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Warren Kinghorn and Abraham Nussbaum: Friendship and people with mental illness

Churches are the front line of encountering suffering in large portions of our culture and have the opportunity and responsibility to minister to people with mental illness, say two psychiatrists trained in theology.

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December 3, 2013

Life for people with serious mental illness can be isolating, but it does not have to be that way, say psychiatrists Warren Kinghorn and Abraham Nussbaum.

Instead, churches can do much to welcome, be with and support those with mental illness.

“The Christian life, with its account of patience, charity, responsibility and the other virtues, offers a more robust response [than the culture at large],” Nussbaum said.

Learning how to be friends with people with mental illness is really about learning how to be friends with people generally, Kinghorn said.

“The practices of friendship, both individually and in community, are essential regardless of whether mental illness is present,” he said.

Trained in both psychiatry and theology, Kinghorn and Nussbaum are organizing the conference “Walking Together: Christian Communities & Faithful Responses to Mental Illness,” to be convened in Houston in February 2014.

Kinghorn is an assistant professor of psychiatry and pastoral and moral theology at Duke University Medical Center and Duke Divinity School. Nussbaum is the director of adult inpatient psychiatry and an assistant professor at Denver Health and the University of Colorado.

They spoke with Faith & Leadership recently about the church, friendship and mental illness. The following is an edited transcript.

Q: Give us an overview of mental illness in the United States today.

KinghornKinghorn: Mental illness is very common in the U.S. and affects most congregations, many families and every community. About 1 percent of the population has schizophrenia, 2 to 3 percent have bipolar disorder, and about 15 percent over the course of their lives will have depression.

Around 30 percent of Americans experience some form of mental disorder in any given year.

That’s not to say that everyone needs to be thought of in terms of mental illness but to say that suffering in our culture is common. It comes up in various ways and often takes the forms that we label mental illness.

There is no one such thing as mental illness. Schizophrenia and bipolar disorder and depression and PTSD and addiction and personality disorder are all different kinds of things and affect people and families and communities in different ways. They need to be seen and treated differently, just as different people with the same mental health condition might experience it in very different ways.

Q: What are some of the challenges of living with mental illness?

NussbaumNussbaum: It depends upon the person, the degree of his or her illness, and their situation, but part of what makes mental illness particularly challenging -- particularly, severe and persistent mental illness -- is that it causes you to change how you perceive yourself and to change how others perceive you.

If you have a broken limb, people don’t necessarily perceive it as a threat to the self. But mental illness, particularly serious mental illness, often constitutes a threat to a person’s identity and can complicate their relationships with other people.

So the first thing is this kind of existential challenge it poses.

The second is that the treatments for mental illness are not as effective as some of the treatments for things like a broken limb and are sometimes difficult to access, particularly in the United States, where insurers provide different levels of access to mental health treatments.

There’s also a stigma around people with severe and persistent mental illness. Part of what our project has been about is saying that we need to acknowledge the people in our homes, neighborhoods, parishes, faith communities who have mental illness and to consider again our responsibility to them and our relationships with them.

Q: Is life with mental illness inherently isolating?

Nussbaum: It can be. It certainly doesn’t have to be.

Life can be very difficult for somebody with a serious and persistent mental illness, but there are alternative social arrangements that can be much more welcoming. Some of those have come under the banner of Christian communities, and our intention is to reclaim those when they are worth reclaiming and to try to engage other people in that work.

Kinghorn: Mental illness is complicated. It does bring challenges, but it also brings opportunities for growth and learning and wisdom, both for people who have mental illness and also for their families and communities.

Mental illness is always an interplay of biology and one’s personal constitution and the culture in which one lives. So a lot of the suffering that comes with mental illness is in how the person is met and greeted and treated by social systems, by educational systems, by communities. The suffering of mental illness is a social reality as well as an individual medical reality.

Q: Speak some to the challenges for friends and family members.

Kinghorn: There are a few. One is that friends and family members are there with the person with mental illness in a more continuous way and over a much longer time than anyone else. There’s a challenge of how do you continue to be present and in someone’s life when others aren’t.

Along with that is the challenge of how to best advocate for someone, especially with severe forms of mental illness, and how to advocate within complex medical systems and educational systems.

Many families also struggle with how to think about accountability -- how to balance between a compassionate approach that sees the person as somehow not accountable for his or her actions and a need to hold the person accountable for certain kinds of actions and behaviors and ways of being and habits of living.

Nussbaum: Much of medicine is built around metaphors taken from trauma medicine and infectious diseases. We talk in psychiatry about how our treatments are antidepressants and antipsychotics and anti-anxiety drugs, and the metaphor is that they’re something like antibiotics.

But an antibiotic for pneumonia is a relatively short treatment that can be lifesaving, whereas the treatments for psychiatric illness are really meant to support the fundamental changes that you have to make. They’re not like taking an antibiotic for pneumonia. So the very structure of contemporary medicine can make that more frustrating for a family.

