Mental-Health-Awareness-Photo-pngOn a regular basis, Orthodox priests find themselves in situations in which they need to accurately assess parishioners’ spiritual well-being. Confession is but one setting where this takes place. There are likely few priests who have not occasionally felt daunted by the challenge of distinguishing which kinds of struggles brought by parishioners fall squarely within the purview of spiritual counsel, and which might benefit from referral to professional mental health providers. Coursework provided by some Orthodox seminaries prepares students for counseling that takes place in the parish, and acknowledges that there is a time for referral to outside professionals.

At the same time, within the dioceses of the Orthodox Church in America (OCA), to note one example, there are no uniform policies or guidelines in place to address these situations.

Beyond the relative lack of guidance on this issue, though, there are more immediate factors that make the handling of these situations problematic. These include:

1). the psychological dynamics entailed in the priest-parishioner relationship, and

2). concerns about what kind of guidance parishioners will receive if they are referred to counselors outside the parish.

Dynamics of the Clergy-Parishioner Relationship 

The relationship between a priest and a parishioner is one laden with spiritual and symbolic significance, informed by the sacramental context in which it occurs. In this relationship, neither party is experienced by the other in merely objective or neutral terms, psychologically speaking, because each represents something of significance to the other that transcends the meaning found in mundane and ordinary human interactions. The parishioner, in accord with the liturgical and sacramental order of which he or she is a part, looks to the priest as a vehicle of divine grace. The hopes and expectations which a parishioner has of a priest are guided—often unconsciously—not only by an assessment of what the priest in his humanity can realistically provide, but by the idea of his symbolic function. When a parishioner looks to a priest, that gaze often includes a sliver—and sometimes more than a sliver— of the expectancy and deference customarily directed toward Christ.

In other words, parishioner-priest interactions necessarily include some idealization of the priest, based on what he symbolically represents in church life and liturgy. By itself, this is not problematic. It becomes problematic when the ideal eclipses awareness of the human reality that persists, and is not obliterated, within the function of the priestly role. Carl Jung (1959/1969) uses the term inflation (p. 84) to describe how an individual can lose realistic perspective on their own identity when they are in the crosshairs of idealizing projections. This danger is present especially for those to whom people turn for spiritual guidance. A priest, for example, can become intoxicated with the image of himself as a bearer of divine truth, and temporarily lose realistic perspective on his own limitations and failings.

The danger of this idealization is magnified in instances where a clergyperson’s motivation for ministry includes, unconsciously, the meeting of their own unfulfilled psychological needs. Particular hazards arise when clergy rely on pastoral interactions to satisfy foundational needs for validation and self worth—dynamics often referred to under the heading of narcissism. To the extent that the meeting of these primary needs unconsciously guides one’s work in ministry, the true aims of spiritual community become distorted.

Does narcissism appear in the ranks of clergy more frequently than in the general population? A paper delivered at the 2015 conference of the American Association of Christian Counselors documented the meeting of criteria for Narcissistic Personality Disorder (NPD) among pastors of the Presbyterian Church of Canada at an incidence between 5 and 30 times greater than that of the general population (Ball & Puls, p. 9). A 2004 study of Roman Catholic and Reformed clergy in the Netherlands concluded that narcissism appears among clergy at a rate roughly equivalent to its appearance among university lecturers and secondary school teachers (Zondag, pp. 431, 433).

Regardless of how these studies are interpreted, an article by forensic psychologist J. R. Meloy (1986) makes a compelling case for ministry’s appeal to people with narcissistic characteristics, including the validation that it can provide for fantasies of personal grandiosity, confirmed by one’s vocational calling, one’s role as spokesperson of the divine word, and the generally positive mirroring—sometimes bordering on adoration—provided by the congregation. He incisively observes:

Those most affected by narcissistic character problems will have the least capacity for personal reflection outside the sanction of their professional identity. They are the least likely to seek individual psychotherapy, and have historically been the most difficult patients to treat; and perhaps, most importantly, will be the readers least likely to finish this article. (p. 50)

One factor in the reluctance of narcissistic individuals to seek therapy is the challenge that doing so presents to their illusions of self-sufficiency. By extension, such a person is not likely to refer others to therapy, either, particularly when doing so might challenge their imagination of themselves as adequate to any crisis that might present itself for their pastoral help.

