Encountering severe mental illness as the Church of Jesus.
I come not to urge personal claims, nor to seek individual benefits; I appear as the advocate of those who cannot plead their own cause; I come as the friend of those who are deserted, oppressed, and desolate. In the Providence of God, I am the voice of the maniac whose piercing cries from the dreary dungeons of your jails penetrate not your Halls of Legislation. I am the Hope of the poor crazed beings who pine in the cells, and stalls, and cages, and waste rooms of your poor-houses. I am the Revelation of hundreds of wailing, suffering creatures, hidden in your private dwellings, and in pens and cabins — shut out, cut off from all healing influences, from all mind-restoring cares.
So began the letter from Dorothea Dix to the North Carolina General Assembly which would lead to the establishment of Dix Hill in 1856. To write her letter, Dix did as she did in other states: she travelled around the countryside, visiting the darkest corners of prisons, basements, and attics, where people with mental illnesses had been stashed for want of a better life.
Dix hill, an expansive 2,000 acre land-grant, established a permanent home for North Carolinians with mental illnesses. The hospital grounds contained farms, livestock, housing, park land, a post office, a chapel (built in 1955), and several other buildings for treatments and maintenance.
Dix became a by-word amongst North Carolina natives as a place of hopeful treatment, but it was a project that eroded over time as the focus of mental health care shifted away from institutionalization toward community-based treatment. Hundreds of acres were doled out by the state government to NC State University, to a Farmer’s Market, and, finally, to the City of Raleigh to form a park. The final patients left in 2012.
The impetus behind the closure — always given the positive-spin of ‘reform’ — was to humanize and enliven the people who received treatment at Dix by having them live in the community. People with Severe and Persistent Mental Illnesses (SPMI) would be given appropriate job training, healthcare, transportation, and living conditions that would allow them to return to a positive and healthy lifestyle.
What has happened? Well, the 2012 headline from the Raleigh News and Observer was prophetic: “As Dix Closes, Reforms Sputter.” Already the problems were tangible and awful: “On Friday, the only beds available for adults in state psychiatric hospitals were on a special unit for deaf people at Broughton Hospital in Morganton. An average of 622 people a month were on waiting lists for state hospital beds over a 12-month period that ended in June, according to the state Department of Health and Human Services. The average wait was nearly three days. Some wait much longer.”
People with SPMI have been left to fend for themselves as mental health treatments changed from provider to provider and has funding bodies have changed time and again across the state. North Carolina lost a massive federal lawsuit — costing the state millions — because they were parking people with mental illnesses in nursing homes rather than finding appropriate community services. The silent sufferers whom Dorothea Dix found and imbued with a new voice have again retreated into the shadows.
The patchwork of services and funding is labyrinthine and moth-eaten, with holes so large that a person with SPMI is like as not to fall through the cracks of treatment without ever achieving anything near healthy.
“I made the world,” the man said to me as we waited in line for turkey and green beans. He looked like an everyday man off the street, not the sort of bedraggled homeless man you might affiliate with such statements. Besides his wild eyes, everything about him was unremarkable.
“I made all of it, and I run it.”
I had no idea how to respond. I had barely begun serving on the Board of Directors for Club Horizon, a day program for adults with SPMI, when I was invited to the annual Christmas party, hosted by a nearby Methodist church. I had only joined the board based on an out-of-the-blue invitation from a parishioner. I naively saw need and stepped in, seeking the Lord’s will in my service.
I nodded and smiled as he continued to tell me about his creative powers. Soon after we exited with our heavy-laden plates, I found a staff member I recognized from my tour of the program.
“Oh him? Yeah, he’s great. He writes withdrawals from the member bank for like two billion dollars. He used to be real bad, but he’s getting better.”
“Real bad,” is a term staff and folks with SPMI will use to describe the dark times when the mental illness ravages the lives and families who suffer from it. “Real bad” means going in and out of hospitals, dealing with homelessness, or struggling with over- or under-medicating. It was one of the least formal words, titles, and phrases I would learn as part of the Board. There’s SPMI, MCO, QI, CPAC, NAMI, MSW, RFP, SAMHSA, VR, VA, LMHC, FBT, etc etc. There’s a complex lexicon of formal and informal phrases used by mental health (MH) professionals. One list I found has over 100 acronyms for handy reference for the confused.
I would see him many times over the coming years as I sat on the Board at Club Horizon and there would be steps forward and steps back. It was thus for many of the members: Jimmy over here would get a job and move into an apartment, while John here would have a massive setback and need to head to the hospital for a while. The staff and members would rally around both along the way, seeking each other’s good while walking their own journey. For the people at Club Horizon, saying ‘I made the world’ was another way of saying ‘help me figure out how to get healthy.’ When you around people with severe mental illnesses, they are not off-putting but a common challenge which could be addressed together.
