What Pastors Need to Know About Mental Health, Ministry, and Liability

Mental health is not often a public topic of conversation—or even a private one. That avoidance appears to be just as prevalent, if not more so, in church settings. In recent years, however, a plethora of research has shown that mental health issues are more common than one might think, cutting across gender, ethnicity, and socioeconomic status. According to the Substance Abuse and Mental Health Services Administration, it’s estimated that almost one in five Americans suffer from some form of mental illness each year.

As churches become increasingly aware of the widespread and serious nature of mental illness, church leaders may wonder how they should engage mental health ministry in the church—and what legal risks they may face in doing so.

The most important mental health case to date

Lisa Runquist, an attorney specializing in nonprofit law, has researched the issue of liability for churches that have chosen to counsel individuals with mental health issues.

For Runquist, the most important court case regarding churches and counseling came in 1988 when a lawsuit—Nally v. Grace Community Church of the Valley—was ultimately decided by the Supreme Court of California. An individual, Kenneth Nally, had sought help from counseling through Grace Community Church of the Valley and later committed suicide. Nally’s parents then brought a wrongful death action lawsuit against the church and four church pastors, alleging “clergyman malpractice” (negligence in failing to prevent the suicide).

Runquist explains the verdict and its importance:

The Supreme Court of California . . . found that the church was not liable for clergy malpractice and did not violate any legal duty to Mr. Nally. Specifically, there was no duty on the church and its pastors (and other “non-therapist counselors”) to refer suicidal persons to licensed psychotherapists. In addition, there was no cause of action for wrongful death based on intentional infliction of emotional distress. Since that time, there have been other cases brought in various other states, also finding no breach of duty by clergy.

For churches worried about the risk of liability for counseling someone with mental health issues, that’s good news. But it’s not the full scope of the issue.

Runquist is quick to note that although the Supreme Court of California ruled in favor of the church in this case, it did so based—at least in part—on several key facts of the case that might not be applicable to future lawsuits against churches. Those key facts in this specific case were:

1. The individual voluntarily sought counsel from the church.
2. The church did not have a professional or clinical counseling ministry. They responded on a spiritual, biblical, or prayer level. "In essence, defendants held themselves out as pastoral counselors able to deal with a variety of problems—not as professional, medical, or psychiatric counselors," according to a concurring opinion from the court.
3. Both the individual's mother and father had been informed by several physicians and psychologists that he needed acute psychiatric care and should commit himself or be committed. The parents rejected this advice.
4. The church actually arranged several visits to physicians or psychologists in addition to encouraging the individual to continue to see and cooperate with the physicians and psychiatrists he was already seeing.

“Although the California Supreme Court rejected the Court of Appeal’s imposition of a duty to refer on pastoral counselors, the facts surrounding the case cannot be overlooked,” says Runquist. “In fact, a concurring opinion found that there was a duty [on the part of the church], but that it was not breached in this case” (emphasis added).

This means that churches may indeed be taking on some legal duty by offering counseling—even if the counseling is solely spiritual in nature and that spiritual nature is made explicit. How much liability they take on, however, depends on the church and what it communicates to its counselees and community.

Pastors need to weigh carefully the help they offer to those dealing with mental illness and how that help is conveyed. This is especially true given the scope of the issue—and the inadequate preparation for it on the part of most pastors.

Pastors have ‘next to zero’ training

The reality of mental illness is larger than has been historically acknowledged in our culture—both in Christian circles and outside of them.

Brad Hoefs is a pastor who started Fresh Hope for Mental Health (or “Fresh Hope”), a peer-to-peer support group similar to Alcoholics Anonymous, for both individuals and the families and friends of those dealing with mental health diagnoses. Hoefs himself has been diagnosed with bipolar disorder and believes the church has a long way to go to adequately minister to people in this area. He sees the issue of mental health as widespread, urgent, and a prime opportunity for ministry.

Take the issue of suicide. There are “now more suicides per year than there are [fatalities due to] car accidents,” says Hoefs. “More people are shot by their own hands than are shot by guns by other people.”

