This morning I'm talking with you from the perspective of the work I am now doing. Three days a week I am in Washington with our United Methodist General Board of Church and Society as Program Director for Health and Wholeness, where one of my focuses is mental illness ministries. Two days a week I am in Columbia as Executive Director of the National Conference of Viet Nam Veteran Ministers, where my primary focus is on a project called Pastoral Care for Trauma Survivors. I am a clergy member of the Baltimore-Washington Annual Conference appointed to do this work as my ministry, and I serve on a Conference Subcommittee on Ministry with Persons with Mental Illness and their Families.

Our Subcommittee's vision is of "the church becoming a community of people who demonstrate the loving grace of God in their relationships with each other, including persons with mental illness and their families." It is a vision of "faith communities becoming places where all persons are welcomed, supported, [and] fully involved; [where all persons] can grow in their relationship with Christ."⁽¹⁾ We are developing presentations that can be given in churches and this morning's sermon is an example. So I want your feedback this morning: did this presentation make sense? Would it be useful to other churches? What should be added or taken out? What does a presentation like this need to make a difference for people, in and near a congregation, who have mental illness? Did this presentation make a difference for you?

This fall the United Methodist Church is sponsoring a massive advertising program called Igniting Ministries.⁽²⁾ The advertising will encourage people to seek out their local United Methodist churches. September is Open House Month for United Methodist congregations. We should be prepared to welcome visitors always, but when the advertising campaign begins in September, if it has any value, we might see some new faces. Are we ready to welcome visitors? The parable in this morning's Gospel reminds us of the rewards which awaited the slaves who were awake and ready to open the door when the Master returned. Other parables of Jesus remind us that the Master sometimes comes in disguise. So the question is always, "Are we prepared for unexpected visitors?"

1. Stigma

Igniting Ministries might just attract the people we find it most easy to welcome - people like us, or perhaps just like the people we pretend to be when we dress up for church - no rough edges, no problems, no stresses, no worries. But how about the others? How about those with mental illness and their families? Will we have a welcome for them?

Making a specific welcome is important because despite the great gains in knowledge over the last 30 years, mental illness still carries a stigma. People still imagine that mental illness reflects a moral weakness. Some Christians still imagine it is God's punishment for a sin or at least a lack of faith, because if you prayed right, wouldn't God take it away?

The Surgeon General 's recent report on Mental Illness describes the forms, both subtle and overt, that stigma can take. Stigma appears as prejudice and discrimination, fear, distrust, and stereotyping. It prompts many people to avoid working, socializing, and living with people who have mental disorders. It gets in the way of people seeking help because they're afraid that the confidentiality of their diagnosis or treatment will be breached. Continuing stigma gives insurers - in the public sector as well as the private - tacit permission to restrict coverage for mental health services in ways we would not tolerate for other illnesses.⁽³⁾ We are fighting stigma by telling the truth about serious mental illness with advocacy and public education and by increasing contact between persons with mental illness and others. The hope is that contact between persons with mental illness and others will help people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, and that when this happens much of the negative stereotyping will dissipate."⁽⁴⁾

But will we wait for stigma to go away before we prepare for unexpected visitors?

2. Mental Illness

The term "serious mental illness" most commonly refers to schizophrenia, bipolar disorder, and clinical depression. These are now commonly referred to as brain disorders, because, like other illnesses, they reflect measurable changes to the physical structure and biochemistry of the body. With the progress of research, these illnesses are increasingly responsive to medication intended to restore the brain's impaired biochemistry.

We may think of schizophrenia first when we think of mental illness, but it affects fewer than two people out of every hundred. Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, emotional expression, and sense of self.⁽⁵⁾ Symptoms include psychotic manifestations such as hallucinations -- hearing or seeing what's not there; delusions -- false personal beliefs; or attaching unusual significance or meaning to normal events. About 10% of persons with schizophrenia remain severely ill over long periods of time; but one half to two thirds significantly improve or recover, some completely. Unlike the picture we may have been given, the course of schizophrenia is not uniformly downhill. ⁽⁶⁾ Schizophrenia seems to be caused by the interaction of genetic endowment and major environmental upheaval during the development of the brain. Immediate biological relatives have about ten times greater risk than general population; yet 40% of identical twins of schizophrenics never develop the disease, suggesting a strong place for environmental factors as well.⁽⁷⁾

The second major mental illness we think of is bipolar, or manic-depressive, disorder, which is also caused by a combination of genetic and environmental factors, and like schizophrenia, affects a very small proportion of people. In the acute manic phase a person may have grandiose thoughts but be paranoid as well. There may be delusions. Auditory and visual hallucinations complicate more severe episodes. The speed of thought increases, and ideas typically race through the manic person's consciousness -- but distractability, poor concentration and sleep deprivation commonly impair implementation. Judgment is severely compromised, with spending sprees, and offensive or reckless behaviors.⁽⁸⁾

