WHAT ABOUT MEDICATION?
Every time I talk about the intersection of mental health and faith, someone in the audience asks me about medication and depression and faith and science and diagnosis and what I think about it all.

In this final review of BIPOLAR FAITH the erudite pastoral theologian John Swinton talks about medical imperialism (how much do I love this term?) and the limitations of diagnosis and the complexity of mental health. And, after a little fangirling, I respond by telling stories that compete with the dominant narrative – both theological and medical.

Whose Story Counts?

Medicine, Theology and the Challenges of Diagnosis

Monica Coleman is clearly one of the leading scholars within the area of theology and mental health. In all of her writings she brings a personal, unique and penetrating perspective to the issue of mental health and mental health care and offers her readers deep insights into the necessity to recognise the complexity of the issues and the deep pain of the experience. In Bipolar Faith she brings new and sometimes quite remarkable insights that emerge from her own narrative of depression. The book is masterful in the way that it winds together experience with theological reflection in a way that shines fresh light on both. It is also deeply poetic and at times quite beautiful. For example Monica’s poignant observation on what it means to cry—“some tears are acceptable”—opens up some fascinating perspectives. It seems that for some, it is alright to cry in the context of worship as you express your awe and wonder at the felt presence of Jesus through the power of the Spirit. But, apparently, it is not acceptable to cry when you are depressed and feeling like the soul of your life has been torn away. She is right, some of us do have some odd spiritual double standards. I wonder where people think Jesus goes when the darkness descends? Are the tears of sorrow that we cry as we search for Jesus in the midst of depression not equally as spiritual as the tears of joy that we weep as we worship and recognise the presence of the Lord? Jesus tells us that he will wipe every tear from their eyes (Rev 21:4). All of our tears are valid and all of our tears are temporary.

As the book unfolds, we finds ourselves drawn into a narrative that is not our own, yet which still manages to find resonance and fit within our emotional and spiritual lives. The ability to draw readers into the depth of a story and wrench out shared feelings, emotions, and experiences in the reader is a mark of a good storyteller. Monica clearly has that gift. I can’t really offer any kind of critique of her work. How could you possibly critique someone’s story? Why would one desire to do so. So other than wondering why, bearing in mind the richness of the narrative and the depth of her trauma, the diagnosis of bipolar disorder seems to become the primary interpretive concept towards the end of the book, I am happy for the narrative to do its own work without my interference. That is not a criticism just an observation and a question. I suspect that Monica has her own theological reasons for taking this position, I just think that the book shows very clearly that there is much more to her experiences than medical diagnoses can really capture, significant as they may be. The diagnosis of bipolar disorder wasn’t always there lurking around waiting to be found. It comes in as a conclusion and a helpful perspective, but it clearly is not an explanation for the things she went through.

There is however one issue that I think it might be helpful for us all to reflect upon, and it does relate to the issue of diagnosis. In Monica’s chapter titled “Diagnosis” she lays out quite clearly the problems and the blessings that diagnosis can bring. It will be worth our while drawing out some of the important points that she makes and infers here as they relate to the book and to the life of the church.

Diagnosis

I’ve been thinking a lot about diagnoses recently in relation to my own work on mental health challenges. What exactly are diagnoses? What do they really explain? Are they helpful re-narrations of a person’s living experiences? Or can they distract us from other stories that may be invaluable for a faithful understanding of caring and being with? I haven’t yet come to a conclusion, but Monica’s reflections on her experience of being diagnosed—both by the church and by medicine—is deeply enlightening. In what follows I would like to offer a few reflections on Monica’s experience of “being diagnosed” within the medical and church communities, and begin to tease out some of the important issues. By using fragments of her narrative I will try to show the epistemological significance of diagnosis for the framing of the experience of depression and in so doing, draw out some medical and theological dynamics that can help deepen our understanding of the practices of naming and the importance of thinking narratively about mental health challenges. Let us begin with two incidents that are described in relation to Monica’s experience of diagnosis; one medical and the other theological. One uses the language of medicine and diagnosis, the other the language of theology and theodicy. Both, in different ways, highlight some key issues that illuminate the tensions within Monica’s acceptance of the explanation of her situation.