The purpose of the program is noble: as a Mental Health Clubhouse accredited by Clubhouse International, Club Horizon exists to furnish opportunities for friendship, education, housing, employment, and community engagement through cooperation and mutual edification. It is something like a very intense daily church small group or a very involved AA crowd. The folks know their problems and share the journey of recovery and health together.
Problem is, who pays for this? For each organization trying to be a community mental health provider, the way money comes in changes with the wind. Some states fund clubhouses directly. Others fund them through counties or Managed Care Organizations or Mental Health Organization or any number of other funding streams. Club Horizon was operating on reimbursement rates from the state which had not changed in a decade, with some extra funds for ASL interpreters as it is the only program of its kind in the state for deaf adults with SPMI.
Money was tight. I asked around for help. Fortunately for me my father was once the head of Behavioral Health services for Wake County, where Club Horizon was located. His advice? “Grow or merge.” As funding shifted from county-level programming to state funding agencies in North Carolina, the state would desire to work with fewer local agencies. Managing small agencies is do-able for a county. A state doesn’t want the headache.
I presented my report to the board, and I got what any go-getter gets: more work. I became Board President just two weeks before the founding Director of the organization left for greener pastures (at a new state-controlled funding agency, nonetheless!) I found myself Acting Director and Board President of a Mental Health Clubhouse having no knowledge of non-profit leadership, budgets, or mental health treatment.
Merge it was. Finding a good agency to merge with was easy, as I went back to my old man who recommended Monarch, one of North Carolina’s larger providers. Et voila, I found myself on the board of a large agency serving people with a broad range of disabilities across the entire state. An agency wit ha $90 million budget. And I was a Youth Pastor who wasn’t even allowed in my own church’s Elder meetings.
The assumption on the part of activists who pushed for community-based mental health programs was that there was a community waiting to receive folks with SPMI. De-institutionalization is a noble idea because institutionalization connotates stigma. We know the trop of the mental health hospital, the ‘insane asylum’ off in the woods somewhere, Shutter Island with its haunted hallways and piercing screams. Mad doctors experiment on patients in those dark places where the shunned go to die.
Institutions make people feel like the ‘other,’ as something less than human. De-institutionalization would ideally lead to people with mental illnesses talking freely about them while regaining their place in their families and communities. That sort of soft landing requires engagement from religious and civic institutions as well as a healthy dose of education. Most folks exiting institutions found little of either. People I have known at Club Horizon and now at Monarch programs have told me of broken families who had no reason to welcome home their own children, of rampant mistrust from the police, and of constant cycles of hospitalizations and incarceration. Some argue that North Carolina’s prisons are on the way to becoming our largest mental health provider, if they are not already.
The evangelical church in North Carolina has not helped. Time and again at Club Horizon I had people tell me how their pastors would try to pray away their Schizophrenia, cast demons out of them or, worst of all, send them away “until they got better.” Add to this baseline phobia the rise of nouthetic counseling movements which reject all traditional medical approaches to mental illness, and you have a growing number of forgotten sufferers. Nouthetic counseling in particular has wreaked havoc on parishioners who faithfully attend a church for years while on psychiatric medication only to be told their medications are unspiritual crutches misleading them about their own sin. Robbed of theological and moral agency, they are forced to leave their churches or quit their medications, either of which destroys an important pillar of overall health and wellbeing.
As I began speaking in my local congregation and among other pastors about severe mental health problems and our inattention to these silent sufferers, I was floored by the number of senior saints who would tell me things like one woman did in the church narthex after the worship service: “I have never told anyone this, but I have been on medication for bipolar disorder for thirty years. I have been in the hospital several times. You are the first person I thought I could tell other than my husband.” Such testimonies were not uncommon. “My brother has schizophrenia,” one said, “and we don’t know what to do about it.” “My son is severely depressed and suicidal… what do we do?”
Absent education and resources, many local pastors turn to the afore-mentioned nouthetic counseling populating our seminaries or hand out calls to local agencies about which they have very little information. My father became popular amongst local pastors as a go-to for tough situations because he was so well networked, but that sort of informal rolodex gold does not exist for most pastors, especially rural ones.
