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Speaking Well in Worship about Mental Illnesses

A Beginner’s Guide to Language and Resources

Most worship services regularly include preaching examples and prayers for people living with physical illnesses. Do your worship services regularly include people living with mental illnesses in these same ways? If not, why not? If so, what language is used for people who live with mental illnesses? Are psychological disorders or symptoms named? Are themes of human struggle and resilience, lament and hope included in your services? This article offers beginning steps for worship leaders to disciple everyone through language used in prayers, preaching examples, songs, litanies, and in-between words woven into weekly worship on a regular basis.

One way we can equip Christians to go beyond mere inclusion to the discipleship of every person in Christian worship is to use language that acknowledges and values people who live with mental illnesses as image-bearers of God who fully belong. While it is important for worship to include broad themes of struggle, pain, and confusion in prayers and preaching, it is also important to name mental illnesses along with physical illnesses in worship. The language we use in worship plays a role in discipleship, shaping how we see others and ourselves in relationship to God, how we pray with petition and thanksgiving, how we interact with each other, and how we understand the ultimate purpose of our lives. In other words, worship leaders have an opportunity to disciple the whole body of Christ—including those directly affected by psychological disorders and those who love and care for them—through the weekly ways we speak, sing, pray, and preach. What we say and how we say it matters.

The 2018 Symposium on Worship at Calvin College held several sessions addressing mental illnesses and disabilities. This article draws on themes that emerged in conversations with presenters Rev. Cindy Holtrop (interim minister of pastoral care at Neland Avenue Christian Reformed Church), Dr. Warren Kinghorn (psychiatrist and theologian at Duke University and the Durham Veterans Affairs Medical Center), Dr. John Swinton (psychiatric nurse, chaplain, and pastoral theologian at the University of Aberdeen, Scotland), and Barbara Newman (leader in disability ministry and inclusion, director of church services, teacher consultant, and author at the Christian Learning Center Network). An additional article will summarize key themes from the panel session “Mental Health and the Practice of Christian Public Worship: An Exploratory Conversation.”

Keeping Personhood Primary

Everyone is an image-bearer of God, known and loved by God. Our language in liturgies and preaching can make clear that nothing can take away our personhood or remove the imago Dei from us—not trauma, not violence, not abuse, not deep disappointment, not cancer, not heart disease, not disabilities, not dementia, not depression, not psychosis, not personality disorders, not eating disorders, not substance use disorders, not suicide. Saying so explicitly in connection with a song such as Marty Haugen’s “Neither Death, Nor Life” LUYH 450—with its refrain that nothing will ever separate us from the love of God poured out through Christ Jesus our Lord—can be powerful (see RW 86:26, GIA 5650). Verse 3 of this song says that “All of the suffering we now must endure is nothing to the glory so soon to be revealed when creation itself is set free,” pointing us to new-creation hope. Even when we cannot sing aloud a song like this, hearing a pastor or song leader make the connection and hearing the congregation sing it can carry hope for us.

When we are reminded that we all—regardless of mental or physical illnesses—are beloved image bearers of God, we see each other more and more in this light. In this vein, John Swinton prompted attenders of his lecture at Calvin College’s January Series and Symposium plenary address to turn to someone nearby and say, “It is good that you are here, and I am glad that you exist”—reminding us that we can bless one another during a time of greeting. I still remember the people who greeted me and whom I greeted in this way. Even if these particular words aren’t used at church, we can greet each other with this eye for personhood as we pass the peace of Christ, making an effort to learn each other’s names, referring to and interacting with each other in ways that make clear that we see one another as beloved children of God. Within this context of being beloved image bearers, known by name, our congregations can begin to engage the experience of living with mental illness as people who belong.

Worship leaders have an opportunity to disciple the whole body of Christ—including those directly affected by psychological disorders and those who love and care for them—through the weekly ways we speak, sing, pray, and preach.