The Hermeneutics of Psychiatric Diagnoses

Put simply, diagnosis relates to the identification of the nature of an illness or other problem by examination of its symptoms/manifestations. Diagnosis is a fundamentally hermeneutical project wherein using the knowledge available, we interpret particular sets of experience and come to certain conclusions that fit within our understanding. So, we bring a certain set of experience to the psychiatrist or the pastor. They then interpret these experiences according to whatever framework they have been trained in. Through this process a diagnosis is inferred and ascribed. The problem of course is that when this process has been completed and the diagnosis given, there is a temptation to forget about the original story. The things I have been through are now all explained by this new interpretation and this new name. Bearing in mind the power of Monica’s story, simply to tie all of that down in terms of a catchall medical category just doesn’t feel real. To do so is to lose the power and significance of her story and risk turning her lived experience into pathology and symptoms.

However, diagnoses are first and foremost, as my friend David Finnegan Hosey reminded me recently, stories (if readers have yet to read David’s book Christ on the Psych Ward, it is well worth checking out). They are stories that are based on a re-narration of a previous story. The final version of the explanatory narrative is inevitably determined by the power of the narrator, which is why mental health diagnoses can be tricky. They tend to draw everything into the same re-narration and proceed from there as if that was the only important story that needs to be told. But the diagnostic story is not the only story in town, as Monica’s story so masterfully illustrates. Medical and theological diagnoses may be necessary for certain purposes, but they are clearly not sufficient.

Monica pushes us to look at diagnosis slightly differently. At one point she provides us with this vignette:

I told the nurse that I was sad, tired, and uninterested in eating. She told me that I was depressed and needed medication. In fact, she added, I would probably have to be on medication for the rest of my life. “Can’t I just see a doctor? Isn’t therapy included in my health plan?” The nurse refused to schedule an appointment with a doctor until I agreed. Until I told her I would take medication for the rest of my life. I was desperate, but there was no way I was letting these people give me another pill. Ever. I took my weak sad self home.

This encounter raises fundamental questions about the hermeneutical power of medical diagnosis and the ability of mental health professionals to determine what it is that we are experiencing. “You can only get help if you believe what I believe!” There is no discussion, no other stories allowed; just a statement about how the world really is for you even if you don’t agree. This is medical imperialism at its worst. “You have an illness like any other illness. You will have to take your medication and continue to take it for the rest of your life.” Depression here is narrated primarily as an incurable illness that can only be dealt with by medicine and via medication. But is that really an accurate narration of the situation? As one reads through Monica’s story it becomes clear pretty quickly that whilst biology may be involved in her depression, her social experiences are fundamental to her story. Does it really make sense to suggest that medication can eradicate the significance of our history? Monica’s lament—“Can’t I just see a doctor? Isn’t therapy included in my health plan?”—is basically a cry for her story and her history to be listened to; for the nurse to hear and to recognise that she has a story to tell that cannot be healed by medication alone even if the “symptoms” of her sadness may find a certain kind of alleviation in the interaction of chemicals. It is a cry for the nurse to try to understand that there are many ways in which people’s mental health experiences can be understood and articulated.

At that stage in her story Monica was avoiding taking medication, but not simply because of the side effects. In her perception at that point in time, taking medication was perceived as being forced to make a major change in her identity. She had no desire to become a “chronic mental health patient.” She knew that there were other stories to be told. When eventually she did begin to move towards medication as a viable option, she hesitates:

I held the green-and-white rectangle of pills in my hands. It was a simple question that required a tectonic shift in my own understanding of myself.

As she stands on the precipice of a major change in her identity, her friend reintroduces her to the significance of faith. But the form of faith that he points her towards is different from what we might assume:

You have to have faith,” he insisted. “I do.” I immediately replied. “I don’t think God hates me or anything. I believe in God.” “No. Listen. You have to have faith in the medication. You have to believe it will help you. Or it won’t. You’re going to have to trust this too. . . . It’s not idolatry. If you really believe God is in everything, if you really believe that, then you have to know that God is in the medicine too.”

Theologically I don’t hold the view that would believe that “God is in the medicine,” or that God is in everything. I am not sure that is the best way to articulate the relationship between God and creation. Nevertheless, there is still something powerful about recognising that God can work through the medicine. Depression is a certain kind of pain. Pain prevents us from relating to ourselves, to one another. Pain, as Stanley Hauerwas has put it, is the enemy of community. Having faith that medication can open up new spiritual connections—with God, self, and others—draws the mundane practice of taking medication onto a spiritual plane which transforms this technical human practice into a mode of divine relational healing. Medication may be necessary but it is not sufficient for our healing. There are other stories that need to be told. None of this should be heard as a criticism of mental health professionals. It is however an argument against medical dogmatism and the kind of shortsightedness of those who have a tendency to try to reduce mental health challenges to within the boundaries of a single narrative.