In the depressive phase, bipolar disorder resembles the third major mental illness, major depression. Depression is both quantitatively and qualitatively different from normal sadness or grief. Severe depression, lasting two or more weeks, reflects a depressed mood and loss of interest or pleasure; it often involves feelings of hopelessness and suicidal thoughts."⁽⁹⁾ Major depression may be chronic or episodic. Whether or not you will have depression seems to reflect a combination of your genetic endowment, your coping skills and social support network, and stressful life events or severe and prolonged stress.⁽¹⁰⁾ Depression, in severe or mild forms, is the most prevalent mental illness in America, with as many as 20 people out of a hundred experiencing it on a given day.

In a September 2001 magazine, Rosie O'Donnell writes about depression: "I have written about an illness I have, one that runs in my family, one people don't like to talk about. Depression isn't fun. It is strong, powerful and too often deadly. .... There are some pretty amazing medications now available to those in need. They work. I know because I take them. There was a time when I was too ashamed to admit that. I am not anymore."

If she were an unexpected visitor, would we be prepared to welcome her?

3. Parity

The stigma of mental illness has resulted in disparate treatment by insurance companies, and a major legislative objective of advocates, including my work at the United Methodist General Board of Church and Society, is parity of insurance coverage for mental illness compared to other illnesses. Last Sunday's Seattle Times⁽¹¹⁾ has the story of a new mother named Martha Silano. If she had had a massive infection following her delivery, her insurance would have covered her month-long hospital stay.

But like as many as two in every thousand women who give birth, what she developed was postpartum psychosis. By the time she was hospitalized, she had become catatonic and delusional. Why? Researchers are still trying to figure it out. Perhaps hormone changes, perhaps decreased blood flow to the brain during delivery. Most agree the disorder is biologically based and triggered by childbirth. But because it is classified as a mental illness, most of the $14,000 hospitalization cost had to come out of pocket.

"Psychiatrists worry that patients without a financial cushion or family support leave treatment prematurely. Postpartum depression, which occurs in an estimated 15 to 20 percent of new mothers, can be treated without hospitalization. But postpartum psychosis presents a medical emergency." 'Anybody with active postpartum psychosis should not be home alone,' [psychiatrist Dr Rex] Gentry said. 'And certainly not home alone with their babies.'

Today Martha Silano is home, delighting in her nine month old son. She's had months of therapy, takes four medications, and feels like her old self again.

If she were an unexpected visitor, would we be prepared to be the church for her?

4. Trauma

Post-traumatic stress disorder is another common disorder. It also is influenced by genetic predisposition and the strength of coping and support systems. But I think of PTSD more as a mental wound than a mental illness. PTSD carries three kinds of symptoms -- arousal, or feeling on guard, having trouble sleeping, being easily startled - avoidance or emotional numbing -- and intrusive symptoms like nightmares, flashbacks and re-experiencing the trauma. In the 1970's it was Vietnam veterans, most of whom are male, who forced the medical profession to take PTSD seriously; but because of child abuse, rape and domestic violence, women are twice as likely as men to have PTSD.

In my work I travel now in two different circles. One set of people are concerned with serious mental illness such as schizophrenia, bipolar disorder and clinical depression, and it's important to them that these are no-fault illnesses - your biochemistry is messed up, and nobody's to blame. Another group of people is more concerned with psychological trauma, which commonly involves violent betrayal of one human being by another.

But the more I associate with both groups, the more I see how the two converge.

On the one hand, like other brain disorders, PTSD reflects physical changes in the brain and medication is an important part of the treatment plan.

On the other hand, mental illness is traumatic. Schizophrenia and bipolar disorder aren't caused by human agents - but when they strike they prompt the same spiritual dismay. Here is an 18 year old who develops schizophrenia and her life is totally changed. "God, how could you let this happen to me?" Here is a 25 year old with depression who commits suicide. The survivors have the same spiritual question: "God, how could you let this happen?"

5. Spiritual Questions

When tragedy happens, mental illness or not, our faith is shaken. One minute, it seems, we live in a world that is safe and predictable, and we give credit to a protective and caring God. The next minute our lives have changed, they are neither safe nor predictable - and we've not only got a problem with mental illness, we've got a problem with God.

I've started a list of some of the questions that inevitably arise when something like mental illness pulls the rug out from under our feet, or those of our family members.

1. Why did this happen to me?

2 Am I a bad person? Is God punishing me?

3. Am I all alone? Has God abandoned me?

4 . Will things ever be made right? Is God just?