When people hear and feel that they are known and loved by God, that they are valued and belong in their worshiping communities, they grow in faith, can cope with life’s hardships, and can flourish. Religious strain, such as feeling abandoned by God and by one’s congregation during difficult times, increases stress and psychological vulnerability. By contrast, religious comfort, such as experiencing God’s love and care (often shown through God’s people), can strengthen those facing difficulties including depression. Further, social belonging, having warm and trusting relationships with other people, and having a sense of direction and meaning in life are key parts of worshiping in community, and they are part of flourishing mental health. People who live with disorders can still flourish, and belonging in worshiping congregations can be part of this.

People Who Live with Mental Illnesses

When we want to address the topic of mental illness, we can speak about people who live with mental illnesses. We can pray for and preach with examples of people who live with disorders. We can listen to people who are ready and open to share their stories of living with specific disorders.

Why is the phrasing “people who live with mental illnesses” helpful? Three elements: “People who,” “live with,” and “mental illnesses.”

People who: Talking about people who live with mental illnesses keeps personhood primary. Language shapes the way we see and interact with each other and even how we see ourselves. Instead of referring to addicts or schizophrenics or anorexics or bulimics (as if a diagnosis replaces personhood), we can speak of people who live with specific substance disorders, schizophrenia, or anorexia or bulimia, or people who are craving heroin, people who are hearing voices or who have disorganized speech, or people whose self-evaluation is overly influenced by their body shape or weight.

Our language for ourselves matters, too. Replacing “I am ADHD” with “I’m someone who lives with ADHD” signals a shift that lives into the reality of being a person first while acknowledging that life includes challenges, including symptom patterns with a name. I have seen the transformative change that occurs in students across subtypes of attention deficit hyperactivity disorder who shift their language and come to see that they are more than their diagnosis and that to flourish, they need to reckon with what living with their diagnosis means for them. No one is ADHD. Rather, people live with, treat, cope with, and can flourish with ADHD.

Live with: The language of “living with” allows us to see the struggles, the strengths, the supports, the persistence, the languishing, and the flourishing people experience. While empathy may lead us to say that people “suffer” with various disorders, we also need to see and name even more: the disappointments and the triumphs, the fear and the gratitude.

In his 2018 January Series and Symposium addresses, Swinton advocated for listening to what people have to say about the human, lived experience of dementia. Beyond the lists of symptoms and scientific explanations—as vital as they indeed are—let’s also listen for what it is like for people to live with dementia. Similarly, in one conversation, Warren Kinghorn noted that if you’ve met one person with PTSD (post-traumatic stress disorder), you have met one person with PTSD. I believe we can wisely ask, “What is it like for this particular person to live with the symptoms, the diagnosis, the treatment, and the experiences in relationships, in the church community, and in worship?” When pastors, elders, deacons, fellow congregants, musicians, liturgists, and those who offer prayers really listen to the lived experiences of people with disorders, they are better equipped to be the body of Christ together in worship and discipleship.

Mental Illnesses: Naming mental illnesses in general and specific disorders in particular can destigmatize them. In any gathering space—including worship—people with diagnosable disorders are already present. Kinghorn shared lifetime prevalence data (based on the National Comorbidity Survey Replication by Kessler et al., Archives of General Psychiatry 62 (2005), 593–602) indicating that 46 percent of the United States population experiences some form of mental disorder at some point in their lifetimes. In terms of lifetime depression, 20 percent of people in the U.S. experience a mood disorder—16 percent depression and 4 percent bipolar disorder—1 percent experience schizophrenia, and 15 percent experience substance use disorders. At any given time, 5 percent of people in the U.S. are experiencing major depression. So if 100 people are gathered for a worship service, and if they are representative of the U.S. national data, about five people—whether congregants or clergy—are dealing with major depression (with only one of those five likely to be receiving adequate treatment); another fifteen people have already experienced or will experience a mood disorder. Many more will experience anxiety and trauma disorders, substance use disorders, impulse control disorders, and beyond—and these can begin in childhood and adolescence. Knowing disorder data can undo shame that people with depression or any other diagnosable condition live with.