Theological Diagnosis

The practice of diagnosing mental health challenges is not something that is confined to the realm of medicine. One might have assumed that the perfect counter story to the kind of narrative reductionism we have discussed thus far is the gospel. The gospel’s wonderful and transformative story about God who in Jesus and through the power of the Holy Spirit offers love, acceptance, salvation and a place of belonging for all within the coming kingdom. Seems like the perfect answer to reductionism. Jesus the healer promises to end our suffering and heal our brokenness. What better way to re-narrate experiences such as Monica’s? Well, Monica reminds us that she loves and trusts Jesus very much, but his followers . . . notsomuch. Monica tells the story of her encounter with Christian psychiatrists, one of whom just happened to be the mother of her best friend:

[The assessment of the Christian psychiatrist was that] I wasn’t depressed. I was lonely. I just needed better social connections. She recommended a local church I might like. I had a church. I had God. I knew the difference between loneliness and illness. I tried another psychiatrist—the mother of a good friend. She knew I was a minister. She even knew my Nashville church. I began to feel comfortable. As we talked on the phone, I told her about the terrible HMO people. I told her about the woman at the counseling center. I told her that I was looking for a referral for a psychiatrist in my part of town. She told me that I didn’t need a doctor; I needed Jesus. I didn’t hear a word she said after this. I made up an excuse to get off the phone. I tried to be polite because she was my friend’s mother. But no, this was not about religion. The conversation added an hour to my daily crying session. It wasn’t hard for people to understand that? Aren’t I telling people I am sad?

The first psychiatrist did, to her credit, seem to push towards a perspective that recognised that there may be social and relational dimensions to depression. However, again, she simply didn’t listen to Monica’s story. Had she listened she would have known that she loved Jesus and that she was deeply engaged with God’s people even if, at times, that was a hard thing to hold onto. Instead she offers a social model to explain her sadness, as if Monica was somehow incapable of seeing the difference between loneliness and illness. Had she listened to her story instead of writing one for herself, things might have been a quite different.

The second psychiatrist was so deeply immersed in her spiritual projections that she was unable to hear any other story. Worse, by implying that Monica was presently out of touch with Jesus, she engages in what we might call casual theodicy. Casual theodicy is a form of lazy thinking wherein Christians ascribe distance from God, sin, or the demonic to explain the presence of psychological distress. Casual theodicy often ends up blaming the individual, locating the problem firmly outside of the social realities of a person’s experiences and placing it firmly within the realm of spiritual alienation, sin and evil. This way of thinking is lazy because it takes no time and makes no effort to explore the complex processes and experiences that are involved in the development of mental health challenges and the complexity of what it means to move towards healing and understanding. It is not just lazy. It is also malignant. It chooses to point the finger of evil at some of the most vulnerable people in our society. It would be rather unusual if a person was stricken by cancer and a pastor were to suggest that what they really need was not chemotherapy or radiotherapy but Jesus. I wonder what Jesus would do?

Conclusion

The problem with casual theodicists and reductionist medics alike, is that they seek to explain people’s mental health experiences without really listening to or hearing their stories. The beauty and the elegance of Monica’s story as it is laid out in Bipolar Faith, is the way in which it refuses to yield to reductionist explanations—be they medical or spiritual—of what has happened to her. In the end she accepts the necessity for diagnosis and medication, but that acceptance only makes sense as we read the practices of naming and medicating, through her narrated history. Her story helps all of us to see that her depression, like all people’s depression, is multifaceted and multi-storied. Depression needs to be narrated to be believed. But narration alone will change nothing unless there are those around who take the time to listen. Monica urges both medicines and theology to listen differently and to hear more faithfully. And that is a great blessing for us all.

Response to John Swinton

It is an honor to engage John Swinton’s reflections on Bipolar Faith. He begins by describing me as “one of the leading scholars within the area of theology and mental health,” but truly the naming of the leading scholar in the area of theology and mental health belongs to him. Swinton’s numerous writings and reflections at this nexus have long inspired me to wade into the waters of this field. I can imagine the challenge of writing a critique or reflection on Bipolar Faith. It is not a theological treatise, although thoroughly theological in reflection and struggle. Reading Swinton’s response helped me to see more clearly ideas I put forth, but it also makes me weep joyful tears of overwhelm. I am bowled over by what he sees in this text that is not just narrative, but my narrative.