The role of the Church is not to answer these questions in the midst of tragedy, because they can't be answered by one person for another. Before tragedy strikes the Church can try to load people up with all the resources and thoughts and faith perspectives it can, but once tragedy strikes us, we have to do the necessary grieving, the letting go, the healing, and the making of meanings which only we can do. In the midst of crisis, any attempt at answer-giving is both irrelevant and cruel. The role of the Church and people in it is to be present, to listen, to show we care.

I remember once sitting with a member of a congregation trying to help her sort through a painful and complicated experience she had been through. Frankly-because I like answers - I had a thought in my mind as to what her experience meant, and I thought that if she could just get hold of what I thought was the answer, she'd be OK. Fortunately I've learned through some painful experiences there are times to keep your mouth shut, and I did. We talked a bit more. Suddenly her face lit up. "You know, it's really about such and such, isn't it!," she exclaimed. She had made sense out of the experience that worked for her and the answer she came up with wasn't even close to the one I had in mind! She didn't even really need confirmation from me. Suddenly she was energized, like a river that had been blocked by a logjam suddenly let loose, and she went on with her life.

The role of the Church is to be a setting where we provide all the resources possible, and people can find their own answers and make their meanings. When people came to Jesus to trick him into saying that blindness was the result of sin, Jesus' answer was to reject the alternatives presented to him and say instead that one man's blindness was an opportunity to show forth God's works: in effect, that disasters are occasions when we have to deal with our relationship with God ourselves.⁽¹²⁾

6. Caring Communities

In 1996 the United Methodist General Conference passed a resolution mandating the General Board of Church and Society to promote to United Methodist congregations a program called Caring Communities - the United Methodist Mental Illness Network.

The Caring Communities program has three pieces to it:

1. Congregations engage in an educational program about mental illness, such as the Adult Sunday School series we did a year ago.

2. The Church Council adopts a resolution or covenant statement identifying the congregation as a Caring Congregation which will be welcoming and supportive of persons with mental illness and their families.

3. The congregation makes its welcome known throughout the community.

I've been able to locate just three congregations in the United States which have taken all three of these steps. I think there are a few more which I haven't been able to find and list on our web site at work. I've talked to people in a few other congregations which have been willing to do the first step - to have an educational program. They've been willing to do the second step - and adopt a resolution. But the third step? That's been the sticking point. What would happen to our congregation if it became known that we welcome mentally ill people here? Would we become type cast? Would all the other people stop coming? Who would pay our bills? Can't we do a quiet welcome and just shake peoples' hands if they somehow manage to find us? Do we have to turn unexpected visitors into expected visitors?

The Surgeon General's report says that for about one in five Americans, adulthood will be interrupted by mental illness.⁽¹³⁾ They and their families need the welcome and support that a church can give. A lot of that welcome and support they can obtain other places. But what other organizations claim to offer people a safe place where they can work out these deep spiritual questions which arise when life betrays us?

This morning's Gospel lesson is a call to be prepared for visitors, those we are expecting and the unexpected ones who may take us by surprise. Jesus' parables remind us again and again that Christ still walks the land. When we welcome even the least of Christ's brothers and sisters, we are welcoming Christ himself.

1. In using the "unexpected visitor" image, there needs to be early clarity that what is unexpected is the "who", not the "when". Focusing on an imagined "when" got one congregant lost early on.

2. It amazed one congregant that people still believe mental illness is a matter of moral weakness. Most people in many of our awareness don't talk that way any more. But it should be noted that viewing mental illness as a moral weakness (which people therefore should be able to overcome with their own efforts) is a primary rationale behind disparate insurance coverage.

3. The stigmatization, or perhaps the view of mental illness as moral weakness, kept a person known to one congregant from seeking assistance for his depression for five years. When he finally received diagnosis, treatment and medication, he was amazed at the change in just two weeks. His imagery of mental illness had kept him from this for five years.

4. One congregant believed more emphasis should have been given to the resemblance between persons with mental illness and the rest of us. "They're not so different." We all experience some symptoms some of the time, and they experience no symptoms some of the time.

5. Because of stigmatization, people carry their illness close to their vest. One congregant was aware of half a dozen people in the congregation who struggle with one mental illness or another. Each imagines himself or herself to be the only sufferer, because none want the congregation member to share their information with others. Were they able to share even with each other, the sense of aloneness would be substantially dispelled.

6. More emphasis needs to be given about the element of loss. It's a major factor in depression, as well as other illnesses. A major emotional loss can trigger these diseases, and mental illness itself is a traumatic loss, a loss of one's previous sense of wellbeing, security and confidence.

7. Finally, one discussion that took place had to do with child abusers. While much of stereotyping of the mentally ill does not reflect reality, there are circumstances in which there needs to be caution. One of these is pedophilia. Churches act appropriately when they take steps to ensure their children are safe. In addition to information forms that churches now require for child care volunteers and workers, many churches now insist that any time there are children around, there be two adults present, thereby safeguarding against any opportunity for inappropriate conduct.