While the idealization of clergy, in accompaniment with clergy who may themselves be using ministry to meet unconscious narcissistic needs, can be detrimental in any spiritual community, Orthodoxy provides a setting in which such a combination can be particularly dangerous, in that a priest may begin to fancy himself as spiritually gifted to an advanced degree, maybe even approaching the stature of a starets, a spiritual elder whom tradition describes as possessing special gifts of discernment and even, sometimes, clairvoyance. The image of the starets may loom in the background of the minds of parishioner and priest, and both may flirt with it, in moments when idealizing projection and narcissistic need unconsciously conspire together to create a state of inflation. Orthodoxy affirms the existence of real spiritual elders. At the same time, authentic Orthodox tradition is served, not challenged, by psychology’s warning about our susceptibility to being carried away by idealized images of ourselves.

Concerns about the Nature of Therapeutic Guidance 

Another barrier to well-considered referrals to mental health services is the perception amongst some clergy that the psychological perspective is inherently antithetical to Christianity––and, in any case, that few therapists will be sufficiently understanding of an Orthodox Christian’s unique needs. It must be admitted that some therapists possess bias against Christianity. This is not inevitable, though, even though modern psychology includes non-Christians and even atheists amongst its major theorists. While it would be convenient to dismiss such concerns by pointing out how we regularly rely on professionals from various fields without full knowledge of their philosophical or spiritual biases, psychology is rightly viewed as belonging in a different category, because it deals with issues of meaning, purpose, and direction. As such, it often broaches on areas in which Orthodoxy already has its own body of recommendations, informed by essential dogmatic and pastoral concerns. It is a fair question, in the mind of a priest, what kind of guidance a parishioner might receive if he or she is referred to a counselor.

One option, in the face of this uncertainty, is to conclude that referrals outside the parish are simply unsafe. Some religious communities do in fact opt for a closed-system approach to interactions with the outside world, resulting in little if any seeking of mental health services. Where this appears within Orthodoxy, it usually relies upon beliefs, sometimes unexamined, about whether professional referrals are really necessary, and about how therapy is likely to affect the faith of an Orthodox Christian.

One such belief is that the parish possesses resources adequate to any mental health needs that might appear amongst parishioners. This often involves the conviction that mental health concerns are, in every case, better seen as spiritual in nature. In fact, there can be overlap between the psychological and the spiritual. For example, depression can sometimes be usefully seen under the category of acedia, and addressed with remedies readily available to a confessor. What about when depression does not yield to this approach, though? Or, what about instances in which a parishioner reports being directed to harm themselves or others by voices that are audible to themselves alone? While it makes sense that traditional prayer, counsel, and sacramental means will be our first recourse, are we willing to assume responsibility for cases in which these approaches do not in themselves suffice, or actually appear to make things worse?

Another such belief is that a parishioner’s Orthodox faith may not survive an environment, such as that found in therapy, in which one is encouraged to explore, understand, and sometimes question, the origins and effects of one’s thoughts, feelings, beliefs, and behaviors. At the root of this fear is a conception of faith as fragile. A purely protectionist stance regarding faith, though, betrays a suspicion that God is not present beyond the walls of the parish, and that a tour of one’s own heart can only result in an encounter with doubt and darkness—which is not necessarily consistent with our confession of God as He who is “everywhere present and fillest all things,” or the observation of the Psalmist, “Whither shall I go from Thy Spirit? or whither shall I flee from Thy presence?” (Ps 137:6 KJV). It is often the case that a person’s faith comes more fully to life when they are allowed to consider its origins and role in their life.

There are instances in which a person’s faith has been held intact solely due to the fact that it has been sheltered from the influence of thought or culture that does not derive specifically from the teachings of the parish. Such protectionist understandings of the faith are questionable, in my opinion, both because of their stunting effects psychologically, and because of their strict identification of theosis with adaptation to the practices and culture of the parish. They do not adequately take into account the presence of the Logos in society, nature, and the depths of the human psyche, even as these have existence beyond the walls of the parish—nor do they consider the extent to which the Holy Spirit has reach into all these areas.

