MEDICAL BACKGROUND AND TRAINING

9Marks: You began your career as a medical doctor and switched to full time teaching and counseling? How does your medical background benefit your counseling work?

Michael Emlet: It has been a lengthy journey and certainly not anything that I anticipated. Because of my involvement in a local church and the interactions I had with patients, I began to think about pastoral ministry. The movement toward ministry seemed to be confirmed externally through church involvement and internally with a growing sense of calling. Over the course of a year or so, I began to wrestle with that calling and finally decided I would go to seminary. I did not think that I would necessarily be counseling as a vocation. I anticipated that I would be in pastoral ministry, and possibly part time in medicine. For example, I saw myself working as a bi-vocational pastor in an urban setting. I ended up attending Westminster Seminary because of CCEF [Christian Counseling and Education Foundation]. I knew that as a pastor, I would be doing a lot of counseling, so I wanted to be better trained.

9M: Why did you want to go to CCEF?

ME: My first exposure to biblical counseling was when I went into practice in South Carolina. There was a real burden to match biblical counselors with Christian family practices throughout the state. It was a terrific idea. In primary care, there are many people that come to their physician with psycho-social-spiritual issues. It is a great opportunity to be able to minister as a physician, but there is just not enough time to be doing that kind of counseling. As a practice, a number of us met with the organizer as well as some of the people that had been trained. It seemed like a great fit, but the person that was assigned to our practice was not actually suited for counseling. He was very abrupt, abrasive and not very personal. After a few months, I did not feel comfortable referring people to him. I had experiences where people were entrenched in certain sin patterns to the point that it created health problems. He gave a cut-and-dried, "Write this verse on a card, and when you're tempted, pull it out." There wasn't much about it that was gospel-centered. For a while, I said I would not go any place where biblical counseling was the norm!

We then had another counselor come along that had a great way with people and really bonded with them. I was encouraged, but after a while I began to be unsure that long-termchange was happening. I knew that theovertly biblical approach didn't seem to connect with people. This new approach seemed to connect, but I wasn't convinced of its ability to deal with deeper issues. I began to hear more about CCEF around this time by talking with a student who had been taking classes and began to get a different sense of biblical counseling.

9M: Are there any worldview assumptions in the medical field that the average Christian or pastor should be aware of as they visit the family doctor?

ME: Generally, a non-Christian physician is going to have a worldview that sees people as simply physical beings. They will be more likely to have a physical or bio-medical explanation for the problems at hand, particularly if there are problems in terms of mood or intellect. This is particularly true when you get into the psychiatric realm. Obviously both Christian and non-Christian physicians will treat something like a broken ankle as a physical problem. But when you get into the issues of mood and intellect, that's where you really see the worldview assumptions coming to bear. Interestingly, even as a Christian physician, all the bio-medical and the physical training I had received caused me to unwittingly and artificially separate the two spheres. In my mind, there was one place where the Scriptures were authoritative, and there was another place where bio-medical knowledge was authoritative. But in my counseling training, I began to see that the Scriptures provide this overarching view to any problem of life.

SORTING OUT THE SPIRITUAL AND THE PHYSICAL

9M: If you had someone arrive at CCEF's door for counseling, expressing some things that may be going on with them psychologically or physically, would you encourage them to also see a medical doctor in conjunction with their counseling?

ME: Yes, sometimes I do. There are some expressions of anxiety and depression that have physical causes. A low functioning thyroid might be associated with depression. An overactive thyroid might be associated with anxiety. Because of my medical background, I tend to approach people holistically. I tend to think—what do I see that is weighted towards the spiritual, towards the heart? What might I be seeing that may have a physical correlation? I try to keep both of these things in mind.

9M: Pastors will often find themselves talking with people who use terms like "major depression," "schizophrenia," or "post traumatic stress disorder." How should pastors think through those labels? Is there any value in them or do they mislead?

ME: I think they have value and can also be misleading. They can be helpful as long as we understand what the labels signify and we are aware of the benefits as well as the risks. In other words, we must be aware of the problems and pitfalls with the psychiatric diagnostic system. Interestingly, even within psychiatry there is disagreement about how we should classify disorders of mood and intellect. The diagnostic and statistical manual of mental disorders is on its fourth edition and they are planning the fifth. It has been delayed because the leaders within psychiatry are fundamentally not sure how we should best classify these problems.

One of the most important things regarding these diagnoses is to realize that they are helpful descriptions of disorders (thinking, behavior, mood), but they are not explanations. Ed Welch talks about this in Blame It on the Brain [P&R, 1998].

Someone comes in (just as they would in any medical situation), describes what they are feeling, what they are experiencing, what they are seeing. Then the physician pulls it all together as a diagnosis.

Similarly, psychiatric diagnoses are a list of symptoms. The difference is that there are no recommended objective tests—physical tests like brain scans or blood tests. There is an increasing interest in examining the brain pattern of someone who has OCD [obsessive-compulsive disorder], or someone who is severely depressed. But no one has determined that to diagnose depression, you need to do a particular blood test; to diagnose OCD you need to do a particular brain scan. We need to recognize that these are good descriptions, but they do not tell you why a person may be depressed—only that they meet the criteria. It gives a helpful outline of what this experience is like, but it doesn't tell you why.