Good Examples of Stories

It is valuable for people to tell their own stories, whether in person or through writing. Good examples include:

The Power of Story

It is especially powerful to hear people tell their own stories of living with mental illnesses. For more than twenty-five years, Stuart Emmons and Craig Geiser have shared their experiences of living with schizophrenia with Hope College students in our behavior disorders classes, and they have each given me permission to include their stories here. Nearly every time they speak to the students, they each say how helpful it is to have a name for their experiences of delusions, hallucinations, disorganized speech or behavior, or apathy. Having a name for their experiences signaled that they weren’t the only ones to experience these things, and that there might be treatments available, giving them hope. Hearing Emmons and Geiser talk about their lived experiences equips students with empathetic perspective taking and concern for the real people who experience these symptoms. Students see their courage and perseverance as well as their gratitude for medications, pastoral care, family psychoeducation, church-based support groups, faithful friends, and the ability to compose poetry and create art.

Having an emotionally aware pastor has been significant for Emmons. “The way he talks about emotions and feelings really connects with me,” Emmons said. “He even told us he takes Tums before preaching to settle his stomach. That makes me feel more comfortable because I take medication [too].” Geiser has told the story of trying to pray while actively ill and finding that all he could say aloud was “Dear God . . . amen.” Emmons helped Geiser understand that his prayer was enough: “The Holy Spirit takes over and prays for you.” Emmons’s theologically formed and pastoral response was so meaningful to Geiser that he has told this story many times. Geiser has said that this and other good experiences of being encouraged have strengthened his faith.

The Importance of Naming Disorders

Knowing about and naming disorders can shed light on conditions that people live with. We can then see that people with the same diagnosis might show variations from one person to the next, or even from one episode to another within a single lifetime (as is true for Emmons and Geiser). Further, distinct disorders may share a common thread—for example, trouble concentrating is a symptom of attention deficit hyperactivity disorder, but also of generalized anxiety, major depression, and persistent depressive disorder, or it can be part of other experiences such as grieving or being sleep deprived.

Disorders differ in terms of what interventions have been shown to be most effective. Exposure-based therapies have been found to be most effective for treating phobias, cognitive-behavioral therapies have been shown to protect against relapses of depression, and interpersonal psychotherapy increases people’s social functioning long term. Even for people whose disorders are best stabilized by lifelong medications (bipolar disorder and schizophrenia, for example), psychoeducation and psychological interventions are important for supporting adherence to the prescribed medication dosing and schedule, for addressing the challenges associated with mental illness, and for supporting the relationships and the sense of purpose and meaning that are part of flourishing.

Theologian Lewis Smedes wrote in his memoir My God and I: A Spiritual Memoir (Eerdmans, 2013) about his gratitude to God for the gift of his antidepressant: “God . . . comes to me each morning and offers me a 20-milligram capsule of Prozac. With this medication he clears the garbage that accumulates in the canals of my brain overnight and gives me a chance to get a fresh morning start.” Smedes himself benefited from the good gift of medication, and so have those of us blessed by his life, compassion, and good writing.

Advice to Consider before Sharing Someone Else’s Story

Whenever we think a personal story of someone we know would fit perfectly as an example, we should pause to consider:

  • For stories distant or past, how will you ensure that confidentiality is fully honored? Omit or tweak enough details so that the wise heart of the story is the focus while the real person’s identity is protected. People in the church often have long memories and multiple unforeseen connections. In the church, we ought to “do no harm” while aiming to do much good.
  • Has this person given you explicit consent to share this story? We should not tell others’ personal stories unless they have given us explicit permission to do so through informed consent.
  • If you have permission from a person to tell his or her story, how will you honor the personhood of this individual through what is told and how the story is shared? Are the person’s strengths named along with the struggles? Do you give room for both lament and hope, for suffering and for flourishing?
  • How will you tell the story so it is helpful while buffering against the risk of harm? Imagine the people who might be most hurt or helped by this story as if they are in the room. Listen with their ears.
  • Ask beforehand about your wording and approach, be willing to change, and ask afterward for feedback to learn if the impact matched your intent. If needed, apologize, then adjust to improve.
  • Leaders need to be especially aware of power differentials and must never pressure anyone to tell his or her story. Rather, we must honor people’s need for safety, respect, care, and agency to decide whether and when they are ready to tell their own stories.