Untreated mental illnesses frequently result in mental health crises. Imagine the enraged man who cannot calm down, the person seeing people who aren’t there, the one who hears voices, the severely depressed person who attempts suicide. After de-institutionalization, hospitals became the new institutions. People languish in waiting rooms for days for beds. Children, especially, can suffer as the number of pediatric beds in the state is woefully low. Counties hate spending on out-of-county transportation for their indigent people with severe mental illnesses, so they let their people sit for days or even weeks while waiting on that one local bed.
What happens when we take people with severe illnesses and push them into communities which are not ready to receive them or pay for their care? What happens to those agencies when the oversight bodies assigned to them (as non-profits) are often made up of people like me who do not have backgrounds in mental health or non-profit development?
Many closed or merged. Monarch has assumed responsibility for dozens of smaller agencies over the last two decades, some of which were in severe violation of state regulations.
Some continued by receiving special treatment from state politicians or counties who can afford to dole out extra cash.
Most merely languish, too poor to be effective at actual community integration, but too important to let go. I have seen “day programs” which were merely large rooms with a TV and billiard table with over-medicated adults with SPMI forced to sit in chairs all day long waiting for lunch and a ride home. They are force out by their group home managers who will not let them stay home during the day as the rates for reimbursement of group homes have not risen much in the last decade, either.
Again, many persons adopt the idea that the insane are not sensible to external circumstances that to their perceptions the dungeon, chains, cold, nakedness, and harsh epithets are as acceptable as a comfortable apartment, freedom from shackles a pleasantly tempered atmosphere, decent clothing, kindly speech, and a courteous address. They assert that coarse, ill-prepared food is as palatable as that which is wholesome and well cooked, that cold and heat, sunshine and cloud, pure air and that loaded with noisome exhalations, liberty and confinement; are all one and the same to the insane, producing like impressions and results on the deranged intellect. Greater error of belief was never adopted; more serious mistakes, and conducting to more fatal results could not be propagated. The insane in most cases fell as acutely and distinguish as readily as the sane.
How can the church ignore the condition of the severely mentally ill? What structures of belief are revealed by our actions? A couple stand out.
First, the sheer amount of resources pulled into Christian-alternative sources of mental health care implies the church always knows best or that the church is always the best place to help people suffering in certain ways. Christian counseling centers (again, many nouthetic in nature) and Christian mental health support systems (where such exist) are largely created in response to congregational need but have no evangelistic value or support value toward the massively-underfunded programs which already exist out in the community. So instead of engaging people where they are — in their group homes, day programs, and other community services — we are creating other sub-standard mental health programs that are likely better funded but less effective.
What if we took the same approach to other ongoing illnesses, like leukemia? Instead of going to pediatric cancer centers, what if we took our children with leukemia to prayer centers and created support groups that were exclusively Christian in nature? The idea is not only laughable, it is abhorrent. This is how mental health professionals and people in crisis view the anti-medication counseling movements afoot in evangelicalism today.
Second, the lack of training and resources on mental health and mental illness for evangelical pastors reveals the belief that mental illness is not actually illness, that it is either some form of demon possession or other spiritual defect. This despite the many great saints who showed mental health problems in our history, and the titans of the faith today who have spoken so widely about it! Imagine telling Spurgeon that his “fainting fits” of anxiety and depression were imaginary or a spiritual defect, or that the great preacher was filled with a demon. Absurd!
Finally, and perhaps most perniciously, the rise of attraction-oriented ministries has pulled the church away from finding the lost toward hoping they come to us. As Board President of Club Horizon and Board Member at Monarch — about a decade combined, now — I can count on one hand the number of churches who have approached me to discuss engaging the mental health community as the church. Individual members will show up, usually moved by what they have experienced in their own struggles with mental health or with family members who are severely ill, and those folks become the backbone of Boards and volunteer bases necessary to keep these programs afloat. But churches? As a ministry? Or Pastors seeking to connect their churches to our programs? So rare as to be nonexistent.
People with mental illnesses have unique needs, but they also have commonalities with all mankind that are greater than their uniquities. The chief one is the spiritual need for a savior. “I know my sins, and my mental illness did not make me sin,” one mother told me as she shared about her severe seasonal depression. “My bipolar disorder does not excuse the tires I slashed,” a man at Club Horizon said. Categorically, people with SPMI are, in fact, people, and thus are sinners, and thus need Jesus. And they need healing. Both/and is the order of the day, not either/or. If we fix in our minds that the man with severe depression is as afflicted by sin and bodily disorder as the man with cancer, we would find the same sort of compassion, the same reliance on secular medical care, and the same turn to pray for both.
Dix Chapel was late in coming to the Dix campus in Raleigh, but it marked the highlight of many institutionalize people’s lives.
