I’m thankful to God for David Powlison, together with his predecessors and successors in the Biblical Counseling movement. By God’s grace, they have restored the pastor’s role in counseling, and led a wonderful reformation of church counseling practice. Their books have been blessed to me personally, and I use their materials extensively in our counseling classes at Puritan Seminary. Recently I was sent this video interview with Dr Powlison.

I agree with Dr Powlison:

1. Psychiatric drugs, like many drugs, are often prescribed to treat symptoms instead of dealing with the causes, the issues of meaning and relationship.

2. Psychiatric drugs, like most drugs to some extent, are often over-prescribed and overused.

3. Psychiatric drugs, like many other drugs, can have a placebo effect in some people.

However, I do have some pastoral concern with some of the emphases in this interview. It is difficult to comment on the paraphrase of the remarks attributed to the Director of the NIMH by Dr Powlison (if anyone can supply me with the exact words and larger context, I would be very grateful). But I’m a bit concerned lest by overreacting to over-use or abuse of medication, we end up with under-use or non-use, especially if it is a life-or-death situation. Also, though some studies do show a significant placebo effect with psychiatric drugs, I would not be quite so dismissive about alleviating the suffering of one third of millions of people with depression.

My major concern though is with Dr Powlison repeatedly describing psychiatric drugs, and the SSRI’s in particular, as only dealing with “symptom alleviation.” Implicitly and explicitly Dr Powlison says again and again that there are always underlying “issues” or causes. The issues are “meaning or relationship,” or “what you are living for and how you are living,” or “the two great commandments.” In other words, the default position in dealing with a depressed person is that their personal sin has caused it, they are responsible for it, and so they must repent and believe the Gospel. Of course, personal sin can and often does cause (or contribute to) depression and anxiety, just as personal sin can and often does cause (or contribute to) heart disease, or certain types of diabetes, or even blindness. But these same diseases and disabilities can also be the result, not of personal sin, but of living in a fallen body in a fallen world.

Just as the curse on this world and our bodies can cause mechanical, chemical and electrical problems in our hearts, our livers, our pancreas, our eyes, etc., so we can also have mechanical, chemical and electrical problems in our brains, which may affect the way we think, and even our personalities. I’m sure we have all seen loved ones with brain injuries, bleeds, or tumors dramatically and painfully change in this way. Nutritionists have also demonstrated how certain foods can affect our moods and thoughts, our feeling and thinking.

The brain is the most complex organ in our body, and so is liable to be the most affected of all our organs by the fall and the divine curse upon our bodies. And as processing our thoughts is the main activity of our brain, we can expect this area at times to fail and break, through no fault of our own, with subsequent emotional and behavioral problems. (And that’s not to deny that a person is responsible for how they respond to mechanical, chemical, or electrical failures and faults in any part of their body.)

In these cases, medication is not merely alleviating symptoms, but addressing the causes. It is no different to me giving my 8-year-old daughter one of her many daily injections of insulin for diabetes. I am not merely alleviating symptoms, but addressing the cause – depleted insulin due to dying or dead cells in her pancreas. And if she is lethargic, weepy, or irrational due to low sugar levels, I do not ask her what commandments she has broken or what “issues of meaning and relationship” she has in her life. I pity her, weep for her, and thank God for His gracious provision of medicine for her.

If we come to the point that our default position in dealing with depression is “it’s sin until proven otherwise,” we are getting painfully close to the disciples position, “Who sinned? This man or his father?” (John 9:2). It is also getting worryingly close to the “health, wealth, and prosperity gospel,” in terms of diagnosis (personal sin) and prescription (more repentance and faith).

I realize that many in the biblical counseling movement have “moved” on the use of psychiatric drugs, and I welcome that. I also realize, as Dr Powlison said, that there are various views within the movement (see Ed Welch’s careful and sensitive Blame it on the brain?). We are all continuing to learn from God and from one another in the community of faith. I dread to think where we would be today without the courageous and wise leadership of the Biblical Counseling Movement.

But I started by saying that my concern was pastoral rather than polemical. And I mean that. Maybe it would help if I explained the particular pastoral context I’m thinking of. I was a pastor for 12 years on the west coast of the Scottish Highlands. Sadly, that beautiful area has one of the highest rates of depression in the western world, and I dealt with many Christians who endured years of mental suffering and spiritual darkness. Although initially, in my youthful zeal, I probed for the sin or “issues,” because I did not want just to “alleviate symptoms,” I came to realize that I was often (though not always) dealing with people whose problem was not “issues of meaning or relationship.” As I got to know them, I came to see that what they were living for and how they were living was not the problem; they were unquestionably living for Christ, and living like Christ.  In fact they were among the most godly Christians I have ever met. The Lord was everything to them and they would not let go of Him despite everything screaming from within and without, “There is no God.”

So, I would encourage pastors dealing with depression to fight strongly against adopting the default of “it’s sin until proven otherwise,” or as Dr Powlison says, “there are always issues, underlying issues”, or “it’s about what they are living for and how they are living,” or “its about the two great commandments.” It may well be. But let’s not begin there and so potentially damage some of the precious people of God in their moments of greatest weakness.