Finally, there are situations in which parish life is itself part of the problem from which a person needs healing and, in some cases, distance. Orthodox Christians, including clergy, can sometimes inflict their own fallen-human psychological dynamics upon others in the parish. Also, however good and holy Orthodox tradition is, objectively speaking, it may, for a variety of reasons, interface with someone’s personal psychology in such a way that it is an aggravating factor in trauma, or the source of trauma itself. While it may sound scandalous to some, there are cases in which the answer to the alleviation of suffering on the part of an Orthodox Christian is not more Orthodoxy. There are even cases in which someone discovers that—in order to honor inviolable conditions of their personal sanity—they need to leave the Orthodox setting, either temporarily or permanently. Some, choosing to leave, may continue to profess Christian faith, while others may cease to call themselves Christian at all. For Orthodox clergy to categorically deny the validity of such decisions, though, is to remove faith from the sphere of freedom, and to diminish the significance of freedom in the occurrence of faith, when faith does occur. At the same time, a competent and ethical counselor, regardless of their own spiritual perspective, will not lead a person to this conclusion, but will lead them to identify and take seriously their own psychological dynamics.

It is understandable that clergy will be concerned about the possibility that therapy might result in a parishioner choosing to distance themselves from parish life. The response to this ought not to be to encourage the parishioner to overlook what they are learning about themselves, though, but to help them understand and embrace the faith in ways that honor their growing understanding of self. A faith that remains at odds with genuine insight into self is destined to eventually fail anyway. More often than not, a parishioner’s Orthodox faith is not actually the direct topic of therapy. When it does move into focus, it often still remains incidental to other areas of life that are under more direct consideration for change. If a therapist has guided the parishioner in a competent and ethical way, their work is not inherently counter to healthy priestly guidance, even if it compels this guidance to take factors of a parishioner’s unique personal development into account. Instead, the therapist’s work can be seen as complementary, offering a perspective that, alongside that provided in spiritual instruction, can facilitate a parishioner’s self-awareness, healing, and growth.

Some Practical Suggestions 

The preceding draws attention to some of the factors that need to be addressed before practical recommendations—such as how a priest can evaluate whether a parishioner’s words or behaviors warrant referral—can reasonably be considered. Practical recommendations will be effective only as part of a broader culture that considers mental health worthy of its attention. The most likely way to foster such a culture is through further conversation at all levels of church life. What follows are suggestions for how this might be done, including seminaries, national church administrations, dioceses, parishes, and organizations specifically devoted to these concerns.


It is important that seminaries prepare their students to deal with mental health issues in the parish setting. This could include at least introductory courses on psychology, incorporating a survey of models of therapy. Those with interest could be encouraged to pursue further studies, perhaps focusing on modes of therapy which they find compelling. Seminaries can also require that their students undergo a period of personal therapy, as part of course or practicum fulfillment. I do not believe this training should necessarily have as its goal that a priest will attempt to practice therapy in the confessional or parish setting. Even in cases where a priest is a trained therapist, therapy requires a setting in which the therapeutic perspective and its tools can be given adequate expression. Although there can be overlap between the perspectives of spiritual counsel and therapy, they are not identical. To attempt to practice therapy in confession presents the risk of distorting both.

Seminaries can facilitate ongoing reflection on the relationship between modern psychological understandings of the human person, on the one hand, and Orthodox theology’s understanding of personal human development, as it appears in hesychastic and ascetical tradition, and in pastoral counsel, on the other—in a spirit of genuine dialogue, and not merely as an occasion for demonstrating the superiority of one over the other.

National Church Administrations

Synods and church administrations can identify specialists with whom they can consult on issues of mental health. Through statements and policies, they can remove stigma from mental illness, and set a tone in which parishes can better address issues of mental health. Discussions on topics of mental health could be scheduled during national assemblies. Budgets could reflect mental health resources amongst their priorities.

Orthodox Associations and Professional Organizations

Pan-Orthodox and independent professional organizations can offer resources tailored towards the needs of the Orthodox parish. The Orthodox Christian Association of Medicine, Psychology, and Religion (OCAMPR), endorsed by the US Assembly of Canonical Orthodox Bishops, is an example of a pan-Orthodox organization focused on concerns relevant to mental health. The Orthodox Christian Counseling Institute (OCCI), is a network of Orthodox therapists in the Chicago area, offering itself as a resource for area parishes. Similar groups exist in other parts of North America.