Not all mental health issues are as life-threatening as depression with the risk of suicide, but all mental illness is serious for those who experience it. Of those with a mental health issue, three out of five receive no treatment, according to Dr. Matthew Stanford, an adjunct professor in the Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine and the Department of Psychology at the University of Houston.

“But the church can really play a role in that,” Stanford says.

Stanford is also the CEO of the Hope and Healing Center & Institute, a comprehensive mental health resource provider in Houston, Texas. He advocates that churches need to engage this issue effectively. It turns out churches may not have a choice when it comes to engaging the issue—only in how they do so.

That’s because some evidence suggests that when people seek help for a mental health issue, they may be more likely to seek out clergy, rather than medical professionals like physicians or even licensed therapists.

If pastors are as likely to be asked for help as mental health professionals—or perhaps even more likely—then a crucial question arises: are churches and church leaders equipped to handle this issue?

Unfortunately, many aren’t.

“We did a study of seminaries to see what kinds of mental health training pastors get,” says Stanford. The results were not encouraging: “it’s next to zero.”

So what training do pastors receive in seminary for these issues? “Most get one counseling course, and those focus more on family and marriage issues,” says Stanford. “When we do surveys of pastors, a vast majority—80 to 90 percent—say that they feel ill-equipped to deal with people with mental illness.” Considering the “next to zero” training for pastors in this area, that’s not too surprising.

What’s stopping the church?

Mental health is a complicated field, one that is foreign to much of the general population. And it’s seldom talked about publicly, even in churches: places meant for depth and healing. But mental health professionals have said that churches’ avoidance of these issues has recently started to change.

Amy Simpson, a popular speaker and author who writes about mental health issues in the church, has noticed a difference. “I get to be part of these conversations that are happening at churches, sponsored by churches, that were not happening 5 to 10 years ago.” Despite those noticeable changes, there are still factors that keep churches from directly, wholeheartedly addressing mental health issues.

Hoefs has years of experience with his Fresh Hope support group ministry, and he thinks he knows the reason churches don’t talk about, let alone actively engage, this issue. “They’re scared of it,” he says—and churches know too little about mental illness to allay their fears.

Hoefs thinks there’s a misconception among pastors when it comes to the reality of mental health, something echoed by other experts interviewed for this piece. That misconception is, in part, due to many in the church failing to see that the brain is like any other bodily organ. It can function well, and it can also malfunction.

The experts interviewed agreed that there’s a tendency in the church to over-spiritualize mental health issues. For example, church leaders can mischaracterize depression, a clinical psychological condition, as solely the result of a lack of joy, one of the fruits of the spirit. In this way, the bodily nature of the brain as an organ is somehow separated, in church leaders’ minds, from the rest of the body. The problem with that, says Hoefs, is it neglects the reality that “we’re whole beings.”

Stanford, too, knows plenty of examples of this misunderstanding of mental health by churches and church leaders. He recalls one instance: “[A] gentleman brought his wife in [to a pastor] and said, ‘She spent all our money. We literally have no money left. I don’t know what to do.’ The pastor said, ‘This is a spiritual issue, and you’re a bad steward.’ The pastor put them in a Dave Ramsey course.” Stanford says that while he loves Dave Ramsey, this was not a stewardship issue. The wife wasn’t a bad steward of God’s resources: she had bipolar disorder.

Being aware of these differences—and the need for different treatments—will be a crucial skill for any pastor offering counseling. It will also be an important skill in protecting the church from potential liability.

Do churches face liability with mental illness?

When it comes to those in ministries who help people affected by mental illness and the attorneys who advise churches on these issues, there’s a fundamental separation. Both groups agree about the seriousness of mental health issues, but they differ when it comes to seeing potential liability for churches in the area of counseling. Therefore, church leaders will need to make their own decisions about how to weigh these risks.

The legal argument for caution in counseling

Attorneys say there may be real liability in offering counseling services to those suffering from mental illness. Churches may still decide that the pastoral need outweighs the legal risks and offer some counseling services, but that decision should be carefully considered.

Erika Cole, a Maryland-based attorney who operates a practice dealing with church and nonprofit law, says that churches, in general, are not equipped to properly navigate counseling services for those with mental health issues.

