Part 1 - The“clinically-informed” in Biblical Counseling
I have shared this story before, but it seems fitting to lead in with it for this article. About five years after salvation (2009), I visited a doctor for some persistent physical symptoms that began about one year after separating from military service. Without exploring any of my history or doing any other clinical medical tests, other than a preliminary basic EKG, a treadmill stress test, and a pulmonary function test, the doctor assumed my heart palpitations were due to an irregular heartbeat, and the chest tightness and frequent shortness of breath were due to asthma. I had never had irregular heartbeat issues and had never had asthma in the thirty-plus years of my life up to that point. It was difficult to accept these two “out of the blue” physical diagnoses. The doctor prescribed Metoprolol for the “heart issues” and Advair for the “asthma.” The meds came with horrendous side effects, but I figured the doctors knew better, so I accepted the side effects as a necessary “evil.”
My original symptoms did not go away, and the anxiety over the side effects made my original symptoms worse. I eventually sought the advice of a heart specialist who did a surgical procedure where a camera was inserted into my leg vein, which was guided to my heart to check for heartbeat function. This is called a cardiac catheterization. The heart specialist sped up my heart and slowed it down with medication. I was half-conscious due to the anesthesia required for this procedure. I saw my heartbeat speed up and slow down on a screen, but I did not feel those effects physically. After the procedure was over and the anesthesia had worn off, he informed me that all my heart circuitry was “absolutely perfect.” He also cautioned me by stressing that I should not be taking Metoprolol. However, due to the potency of this medication on the heart, he strongly warned me to wean off slowly due to the unpleasant heart side effects of lowering the dosage. It took me about 2 years to wean off this medication. Though this was the worst two years of my life, psychologically, physiologically, and physically, my faith in Christ remained secure and grew theologically.
Looking back at the clinical medical assessment of that initial doctor, had she been trauma-informed, she would have recognized that all my symptoms were related to PTSD, not heart or lung. It is possible that she had an ill-informed view of PTSD symptoms and assumed I did not fit the typical profile. It is important to say that not all PTSD symptoms are evident as rage, anger, or outward violence (as stereotypically seen on TV or in movies). Symptoms are also not a result of intentional or conscious cognitive memory retrieval, as some biblical counselors have stated in nouthetic biblical counseling literature. Sometimes, they are inward physiological activations due to an unconscious reaction to overwhelming life circumstances that might not seem overwhelming to another person. Present-day bodily activations are a result of the body’s interactions with past overwhelming experiences, and these symptoms have made them a home in their body, hence the term post-traumatic stress symptoms.
Psychological trauma symptoms should never be seen as deterministic assumptions, as some secular clinicians and researchers might assume. Still, they can last a lifetime if the right kind of help or counseling is not provided. However, it can also be said that a biblical counselor who is not clinically-informed or trauma-informed can run the risk of either denying the reality of PTSD symptoms, minimizing PTSD struggles, or spiritually harming suffering saints by erroneously “diagnosing” intentional sin to an already struggling believer’s Christian life.
With that said, it is important to point out that the term “trauma-informed” has been hijacked, or rather adopted by social justice advocates, educators, and activists for various reasons to influence policy changes in law enforcement, work environments, and education. Over the last several years, the term “trauma-informed” has lost its clinical relevance due to the masses applying it too loosely. As a result, it has become a pop psychology buzzword or a political tool that has been stripped of its clinical use in a counseling setting. Due to this hijacking, some secular, as well as some Christian cultural discourse, has resulted in disdain or outward rejection of the term “trauma-informed,” especially as it relates to clinically informed biblical counseling. It is important to note that the use of the term ‘clinical’ in biblical counseling is only used in the context of assessing the presenting struggles of a Christian’s life, not a description of interventions employed by individual biblical counselors. Interventions do not make biblical counseling clinically informed. Assessment does - meaning what is being assessed and for what purpose.