For example, you see me and my face is red and I am stomping around, yelling and my brow is furrowed. You might say, "Oh, you're angry." Then you might ask, "Why are you angry?" What if I replied, "It's because my brow is furrowed, my face is red, and I'm stomping around!" That wouldn't be a very satisfactory answer. I am just using one word, anger, to describe many things—furrowed brow, red face, and stomping.

In a similar way, psychiatric diagnoses use one word (e.g. major depression, OCD, post traumatic stress disorder) to characterize a list of symptoms. It still does not tell you why a person might be struggling in a certain way. I think the diagnoses can come across as more authoritative than they really are. On the other hand, I think those descriptions can be really helpful.

I remember a prime example of this in my own practice. I had someone come in with the diagnosis of asperger syndrome. I never heard of asperger syndrome. It's a relatively recent diagnosis. Was it helpful to me to pull out my DSM and read about it? Yes! It helped me craft questions and better understand the person's experience.

9M: Can you give pastors any wisdom on how to distinguish between medical and non-medical problems? How can they help the people that are coming in the doors of their local church?

ME: I think the first thing is to have your radar up for the possibility that there could be something physical going on. I urge anyone in ministry to avoid the extremes. Do not put all your eggs into the spiritual basket or all your eggs into the physical basket. Always ask the question, "What do I see here that is either in line or is not in line with the gospel?" If something is not in line with the gospel, ask, "What might be going on at the level of the heart? What might be motivating this person?"

Secondly, a pastor should consider what the potential physical aspects of this struggle are? I want to know if I'm dealing with someone who is angry or depressed. What is going on at the home front? If they are being persecuted at work or if they are in a very contentious family situation, these contextual factors matter in terms of the way I approach them. In the same way, I want to be aware of the physical context. These two aspects of our personhood—physical and spiritual—are absolutely intertwined. We need a healthy awareness that both are at work.

Again, if you're dealing with a broken ankle, you're going to be focused on the physical. If you're dealing with someone who is gossiping or complaining, you're going to be focused more on the spiritual side of things. But I don't want to create an artificial distinction. I can't gossip without neurons firing in my brain, so I'm absolutely intertwined.

If someone is on a lot of medications, there is an increased likelihood of disturbances in thinking or mood. The medications may have side effects. The more medications a person is on, (not just psycho-active meds, anti-depressants, etc., but even simple blood pressure medications) there is potential interaction. There may also be sleep issues involved, or symptoms that occur later in life with an abrupt change—that is indication of something going on physically.

Obviously the gospel transforms us, but if I've been an introvert all of my life and, at age 45, I start being extremely extroverted; or I've been extremely thrifty and I suddenly begin spending thousands on a credit card, a pastor should start to wonder if something might be going on physically.

TRAINING COUNSELORS AND PASTORS

9M: You are involved with the counseling internship at CCEF. What does CCEF train interns to do?

ME: The internship falls right in line with CCEF's vision to "Restore Christ to Counseling and Counseling to the Church." We want to equip men and women to use counseling-related gifts to help the church both locally and globally. The internship provides a practical component. It is hands-on training to help people grow in their counseling skills for their field of ministry,  whether it's pastor, director of women's ministry, counselor on staff, or the youth director.

9M: How do you integrate this into local churches? What roles do they play?

ME: Most if not all the interns are in their final year of an MA or the M.Div. in counseling and are involved in their local church. Some are serving in the church and participating in the internship simultaneously. Most of them are involved in leadership. Many are leading Bible studies, perhaps teaching in some capacity. During the application process, we inquire about their level of involvement with their local church and require a letter of reference from the pastor. We need a sense from the pastor that this person is trusted, respected, and actively involved.

PROMOTING CHANGE

9M: What are the most important things pastors and elders should think about as they seek to promote discipleship in their church?

ME: I think the first (and maybe the most important) thing is whether the pastor/elder is exhibiting a lifestyle of being transformed by the grace of Christ. One of my former pastors used to say, "For the church to change, I must change." I think that's right on the money. Whether it is in the context of public ministry, informal conversations, or session meetings, if the pastoral staff is exhibiting that kind of lifestyle (gospel-centered, heart-directed change), then they are essentially mentoring the congregation to do the same.

And this may show up in a man's preaching. I am reminded of a conversation with my former pastor, Joe Novenson, where we discussed whether preaching more grace-saturated messages would decrease or increase your counseling load? We decided that it would increase them, and that has certainly been my experience. As the pastor self-discloses in an appropriate way and makes the Scriptures applicable to daily living, it emboldens people to come forward and say, "I don't have to have my act together. I can be honest about my struggles and failures. I can find help here."

Michael R. Emlet, M.Div., M.D., practiced as a family physician for twelve years before becoming a counselor and faculty member at CCEF. He is the author of many counseling articles, two booklets, Asperger Syndrome and OCD: Freedom for the Obsessive Compulsive, and a book entitled, CrossTalk: Where Life and Scripture Meet to be released by New Growth Press in the fall of 2009.

• November/December 2008 eJournal Editor's Note