“It is a legal quagmire, frankly, for churches,” says Cole. “It is a difficult area to maneuver for a lot of reasons.” Those reasons, according to Cole, include limited pastoral training, a lack of expertise in this area, and understaffing. In most pastoral counseling, pastors are “dealing with everything from marriage counseling to raising kids,” she says. “Mental health really is its own area of concern.”

Is there evidence that churches take on liability by offering counseling services to individuals with mental health struggles? Cole says there is. And the aforementioned Nally case proves it.

From that case (and similar ones), “it seems there is potential that a court may hold a pastor or minister who provides counseling for the purpose of addressing mental health concerns to a higher standard of a licensed counselor, even though he or she may not hold himself out as such or be licensed,” says Cole. “That in and of itself creates [a] higher standard, and so that could mean that . . . the ministry would be evaluated by a court in a more stringent way.”

Though Nally is now a well-known case, Cole says it’s not the only one: “there are cases filed on a regular basis claiming that the pastor or church is liable” for the outcomes when individuals with mental illness sought help from those leaders and churches. “I just think we should proceed with an awareness of the potential liability and with a plan of action for how to address those potential pitfalls,” she says.

Cole says there is no one-size-fits-all approach for churches in the realm of mental health and ministry. Instead, “there are options to be considered based upon any particular church’s potential for liability and what risks they are willing to assume.” Some churches decide to still engage intentionally with ministry toward those struggling with mental health issues because they feel strongly that it’s the right thing to do. Though churches can never operate risk-free in this area (or in any other), they can manage and minimize their risk. To that end, Cole says there are a few options churches might choose:

Outsourcing mental health counseling
Outsourcing counseling for individuals with mental health issues, rather than providing it internally, ensures that the church can still make referrals but that the liability for the actual treatment will rest with another organization: hopefully one better equipped to meet the higher standards of a licensed counselor.

Licensing the church’s own counselors
Some churches have decided to make sure their counselors are licensed as mental health care professionals: “[i]n other words,” Cole explains, “if you’re going to be held to a higher standard, make sure you have the training of that higher standard.”

Pastoral counseling despite liability
Other churches take the stand that they have a spiritual and ministerial duty to serve the spiritual needs of those struggling with mental health issues. In Cole’s experience, in order to meet those spiritual needs, these churches essentially “let the chips fall where they may” from a liability standpoint.

Those in support of this stance may receive partial support from the fact that relatively few churches to date have been successfully sued for ministering (or attempting to minister) to those with mental health issues. The Nally case occurred in the 1980s—almost 30 years ago—and it’s likely the most relevant case to date. It’s important to note, however, that even if churches haven’t been sued over such issues often, that could change in the future—and the legal landscape may already be changing.

“It used to be unusual for churches to be brought to court, unusual for a church to be sued or a pastor to be sued. [It was] certainly unusual for a pastor to be sued simply because they’re trying to help,” says Cole. “Unfortunately, our current climate reflects an increase in cases filed against churches and pastors across the board, including litigation in the context of church counseling.”

In fact, warns Cole, some jurisdictions in the country have already taken steps to hold even church counseling to the standard of a licensed counselor. Cole says this higher standard creates the potential for a church to be sued if its counseling ministry to mental health issues proves unhelpful or even harmful.

Crafting a policy for in-house pastoral counseling

That potential for a lawsuit is a large warning flag to leaders charged with the risk management of a church and its ministry. But there are ways to approach and mitigate the legal risks associated with offering pastoral counseling to those with mental health issues. Cole offers three guidelines:

1. Churches should have a counseling policy. “That [policy] will address the potential legal pitfalls, and it will outline for both counselor and counselee what that church’s approach is internally.”
2. If a church does provide counseling internally, it should be (I) biblical counseling and (II) limited to a specific number of sessions. Failing to have one or both of these components opens up a church to “arenas where, in case law, we’ve seen potential for increased liability over time.”
3. Once counseling sessions are complete, a church should provide its counselee with a referral to an individual or organization that can provide licensed counseling for mental health. “It’s important that churches have referrals at the ready to someone who is a licensed professional.”