Using the Right Language

Mental illnesses and psychological disorders are terms with fuzzy borders. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (American Psychiatric Association, 2014) is a human effort to describe the researched patterns of thoughts, feelings, behaviors, and physical responses that are experienced as dysfunctional, unexpected in their cultural context, and associated with personal distress or impairment in important areas of functioning or with an increased risk of suffering, death, pain, or impairment. The DSM-5 (See sidebar on p. 18) offers a taxonomy intended to facilitate professional assessment, diagnosis, treatment, communication, collaboration, and research in order to serve people effectively by reducing their symptoms while strengthening their social, occupational, or other important areas of functioning.

It’s important to note that language for disorders, disabilities, and diagnoses varies across mental health, educational, legal, and insurance contexts. As Barbara Newman notes, many professionals avoid using words such dysfunction, impairment, or suffering because they want to be sure people don’t slip into talking about people “suffering from dementia,” instead preferring—as this article suggests—people living with dementia, which also allows us to see more of who people are. In general, it is wise to follow people’s lead in the language they use for their disorders. We need to remember that everyone has both strengths and struggles, and we should acknowledge both abilities and disabilities. We can speak in ways that keep the focus on the people who live with disorders, that equip us to be present alongside each other in challenging times, and that support one another’s flourishing.

The DSM-5 includes many diagnoses, as noted in the sidebar. Some of these disorders seem to fit common notions of mental illness (for example, mood disorders or psychotic disorders). Others don’t (for example, sexual dysfunctions). Some people consider some of these disorders to be disabilities rather than mental illnesses (for example, neurodevelopmental disorders such as intellectual disability, autism spectrum disorder, and specific learning disorders), and sometimes having a mental illness counts as a disability. Other diagnoses involve patterns of thought as well as behaviors that can be criminally charged. For example, pedophilic behavior by Larry Nassar (former USA Gymnastics and Michigan State University physician) included criminally prosecuted behaviors, but people’s unwillingness to talk about his behavior allowed him to continue to perpetrate crimes against young girls and adolescent women. This later cost Rachael Denhollander her church because of backlash against her when she identified the need for safety and justice for victims and accountability for perpetrators of sexual wrongdoing. Too often, people in the church press victims to forgive rather than ensuring safety, respect, justice, and accountability—the soil in which genuine forgiveness naturally grows. (See this interview with Denhollander in Christianity Today: https://goo.gl/bWwTjf.) These are important matters, and silence in the church is not the solution.

THE DSM-5

The DSM-5 includes many diagnoses, including:

  • anxiety disorders (panic disorder, generalized anxiety disorder, phobias), obsessive-compulsive disorder and related disorders (hoarding, trichotillomania, excoriation), post-traumatic stress disorder and related disorders (reactive attachment disorder, disinhibited social engagement disorder);
  • somatic disorders (e.g., functional neurological symptom disorder) and dissociative disorders (e.g., dissociative identity disorder);
  • mood disorders such as depression (major depression, persistent depressive disorder) and bipolar disorders (bipolar I with mania, bipolar II with hypomania, cyclothymia);
  • feeding and eating disorders (pica, rumination, anorexia, bulimia, binge-eating disorder);
  • sleep-wake disorders (insomnia, hypersomnolence, narcolepsy, breathing-related disorders, circadian rhythm sleep disorder);
  • sexual dysfunctions, paraphilic disorders, and gender dysphoria;
  • substance-related and addictive disorders (substance use disorders, intoxication, and withdrawal for alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, and other substances; gambling disorder);
  • impulse-control disorders (e.g., intermittent explosive disorder, oppositional defiant disorder, conduct disorder, kleptomania, pyromania);
  • personality disorders (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, obsessive-compulsive personality disorder);
  • schizophrenia spectrum disorders and other psychotic disorders (for example, brief psychotic disorder, delusional disorder, medication-induced psychotic disorder, schizoaffective disorder—superimposing a mood disorder and schizophrenia);
  • neurodevelopmental disorders including autism spectrum disorder, intellectual disability, specific learning disorder with impairment in reading, expression, or mathematics, as well as Attention Deficit Hyperactivity Disorder (combined presentation, predominantly inattentive presentation, or predominantly hyperactive/impulsive presentation);
  • tic disorders (Tourette’s disorder); and
  • neurocognitive disorders, including delirium and disorders often called dementia (whether due to Alzheimer’s disease, Lewy body disease, Prion disease, Parkinson’s disease, Huntington’s disease, vascular disease, substance/medication use, HIV infection, frontotemporal lobar degeneration, unknown or multiple etiologies).