Q: So how does one go about being with and being friends with people with mental illness? And what’s the church’s role in that?

Nussbaum: The short answer is that they go about being friends the same way they do with everybody else.

People with mental illness are all around us, so I’m pretty uncomfortable with this strong distinction between those with and without.

There are some special gifts to Christian friendship that need to be reclaimed. Christian friendships ought to be more focused on the virtues. The question of patience, for example, is different from many accounts of friendship. In contemporary American life, friendship is often reduced to an exchange -- it’s somebody who is able to do the same things and enjoy the same things I do.

But the Christian life, with its account of patience, charity, responsibility and the other virtues, offers a more robust response.

Kinghorn: The best way to cultivate the ability to be friends with people with mental illness is to cultivate the ability to be friends with people, period. The practices of friendship, both individually and in community, are essential regardless of whether mental illness is present.

Respecting human dignity, of people both with and without mental illness, is a matter of respecting people as agents in the world, as those whose beliefs and actions and ways of being matter. So any friendship with people with mental illness needs to focus on how can I really respect this person as an agent and honor that.

That might mean, actually, to hold people accountable for actions and for ways that people are present or not in communities. It doesn’t mean simply to adopt a position of thinking that this person is sick and needs some kind of treatment, but rather that this person is a human being in our community or in my relationship and needs to be treated primarily as such and not as anything else.

Nussbaum: One way to think about mental illness that also helps explain why it’s often so challenging for people who have mental illness, and for the people who are in relationship with them, is that people with mental illness often suffer from a diminishment of their own agency.

That’s one of the ways [of understanding it] that ties together the very different kinds of things that we call mental illness in contemporary life. A personality disorder and bipolar disorder and alcoholism are all very different, but in each case there’s a diminishment in somebody’s agency. So one of the things that you want to do in the context of being in relationship with people with mental illness is to increase agency.

Kinghorn: In Christian terms, agency comes in healthy relationship. We gain ourselves and our selfhood in relation with each other and with God, so cultivating good, healthy relationships is central to that ability to encourage agency.

Attention to context is really important. For example, I work at the Durham VA Medical Center and work a lot with veterans with combat-related PTSD. As long as they are seen in our medical system only as people with PTSD with certain symptoms that need to be treated, then they’re going to be treated in relatively technical ways, and clinicians who are not veterans are just not going to understand the context of that experience.

But if clinicians or others can begin to inhabit the reality of what it would be like to go to war and to be faced with the kind of experiences and memories and actions that modern warfare entails, then suddenly veterans with PTSD look much less like abstract medical patients and much more like human beings who are doing the best that we can to make it in a world that is often confusing and broken.

There’s a humanity that is often concealed through the medical language that we use to describe psychiatric disorder. So context is important in terms of where somebody lives and what the home situation is like and what kinds of relationships do people have and what are the experiences that have formed people in the way that they’re formed.

I have a mantra that I always teach my residents, which is that people will do their best with what they’ve learned to get what they think they need in any given situation. That applies not just to people diagnosed with mental illness but to all of us, and because it applies to all of us, it is helpful in being friends with people with mental illness.

Q: What could and should churches be doing? And tell us about your upcoming conference.

Nussbaum: My hope would be that churches would be a place where we learn to be friends with each other, not just with the people that we choose but with the people we are given by God. It’s not about learning to be friends with people with mental illness. It’s about learning to be friends in general.

The second thing is that throughout church history, different churches have responded in different ways to persons with mental illness. Certainly, there are many instances where churches have increased the stigma and shaming of persons with mental illness. But what we’re trying to do in this project is to reclaim some other examples that are less well-known.

Part of this project began out of our friendship and our own training. Warren and I trained to be psychiatrists at roughly the same time, and we both studied theology at roughly the same time. And we began looking for nonmedical examples -- examples where the church was providing care to persons with mental illness.

We were surprised how few well-studied examples we could find, so we’ve been talking for the last three years about how to learn more about these examples, both for ourselves and as a resource for the larger church, as a reminder of what it’s capable of doing with persons with mental illness.

We started talking about some examples, and wrote a couple of papers, but then asked other people to help us in writing more.

Q: What’s the conference about?

Kinghorn: Feb. 6-8, in Houston, we’ll be convening a group of scholars, clinicians and local community leaders and congregations to listen to stories throughout Christian history about Christian communities that engaged in creative ways of caring for people with mental illness.

Our presenters will be telling stories from history in an effort to mine how they might be applied today in congregations. We’ll think together about how to engage the examples of these stories to imagine new possibilities about creative and faithful ways to walk with people with mental illness.

Churches are the front line of encountering suffering in large portions of our culture. So they have an incredible opportunity and responsibility to minister to people who are going through various kinds of suffering, much more so than any clinical system.