“My favorite memories were the chapel,” said [Lori] Brinson, who received treatment at Dix during periods in the 1980s and ’90s. “I enjoyed the chapel more than any other place. I would go to the church on Sunday mornings and when I got my pass, I would walk to the chapel and read the Bible in the front, which is usually turned to Psalms. That was probably one of the most peaceful places.”
A handful of my friends at Club Horizon shared how they sang in their church choirs. Most, though, said they did not have a church home or a pastor who would call on them. They were swimming alone, spiritually and socially, as the community the de-institutionalize movement thought would form never materialized.
Have pity upon him, have pity upon him for the hand of God hath smitten him! Talk not of expense — of the cost of supporting and ministering remedies for these afflicted ones. Who shall dare compute in dollars and cents the worth of one mind! Who will weigh gold against the priceless possession of a sound understanding? You turn not away from the beggar at your door, ready to perish: you open your hand, and he is warmed, and fed, and clothed: will you refuse to the maniac the solace of a decent shelter, the protection of a fit asylum, the cares that shall raise him from the condition of the brute, and the healing remedies that shall re-illume the temple of reason? Who amongst you is so strong that he may not become weak? Whose reason so sound that madness may not overwhelm in an hour the noblest intellect?
Who amongst us is so strong that he may not become weak, indeed?
If you are not personally experiencing depression already from COVID and the madness of 2020, consider carefully the list of pastors and public leaders who have died by suicide or dealt publicly with depression and anxiety in recent years. Without robust public resources for people with mental illness, where would we have our pastors and parishioners turn? Primary Care doctors can assign the appropriate medicine and do the check-ups, but they do not provide community services or help in de-institutionalizing or de-stigmatizing mental illness. Secular community programs — most of them day programs — offer help for those with SPMI but nothing for those who are borderline or who need to work during the day.
One easy beginning is to consider small groups or special meetings for folks dealing with mental health issues. For the older generation of Americans most steeped in stigma, these groups create spaces to share about mental health struggles. Merely inviting the conversation has a healing effect on those who have bottled up their shame about medication, hospitalization, and other treatments.
The larger task is de-institutionalizing the conversation about mental health in the church. Leaders are stepping forward with their stories. Michael Wilkes, Pastor of Center Baptist Church in Helen, GA, shared his story after the death by suicide of Jarrid Wilson, even recounting his suicidal ideation. “My family and church would be better off if I was not there to just take up space.” Daniel Huyn of The Village Church in Baltimore, MD wrote of his own path in depression, “God has shown me that though He can heal, this darkness may always be a part of my journey, maybe until the end of this physical life.” Dennis Bickers, a church consultant and former pastor, wrote, “I know my depression brought many difficult times for my family. They struggled to understand what was happening to me. My yearlong recovery had numerous setbacks that were difficult for everyone.” These narratives chip away the wall of mental health stigma surrounding the church and invite parishioners into the conversation about their pain.
These personal narratives work well in tandem with a broader conversation across the church. Amy Simpson has written extensively of the resources Pastors and lay leaders can use here. Her curriculum Troubled Minds: Responding to Mental Illness is a good starting place for churches starting the conversation.
The next phase of this mental health awakening within the church is most critical for those with a missional mindset: we must widen the conversation from personal narratives and care within the church to a broader search for those who are “deserted, oppressed, and desolate.” Dorothea Dix, though not an evangelist (and not even an orthodox believer), displayed an evangelist’s fervor in her search for the hurting. Driven by her own experiences and by the horror in what she beheld she would visit as many as 35 asylums and jails in one week in her search for the deserted.
Programs like Monarch and Club Horizon abound across the nation. A simple call to your local or state chapter of the National Alliance on Mental Illness chapter (NAMI.org) will yield a bevy of local organizations. The therapists — counselors, psychiatrists, and the like — likely will not need volunteers, but if you engage them on the question of community engagement, they can open the door to organizations who are badly in need of resources, board members, leaders, volunteers, and a loving church family for folks needing hope. In this proximity, those who are alone and lonely may well find a hope which surpasses understanding.
 Dorothea Dix, “Memorial Soliciting A State Hospital for The Protection and Cure of The Insane, Submitted to The General Assembly of North Carolina. November. 1848” p. 3 https://docsouth.unc.edu/nc/dixdl/dixdl.html
 Dix, p.6
 https://www.christianitytoday.com/pastors/2013/april-online-only/addressing-depression-and-suicide-in-your-church.html and https://www.christianitytoday.com/pastors/2016/april-web-exclusives/top-10-resources-for-mental-health-ministry.html among others