The pastoral argument for ministering despite risks

Stanford, Hoefs, and others who are on the ministry side of this issue view the legal liability as incredibly small. And from a pastoral standpoint, they argue that with a need so great and a problem so widespread, the greater danger for ministry lies in churches not engaging these issues in practical ways.

“Yeah, there’s risk. There’s always risk on this side of heaven,” says Hoefs. “But isn’t there a greater risk of not having to reach people for Jesus?”

The church, as a whole, is becoming more aware of the great need and opportunity for ministering to those suffering from mental illness, in addition to their family and friends. With the rise of nationally recognized mental health ministry events, such as Saddleback Church’s “The Gathering on Mental Health and the Church,” it’s clear that at least some churches and ministers are waking up to the reality of mental health issues that already exist among churchgoers. Whether church leaders wish to minister to mental health needs or not, that one in five Americans have a mental health issue each year means people with mental health issues are likely already in their pews. “What is big, dark, and horrible,” says Hoefs, is “if you don’t do anything and you lose somebody to suicide.” Hoefs is speaking from experience: he lost his own mother to suicide some 30 years ago. He says the fear of helping people with mental health issues is “more of a stigma than a risk factor.”

It’s an important distinction, too, that not all church ministries to those with mental illness have to look like traditional pastoral counseling. In addition to referrals to licensed medical professionals, churches can offer space and support through other means.

One way of doing that is to host peer group programs that don’t purport to be professional help. Hoefs’s ministry, Fresh Hope, offers an effective example. As peer-to-peer support groups, they likely sidestep the major concerns for liability. “There’s no more risk in doing mental health stuff than doing a nursery ministry or celebrating recovery,” Hoefs says.

Stanford agrees and admonishes churches to not stigmatize mental health ministry as untouchable: “The majority of AA meetings happen in churches. AA [groups] are just autonomous groups that just use church buildings. I’ve never heard a church go, ‘Oh, I don’t know if we want those alcoholics in here with liability issues.’ Forty-three percent of people with substance abuse problems also have a serious mental illness.” Stanford suspects that concerns about liability issues are often “just an excuse to try to keep ‘those people’ out of our places.”

At least for peer-to-peer groups like Fresh Hope, Cole says that although she’s not aware of prior legal cases that test their liability, those groups likely avoid the main liability issues of counseling. She explains:

Presuming it is a group where everyone is on the same level and simply comes together to share their personal experiences, it is likely to not rise to the level of counseling. As such, I can see that there could be the potential for real good there. . . . Just from a base human perspective, we appreciate when others can relate, and that itself provides a high level of support. I don’t know that such a program could take the place of actual [licensed] counseling, but if an individual were to utilize that system and find it to be helpful, I imagine that would be of benefit to the individual and pose less potential for legal liability because it is peer-to-peer.

What church leaders should know about mental health first aid

Regardless of the policy a church chooses to adopt in the area of pastoral counseling for mental health issues, anyone could benefit from taking what is called “mental health first aid.”

Mental health first aid operates on the same principle as something like CPR: most people can’t become licensed medical professionals, but the average person can learn some basic, yet vital, skills for recognizing and responding to medical crises.

Judy Smith teaches mental health first aid in the western suburbs of Chicago. “Across the board, mental health literacy is pretty low,” she says. A key solution she advocates for—especially for pastors—is the basic training provided by mental health first aid.

These courses cover the basics: understanding what mental illnesses are and understanding what help a person might need until a professional steps in. It’s important to note that this basic training does not elevate pastors to the realm of mental health professionals. Instead, the training gives pastors objective ways to recognize the difference between what is mental illness and what is not.

Pastors and church leaders can learn from mental health first aid the basics of recognizing and/or responding to issues such as:

• Panic attacks
• Depression
• Anxiety
• Psychosis
• Substance use disorder (SUD)
• Suicide

On the issue of suicide, for example, the class teaches individuals how to ask if the person is thinking about taking his or her own life. For individuals who are thinking about it, they’re likely to be honest and relieved. “We’re not going to trigger anything,” says Smith, hoping to allay any fears that asking about suicidal thoughts would somehow be detrimental.