I appreciate Swinton’s engagement of the concept of diagnosis within Bipolar Faith and he poses one of the major questions I wrestled with in the writing. “Why,” he asks, “does the diagnosis of bipolar disorder become the primary interpretive concept towards the end of the book when the book shows that there is much more to [my] experiences than medical diagnoses can really capture?” For those of us who live with mental health challenges, diagnosis becomes a necessary interlocutor. For better or worse, the medical model reigns supreme in Western societies. By discussing diagnosis, I tried to shine a light on four common challenges, many of which Swinton names more beautifully than I did.

First, the encounter with what Swinton names as the medical system is complex and difficult even for an educated relatively privileged person such as myself. I love that Swinton names it “medical imperialism” (you will find me citing this all over the place now) because that is indeed what it is. It is the dominance of one narrative about mental health that is generally unyielding and resistant to other forms of understanding. Yet, when seeking assistance for a mental health challenge, those of us living with the challenge will run into the fact that most therapeutic, clinical, and medical practitioners will strive to diagnose first. I wanted to show the limitations of diagnosis—that checking off a list of symptoms is only one part of a multifaceted life. I don’t completely decry identification of symptoms because, after all, symptoms can end a life. The symptoms of under-eating, sleeplessness, and suicidal ideation can quickly become serious and life-threatening. But they are symptoms; they are not root causes and they are not a life. Swinton sees this well. He sees that we-who-are-diagnosed encounter an imperial narrative about how our condition works and what will make it better. Its imperial nature cares little for who we are, how we got there, and where we want to go in our lives. It has one dramatic arc. And all of us-who-are-diagnosed wrestle with this dehumanizing system that is supposed to save our lives. I could not write about mental health and not talk about how challenging it is to try to preserve one’s life in the midst of this overarching narrative.

Because of the power of this imperial narrative, I had to write about medication. I wanted to show how I stand between the medical narrative that does not like to be questioned—that lifelong medication is the only treatment—and a spiritually terrorizing narrative that suggests that the only cure for mental health challenges is more prayer, more spiritual engagement and never medication. Swinton well articulates these as incomplete and often-competing narratives. Here is where Swinton and I differ. I am a panentheist. I believe that God does more than work through medication; rather God is in everything and, in true process theological fashion, everything is in God. For me, God and the world are not collapsed into each other; the world is not God; there is a distinction. I do believe that God and the world are internally related, thus composing one another. And I found both peace and power in the concept that God is in the medicine—a concept that operates as both faith and fact for me. Swinton recalls that taking medication represented a shift for me. The shift, however, was less one of identity, and more having to put my faith in a Western medical system that I didn’t trust. I didn’t trust them to accurately diagnose me. I didn’t trust them to listen to me. I didn’t trust them to medicate my non-white non-biologically male body (after all, so many drug trials about “therapeutic dosages” are conducted on white men’s bodies). I also wanted to share about faith in the face of the fact that I, like so many others, had to operate within a system that was never meant for my survival.

As a third point, I did want to write about Bipolar II as a depressive condition, and this falls squarely within the realm of diagnosis. Bipolar II is lesser known than Bipolar I, and—at the time of my diagnosis—often misdiagnosed as unipolar depression. I wanted to show that there are different kinds of depressions and challenges in getting diagnosed accurately. I had read no memoirs about a person living with Bipolar II, someone who never experienced the more dramatic highs of mania, but did have a hypomania. I wanted to share my part of that story to contribute to the landscape of how a wider public thinks about depressive conditions.

Swinton’s question is poignant because his conclusion is the same as mine. While I wanted to tell the diagnosis story, my overarching intent with Bipolar Faith was to say that living with a depressive condition is so much more complicated than the medical imperialist narrative. I wanted to highlight the complexities of poverty, war, alcoholism, sharecropping, abuse, sexual violence, trauma, and institutionalized racism. I wanted to say that all of these can drive a person mad, even when (even though) the medical imperialist narrative doesn’t want to hear these stories. This is the story I wanted to tell: naming and understanding the mental health challenges that I experience, that many women experience, that many African Americans experience, that many communities that live in and through unacknowledged trauma experience . . . is complicated.

 

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