In addition to echoing concern for mental health expressed by national church administrations, dioceses can coordinate lists of regional Orthodox-friendly mental health services, and serve as clearing houses for best practices demonstrated by parishes within the diocese. As with national administrations, dioceses can highlight issues of mental health at assemblies and retreats. Dioceses can formulate rationale for parishes to use in addressing mental health scenarios. The Archdiocese of Western Pennsylvania in the OCA, for example, has a system whereby clergy can consult with local deans, if necessary, then the Chancellor and Archbishop, in situations that require special consideration. The Chancellor maintains a list of area mental health professionals for this purpose.

Local Parishes

Priests and others in the position of offering spiritual guidance can be more helpful in referrals when they have knowledge of what takes place in therapy. An ideal way for them to acquire this knowledge is to undergo a period of therapy themselves. This can help them develop a realistic understanding of therapy’s potential and limits. Alongside their own participation in the sacrament of confession and spiritual consultation, therapy can help them cope with stress, achieve greater life balance, and become aware of how their own developmental dynamics might spill out into their exercise of ministry.

Parishes can maintain lists of local mental health resources, and of therapists who can be trusted to deal with spiritual concerns and people of Orthodox faith in a sensitive manner. Homilists can refrain from categorically demonizing psychology and professional mental health services, dismissing them as mere secular delusions, even when it might be tempting, from a rhetorical standpoint, to do so. They can directly challenge stigma regarding the seeking of mental health help.


Psychology and theology both focus attention on the human person and what it means to be whole. Each does so in its own way, though, relying on its own set of lenses and tools. These approaches need not be contradictory, and often can overlap and complement each other. Orthodox priests deprive themselves and their parishioners of a potential ally when they neglect resources of mental health therapy. A healthy pastoral approach will seek to understand and utilize them responsibly.

In the Orthodox Church, barriers to mental health referrals include complicated psychological dynamics that involve clergy themselves, conceptions of mental health services as inherently antagonistic to faith, and theological understandings that strictly identify personal growth with adaptation to conditions of church life. Thoughtful referrals presuppose that clergy possess adequate psychological self-awareness, and a realistic appreciation of where therapy can be helpful—and, in some cases, imperative.

On a practical level, what is often lacking is a stated set of practices for how mental health concerns should be handled. All of these factors can be addressed, provided there is openness for discussion of them at all levels of church life. May God grant that the words of this article contribute to fruitful conversation about this area of pastoral care which is often left tragically undefined.


Ball, R. G., & Puls, D. (2015). Frequency of narcissistic personality disorder in pastors: A preliminary study, presented at Conference of the American Association of Christian Counselors Nashville, TN, 2015.
Meloy, J. (1986). Narcissistic psychopathology and the clergy. Pastoral Psychology, 35(1), 50-55.
Jung, C. (1969). Aion: Researches into the phenomenology of the self (R. F. C. Hull, Trans.) (H. Read, M. Fordham, G. Adler, & W. McGuire, Eds.), The collected works of C. G. Jung (2nd ed., Vol. 9, Pt. 2). Princeton, NJ: Princeton University Press. (Original work published 1959.)
Zondag, H. J. (2004). Just like other people: Narcissism among pastors. Pastoral Psychology, 52(5), 423-437.

V. Rev. Isaac Skidmore holds an MDiv from St. Vladimir’s Orthodox Theological Seminary and a PhD in Depth Psychology from Pacifica Graduate Institute in Carpinteria CA. He is an adjunct instructor in the clinical mental health counseling program at Southern Oregon University. He practices as a licensed counselor in Southern Oregon, frequently working with people who are exploring issues of faith, meaning, and identity. He served as rector at Archangel Gabriel Orthodox Church (OCA) in Ashland OR during a decade of its growth as a mission parish, where he remains attached as auxiliary priest.

Orthodoxy in Dialogue seeks to promote the free exchange of ideas by offering a wide range of perspectives on an unlimited variety of topics. Our decision to publish implies neither our agreement nor disagreement with an author, in whole or in part.
Orthodoxy in Dialogue is on partial hiatus until late spring/early summer 2019.
You are still encouraged to contact us if you wish to write for us during this time.

A most blessed Holy Week to all our Orthodox brothers and sisters around the world.