Using Specific Diagnostic Language in Worship

Naming specific disorders can be a gift, but only if the impact matches the intent to bless.

The specificity of naming disorders—starting with a gentle naming in general prayers or in preaching references to mood or anxiety disorders—makes them more familiar, allowing us to learn about the experience of living with these disorders. When we name gently and respectfully in ways that honor personhood, we peel away stigma and shame. This is especially so when people experience the readiness, openness, and willingness to tell their own stories of living with anorexia or bipolar disorder, or alcohol use disorder, or post-traumatic stress disorder, or schizophrenia—perhaps in a prayer request or testimony, an education class or a retreat. Still, as Cindy Holtrop wisely notes, “There is no one-size-fits-all pastoral care so be in dialogue with those you know who are living with mental illnesses. The more aware and pastorally sensitive you are as a worship leader, the fewer barriers will be in the way of the full, conscious, and active participation of all members in the worship of God” (p. 29)

The stories of Emmons and Geiser (described above) have been meaningful to many students and readers of their book, Living with Schizophrenia. Viewing Geiser’s art about Jesus making his disciples fishers of people could be used in connection with Matthew 4:19. Reading Emmons’s poetry about his relationship with God and his delight in God’s creation could be a meaningful example and source of encouragement in a sermon about Psalm 104. A long and colorful illustration for Psalm 104 is Christopher Smart’s poetry (“Jubilate Agno, Fragment B [For I will consider my Cat Jeoffry],” written in an asylum in the mid-1700s), a portion of which appears in Benjamin Britten’s choral work Rejoice in the Lamb.

Hymns also help us address the experience of living with disorders. David Mowbray’s “Gift of Christ from God Our Father” SNC 167 includes this line in verse 3: “Gift of Christ to help us praying, come, Spirit, come! Advocate beside us staying, come, Spirit, come! . . . In the work of intercession, in the healing of confession, in success and in depression, come, Spirit, come!” Mary Louise Bringle’s hymn “When Memory Fades” LUYH 449 gives voice to the losses experienced with dementia, especially in older adults. This hymn has been a blessing
to many who love someone with dementia. In addition, we know that for those who already experience neurocognitive decline, the hymns and songs learned in their youth and sung throughout their lifetimes come back to bless in worship. So, too, with the repeated patterns of liturgies, including the Lord’s Supper. Indeed, Christ’s body and blood are given for you, known by name, beloved and belonging.

General Language Allows Everyone to Connect

Naming the human experience of emotion; of lament over loss, anguish, and disappointment; of overcoming and persistence; of being carried in hope—all of this can be life-giving to a broad range of people. Using general language for human suffering allows everyone to connect to experiences of disappointment, hardship, and anguish. Cindy Holtrop has composed a litany prayer which uses general language in a very meaningful way (see p. 29).

The psalms of lament, of disorientation and orientation, can be a source of deep strength for people whose emotions are too raw and painful to be used on a Hallmark card. Wise worship leaders ask: Do we present psalms of lament as a gift, allowing full expression and forming us to be able to worship when life is hard?

Giving voice to lament through Scripture such as Psalm 13 allows people to connect to the desire for deliverance from the experience of bearing pain in our soul, having sorrow in our heart, feeling that the foe is winning, and wanting God to answer, to do something. When it feels like everything is a disaster, the psalmist pivots in trust with a vow to praise God. Some parts of the psalm may fit with our own experience at the time, and others can expand our empathy and connection to the people in the church who can voice that portion even when we cannot—yet.

Language Patterns to Avoid

Even though people sometimes easily dismiss the idea that care in our language matters, it does. When preparing the words we use in worship, it is wise to listen with the ears of people who have significant trauma histories or who live with psychiatric diagnoses.