Although similar in function, the “clinically-informed” assessment for biblical counseling differs significantly from a clinical medical assessment, which is reserved for doctors, nurses, or other medical professionals, which is used to evaluate physical health and diagnose diseases or injuries. The focus of a clinical medical assessment is to identify physical symptoms, review the medical history, and/or use laboratory tests to aid in a diagnosis. A medical clinical assessment is used to determine a proper treatment plan, predict a prognosis, prescribe medication, plan necessary surgery, or refer the patient to a specialist who will treat the disease or injury. The diagnosis and prognosis are typically shared with the patient to help them understand their physical limitations resulting from a disease or injury.
Psychiatrists, who are considered licensed physicians, will use a clinical assessment for mental health conditions, diagnose according to the DSM, and formulate a treatment plan that includes a psychopharmacological component that assesses physical health for medication management (antidepressants, antipsychotics, mood stabilizers, anti-anxiety, stimulants, sedatives, and SSRIs). Psychiatrists undergo pre-medical studies, complete a general medical education, and earn a medical license, similar to that of medical doctors. The primary difference between medical and psychiatric training is the location of the residency. A medical resident will complete their 3–to 7-year residency in a hospital. Although a psychiatry resident will also undergo their residency in a hospital, they are typically based in a psychiatric department or a stand-alone psychiatric hospital, community health centers with mental health services, Veterans Affairs facilities, or correctional facilities. Types of residencies include adult inpatient, outpatient, emergency, addiction, geriatric, post-military service, and forensic.
Psychologists, licensed counselors, or therapists, on the other hand, do not typically prescribe medication. The only exception lies with psychologists who have advanced post-doctoral psychopharmacology training and a license to prescribe, despite having a license to provide psychological therapy services. This allowance for licensed psychologists to prescribe medication is only accepted in a few states, but is allowed in VA settings.
Regardless of how one feels about DSM diagnoses, or medication for that matter (which is not the focus of this article), it is important to clarify that a psychiatric or even a psychological clinical assessment is the means by which psychiatrists, psychologists, and licensed counselors/therapists determine criteria and observe symptoms for diagnosing mental health conditions. Psychiatrists, clinical psychologists, or counselors do not establish causes for mental health conditions in the same way a medical doctor does not determine the cause of physical illness. Though doctors might affirm that a broken bone was caused by a fall or a damaged liver was caused by a lifetime of alcohol abuse, the primary goal of medical doctors, psychiatrists, or psychologists is to treat the symptoms related to an illness, injury, or wound. Symptoms can be visible and overt, like a broken bone, or hidden and covert, liver damage or cancer.
There has been some pushback on the entirety of psychiatry and psychology from some biblical counselors. Omri Miles, a pastor and outspoken critic of mental health conditions, writes, “Psychologists and psychiatrists do not treat the body. This will be news to many, I’m sure, but this act should be easily discerned and uncontroversial to say to Christians. No one would permit invasive, brain, and life-altering surgery after 15-60 minutes of describing their own distressing experiences. But this is exactly the kind of power and privilege that the state has granted mental health experts.”
He is not alone in this kind of reasoning regarding what psychiatrists and/or psychologists do. There seems to be a misconception regarding what constitutes “treating the body” when it comes to mental health challenges. Heath Lambert appears to suggest a clear demarcation in body/soul jurisdiction when it comes to counseling (Lambert, 2017). Keith Palmer presents a rudimentary yet misunderstood biblical anthropology in his interpretation of the interaction between the body/soul in relation to morality and the heart (Palmer, 2024). This is precisely what modern secular psychology wants. They want Christians to stay in their lane and remain uninformed about psychological concerns so they can appear to be wiser than the religious leaders. Clinically-informed or trauma-informed biblical counseling can mediate between pastoral or nouthetic biblical counseling and secular psychology. Instead of waging war with each other, all those who counsel biblically should recognize that we are all on the same team, or rather, we belong to the same kingdom of God.
In the state of California, there is a Welfare and Institutions Code, 5150, that refers to an individual who has been deemed a danger to themselves or others. This is often a result of a mental health condition that calls for an involuntary hold for at least 72 hours for clinical assessment, evaluation, and stabilization in a psychiatric hospital or ward. These cases are not simply a person “describing their own distressing experiences for 15-60 minutes.” Those authorized to implement a 5150 hold include psychiatrists, psychologists, social workers, professional clinical counselors, law enforcement personnel, and emergency medical personnel. Not on this list are pastors, reverends, preachers, or biblical counselors. My husband, who is a law enforcement officer, can implement a 5150 on a person, even though he has no clinical psychological training. I, on the other hand, though I am certified as a biblical counselor, I cannot, despite having clinical training and education, because I am not licensed.
