vocation while maintaining a biblical worldview?
While not directly addressing referral to a psychiatrist, Powlison does directly affirm the role of psychiatry. I listened to the video and created the following transcript.
1:06: “Great question. Here’s the short answer. Is it possible to pursue psychiatry as a vocation while maintaining a strong biblical worldview? Yes!” (1:11).
1:12: “This is one of the things that probably surprises outsiders who really don’t understand biblical counseling. But right from the very start in the 1960s, biblical counseling has always viewed psychiatry as potentially an extremely valuable and helpful discipline.” (1:31).
1:32: “And the concern has simply been when psychiatry becomes imperialistic and transgress on some of the issues where the church really needs to take the lead. But there has never been an objection to psychiatrists doing what psychiatrists do best which is being able to have an understanding of the physical—after all, psychiatry is a medical discipline—so they ought to build a thoughtful understanding and case experience about the physical component in people’s difficulties.” (2:07).
2:08 “In fact, I would probably tweak the question a little bit, ‘in helping people deal with their emotional and mental issues,’ I’d probably say, ‘your psychiatric background can contribute something on what you could call the physical component that may or may not be playing a role in emotional and mental issues.’ That’s one thing that is a genuine gift.” (2:31).
2:32: “Another genuine gift you can bring, whether for good or bad reasons, people will invest authority in you. To be someone who is deeply committed to a biblical worldview and who is able to interpret emotional and mental struggles through biblical eyes, in the way, that you might say, being the best doctor you can be, you weigh rightly the physical component that may be there, being committed biblically, when you open your mouth to help someone sort through, you talk like a biblical counselor. It is entirely possible, and desirable, for psychiatrists to be biblical counselors. It combines two sets of expertise.” (3:30).
3:35: “That said, ‘is it possible,’ is a really good question, because there is a strong pressure in the field to overmedicalize people’s problems. So, I would make a very strong suggestion that you get a dual education. That you pursue your medical studies but make sure that in there is very thoughtful attention to a biblical understanding of the relationship between mind and body, how do you help people with their anxieties, with their anger, their conflict, their depression, their addictions in a way that while seeking to understand possible medical components, always recognizes there is a person here. When I talk to a person, I’m talking to an image bearer of God, I’m talking to one who sins against God. I’m talking to someone whose redeemable, whose faith and love growing can be a critical part of their growth.” (4:36).
4:51: “All that said, you want to go in eyes open for where is the genuine good that psychiatry can accomplish, but also where are the places that the field itself has transgressed what would be normal biblically set boundaries.” (5:03).
History Lesson #4: Martha Peace on When a Biblical Counselor Should Consult a Physician or Psychiatrist
In 2023, Charles D. Hodges, Jr., edited the co-authored biblical counseling book, The Christian Counselor’s Medical Desk Reference, 2nd Edition. It is the definitive current reference work for the modern biblical counseling movement regarding counseling and medical issues.
In chapter 4, When Should a Biblical Counselor Consult a Doctor?, Martha Peace, RN, writes:
“Over my thirty-two years of being a NANC/ACBC counselor, there have been many times that I have consulted with or referred a counselee to their doctor. Often, it was their primary care physician, but sometimes it was their psychiatrist” (51).
Later in the same chapter, Peace explains,
“Someone who is in the middle of a psychotic break usually needs the help of a psychiatrist” (56).
“Depending on the situation, if they are threatening to harm themselves or someone else, and if they will not voluntarily go for a psychiatric evaluation, you may need to call the police because what they are threatening to do is illegal. The police and/or emergency medical personnel will take them to an emergency room for an evaluation” (56).
Speaking specifically of a suicidal counselee, Peace states:
“…their family needs to know and take responsibility to keep close watch on their loved one and/or take them for a psychiatric evaluation if deemed necessary” (57).
“Suicide threats are scary and obviously can be acted on. I have sent several counselees who were threatening suicide for a psychiatric evaluation (accompanied by their family). Most times, they were admitted to the hospital for several days. I have even gone with one counselee’s husband when he took his wife for a psychiatric evaluation” (57).
History Lesson #5: Daniel Dionne on Referral to Psychiatrists
We see a similar mindset in another chapter of The Christian Counselor’s Medical Desk Reference, 2nd Edition. In chapter 18, “Suicide and the God of All Comfort,” biblical counselor and MD, Daniel Dionne, writing about suicidal counselees, states:
“If you counselee becomes agitated and wants to leave, then your first priority is their safety. In your community, the safest place to take them is the emergency department of your local hospital, where they can be assessed by physicians and psychiatric professionals to see if they need to be kept in the hospital for a few days” (331).
“I always encourage counselors not to consider a hospitalization as a ‘failure’ of biblical counseling. It is a tool you can use to keep your counselee safe while the church rallies to help them” (331).
“If you haven’t already, you should also find out about other available resources in your community. If there is a mental health system, you and your counseling ministry should ask them to talk to you about how they assess and prevent suicide” (331).
History Is Not Sufficient; Current Opinions Are Not Sufficient; Scripture Is Sufficient
Of course, David Powlison, Mike Emlet, Martha Peace, and Daniel Dionne are not the authoritative final word when they all uniformly assert that it can be biblical for a biblical counselor to refer a counselee to a psychiatrist.
And, of course, no current biblical counseling group, or individual biblical counseling leader, is the authoritative final word when they assert that it is not biblical for a biblical counselor to refer a counselee to a psychiatrist.
Scripture alone is authoritative and sufficient in all matters of life and doctrine.
The issue then is,
How do we interpret and apply the Scriptures to the current issue of whether it might ever be legitimate for a biblical counselor to refer a counselee to a psychiatrist?
Some in the modern biblical counseling world, as the Twitter/X thread (A Personal Open Letter for ACBC Members) indicates, are saying a biblical counselor should not refer to a psychiatrist. Historically, within the modern biblical counseling movement, that view is an anomaly—it is at variance with what respected biblical counseling leaders like David Powlison, Mike Emlet, Martha Peace, Daniel Dionne, and others have historically taught. These biblical counseling leaders have clearly seen a legitimate role for psychiatry, and a legitimate place for careful, wise referral to a psychiatrist.
Others can interpret and apply Scriptures differently—and come to the opinion that biblical counselors should not refer counselees to psychiatrists. If they do come to that opinion, then they should have the historical integrity to acknowledge that they have tightened, narrowed, and limited the historic view of other leaders in the modern nouthetic biblical counseling movement.