Likewise, in Smith’s class, she gives a five-point guide for pastors who do encounter someone dealing with mental health issues:

• Assess for risk of suicide or harm
• Listen nonjudgmentally
• Give assistance and information
• Encourage appropriate professional help
• Encourage self-help and other support

Smith cautions pastors against some don’ts in the realm of mental health, in addition to the do’s. She tells them to avoid stigmatizing or shaming the individual: “shame is totally not productive.”

According to Smith, research shows that individuals struggling with mental health issues do better with the love and support of their communities. That’s why she offers her course to both church leaders and to entire congregations.

Another suggestion for pastors hoping to learn more about these issues? Talk with the therapists and licensed counselors in their own congregations, says Hoefs: “They [pastors] could learn so much.”

What mental illness offers the church

The church has an important role to play in helping those with mental health issues, and those who do suffer from these issues offer something to the church. They offer their own gifts and experiences, and they offer a chance for radical ministry.

Stanford, like others, is worried that, out of fear, the church will fail to be a place of hope and healing on this issue: “I think the real risk is we’re going to miss it—going to miss the opportunity to help a lot of people who have been broken by life circumstances.”

A major fear that could hold pastors back from engaging is that individuals with mental illness are more violent. That’s a mistaken notion, says Amy Simpson. “Most people with mental illness are not more violent than the rest of us; they’re actually more vulnerable than the rest of us.”

Simpson has been writing about the intersection of faith and mental health for years, and her own life has been profoundly shaped by witnessing her own mother’s struggles with schizophrenia. She is passionate about the good churches and faith leaders can do in mental health ministry and support.

To her, churches’ efforts to minister in this area don’t have to be an undue burden. “It doesn’t take a degree in psychology to walk alongside somebody,” she says, and it “doesn’t have to be a ministry that is added to the plate of a senior pastor . . . or a member of the church staff.” Instead, churches could have individuals versed in mental health issues—or who are stable in their own mental health struggles—leading mental health ministries. Many such ministry models already exist. (Note: Further resources are listed at the end of this article.)

Simpson and others want pastors to recognize that because so many people—even the non-religious—are more likely to turn to pastors for help in this area, pastors really are a vital part of the mental health care system already. To bear that role responsibly, Simpson encourages pastors to “connect with others in that system. Form partnerships, create a list of resources in your area, go to community events, go to a NAMI [National Alliance on Mental Illness] seminar.”

Basic training in mental health issues, like mental health first aid, can be acquired easily: Stanford says that training in recognizing symptoms and giving appropriate referrals can be given to pastors “in just a couple of hours.” And if you’re a pastor who is providing counseling, you might consider another recommendation from Simpson: asking that person to sign a release form allowing you to access information from the mental health provider in order for you to partner in this person’s care.

In other words, pastors should be prepared for the serious and sacred duty that they have in this arena because, says Simpson, “you are a first responder, whether you know it or not.”

“[U]ltimately it’s up to [pastors] to say, ‘I’m going to bypass my fear,’” Stanford says, and move on to minister to those with mental health struggles.

Hoefs agrees. “The church has to develop a theology that overcomes the stigma and fear and perceived risks,” he explains. “Churches will become irrelevant if they don’t learn to help broken people.”

In Depth

The following resources can help you go deeper on mental health issues and on effective ways to minister to those suffering from mental illness.

• Our sister site SmallGroups.com has a new resource, How to Respond to Mental Illness.
• Dr. Matt Stanford serves as CEO of the Hope & Healing Center.
• Fresh Hope for Mental Health is Brad Hoefs’s organization.
• Hope4MentalHealth.com is Rick and Kay Warren’s website and a project of Saddleback Church.
• Minds Renewed is a national mental health ministry working primarily through the internet. Judy Smith is a board member.
• Amy Simpson’s books can be found on her website.
• “Study of Acute Mental Illness and Christian Faith” is a report by Lifeway Research.
• The National Alliance on Mental Health (NAMI) is “the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness.”
• MentalHealth.gov has many resources and training tools available.
• Mental Health First Aid provides “an 8-hour course that teaches you how to identify, understand and respond to signs of mental illnesses and substance use disorders.”