California is not the only state that does this. Each state has its own designation for these kinds of cases. Florida has the Baker Act, New York has the Mental Hygiene Law 9.39, Texas has the Emergency Detention Order, and Illinois has the Petition for Involuntary Admission. The list goes on. It is irresponsible for biblical counselors to make broad, uninformed statements about a profession that is necessary when dealing with individuals who need help beyond the free church meal, if even offered that.
There can be a healthy Christian debate as to why individuals are deemed 5150 in the first place. However, suppose pastors or biblical counselors do not actually work with these populations or interact with them in any way. In that case, there can be a lack of awareness of all the vocations involved in helping these individuals avoid harm to themselves or others, not just during the stabilization phase, but also during the treatment stage.
Aside from psychiatrists who deal with these kinds of cases, many professionals who offer regular counseling, therapy, and psychotherapy services also use general clinical assessments. This means that clinical assessment is not limited to medical or psychiatric stabilization and diagnosis purposes. A clinical assessment is also used to identify general mental health struggles, which include emotional and cognitive concerns, and to identify any behavior patterns or emotional and cognitive deficits that contribute to these mental health struggles. This is accomplished by using reliable and valid inventories or scales, or it can be conducted through simple observational methods, such as a clinical interview (structured, semi-structured, or unstructured).
For biblical counselors, a clinically-informed assessment for biblical counseling should include a comprehensive picture of presenting faith-related struggles, physical health history, family history, church and faith history, family dynamics, social and/or marital relationships, vocational functioning, substance use, and history of traumatic experiences. Some biblical counselors have an extensive, clinically-informed assessment, and others are less invasive. How it is done is often determined by the counselor’s education, competency, and specialization. The data gleaned from a clinically informed assessment should match the biblical counselor’s competency, meaning that the counselor collects only information that is pertinent to their biblical counseling approach.
A clinically informed assessment is used as an observational and evaluation tool that can help a clinically informed biblical counselor gather informational and observational data from their counselees, understand any presenting struggles, plan both somatization and theological counseling goals, offer comforting reminders from Scriptural truth, and if necessary, re-teach sound theology from a theological anthropology that affirms the biblical reality of creation, Fall, redemption using a Gospel driven theo-psyche (theological & psychological) framework, analysis, and outflow. The end goal of a clinically informed biblical counseling assessment is to evoke a Holy Spirit-led egression from old nature habits to new nature identity.
A clinically informed assessment for biblical counseling is to help a counselor understand and appeal to the heart of their counselees by drawing out the deep water of body and soul struggles (Proverbs 20:5). This method of drawing out includes gathering clinically-informed data necessary (mentioned above) from a professing Christian who is seeking biblical counseling. After collecting this data, the counselor can offer contextual hope and encouragement through various interventions that include not only Scriptural reminders of truth but also bodily interventions that can help alleviate physiological symptoms, as well as introduce biblical psyche-theological education that affirms a proper biblical anthropology, grounded in a creation, Fall, and redemption framework that is gospel saturated and Christ-centered.
Lambert, H. (2017, October 13). Myths about biblical counseling and medication. Association of Certified Biblical Counselors. https://biblicalcounseling.com/resource-library/podcast-episodes/til-121-myths-about-biblical-counseling-and-medication/?srsltid=AfmBOop_xDagEEXNkv7lzsn1aDT_8FOjtMOz0mzZCIzCvHEDtcNqf8h8
Palmer, K. (2024, May 23). Biblical psychosomatics. Association of Certified Biblical Counselors. https://biblicalcounseling.com/resource-library/conference-messages/biblical-pyschosomatics/?srsltid=AfmBOop_yhvYRo4V2dvo3TcqwnmHSbAU4Sjmj0yWZhzbjL4RhuHfxdmr