  1. Avoid using diagnostic terms as general metaphors. If a meeting was chaotic, say so—don’t say it was schizophrenic. If you forgot something, say so—don’t call it a dementia day. Communicate clearly without creating barriers that alienate people.
  2. Listen to songs and prayers with an ear for people who have histories of sexual assault. Warren Kinghorn recalled the experience of a survivor of sexual abuse hearing prayers and songs in her church’s worship
    service that referenced God “having his way with us” and using sexually evocative language for spiritual intimacy, to which Warren Kinghorn quoted her as saying: “No. Just no.” Instead, we can pray for God’s comfort and presence, and for God to equip us.
  3. Resist “other-izing” words such as lunatics, idiots, psycho, and crazy. Word usage and meanings do change over time, and who says what does matter. Compared to twenty years ago, “crazy” has broadened to refer not only to being out of touch with reality or psychotic, but also to feeling overwhelmed or unpredictable or extreme (as in crazy good). Yet, if the church context doesn’t have a good track record of using person-focused language and honoring disciples with diagnoses as full members, then the flippant use of “crazy” (or lunatic, or psycho) can alienate people who really do struggle with delusions and hallucinations. Calling people idiots totalizes them in a demeaning way, infrahumanizing (viewing people in particular groups as less than human) people with intellectual disabilities. We can replace totalizing terms with person-focused language that names the specific point we aim to make.
  4. Pay attention to and rework language that totalizes people in terms of their disorders. Avoid saying addicts, anorexics, bulimics, schizophrenics, and depressives. Rather, speak of people who live with substance use disorders, anorexia, bulimia, schizophrenia, or depression. Such a language shift honors people facing their own disorders as well as the family, loved ones, and care providers of people living with disorders. Nothing is lost. So much is gained.
  5. Even those of us who resist a “health and wealth” gospel can find faint echoes of it lingering in our language. Pay attention to language that suggests people without mental illnesses or physical illnesses are more blessed or better Christians than the “less fortunate,” as if they are loved just a little more by God.
  6. Avoid talking only about problems. Listen and learn from people who live with disorders. See their strengths and hopes. Notice the gifts of therapy, medications, and support groups even as people make wise choices and develop coping skills in their recovery. Remember that people who live with disorders have many roles in life: They are friends, family members, workers, volunteers, artists, and athletes. Remember to name strengths along with struggles. People who live with diagnosable disorders can still flourish, experiencing resilience, good relationships, purpose, and meaning. Research has demonstrated that the presence of hope is even more powerful than symptoms of depression and anxiety for people’s flourishing.

Prayer

Adapt as needed

Loving God,
we pray for all who face cognitive, emotional, relational, physical, or behavioral impairments and distress.

We pray for those who bear pain for loved ones, themselves, or those in their professional or congregational care.

May all draw strength, wisdom, and hope from you.

We thank you for discoveries of approaches and interventions that alleviate suffering and promote flourishing.

Embolden us to welcome the many ways in which your care and healing may come to and through us.

Grant us gratitude for your willingness
to enter into our pain,
trust that your faithful love
does not depend on our feelings,
grace and hospitality to welcome,
compassion to serve faithfully,
strength to bear the weight of confidentiality,
restraint from actions and words that alienate,
wisdom to discern appropriate responses,
fervency in translating our hopes and fears into prayer,
assurance of your abiding love,
and hope in your everlasting promises.

Through Jesus Christ we pray. Amen.

—Charlotte vanOyen Witvliet. Reprinted with permission from The Worship Sourcebook, Second Edition © 2013, Faith Alive Christian Resources.

Final Thoughts

The church already includes people with psychological disorders now. Some may be undiagnosed or untreated, some may be afraid that others will find out, and some are ready to have others know so they can be both known and loved, both discipled and discipling others through worship and church life.

Worship words can welcome, include, and disciple God’s people living with mental illnesses. Language can bless people who experience disorders in their own lives or the lives of people they know, work with, and care about. Worship leaders have an opportunity to craft announcements, litanies, prayers, sermons, and songs in ways that disciple the diverse body of Christ.