Twenty or so years ago, I found myself in a board meeting at church, listening as our children's ministry director described the challenges some of our most committed members were experiencing in maintaining their church involvement after adopting children from orphanages in Eastern Europe, and the steps our church was taking to support them.

As a physician specializing in child and adolescent psychiatry, I wondered whether church participation was a problem for the types of families served by our practice—kids with anxiety, depression, or ADHD, and parents who were often receiving treatment for a mental health condition. I began informally surveying families about their church involvement during follow-up visits and was floored by some of the stories they shared.

In my experience, families in which a child or parent is being treated for a mental health condition are significantly less likely to regularly attend worship services or participate in small groups, Christian education, or service activities than their friends or neighbors. Given that one in five children and adults in the U.S. experience at least one mental health condition at any given time, their families represent a large population desperately in need of tangible expressions of the love of Christ and the spiritual benefits associated with active participation in the life of a local church.

Reaching those outside the church

Evangelically-minded churches have made great strides in recognizing the struggles common among persons in the church with mental illness. Where we have much work yet to do is in connecting with individuals and families outside the church and formulating strategies for welcoming them into our worship services and including them in activities most critical for making disciples.

A first step to effective outreach and inclusion is to recognize why church involvement is so difficult for families affected by mental illness.

A first step to effective outreach and inclusion is to recognize why church involvement is so difficult for families affected by mental illness. Here are seven potential barriers to church involvement for persons with common mental health conditions and their families:

1. Stigma: Our churches are widely perceived by outsiders to be unwelcoming places for persons with mental illness. According to one study by LifeWay Research, 55 percent of respondents who never attend worship services disagreed with the statement, "If I had a mental health issue, I believe most churches would welcome me." This perception may be fueled by the stories shared by persons who reported negative experiences or left the church entirely after seeking help for a mental health condition. Similar to Job's friends who sought to support him in his grief and loss, many church leaders and attendees are quick to assume that suffering associated with mental illness is a consequence of personal sin or to suggest the persistence of illness is a consequence of insufficient faith or an inadequate prayer life.

2. Anxiety: One in 15 American adults experience social anxiety disorder—a condition resulting in significant fear and distress in situations where their words or actions may be exposed to the scrutiny of others. How many social interactions might a first-time visitor to a weekend worship service need to navigate at your church? Persons with agoraphobia frequently experience intense fear, heart palpitations, breathing difficulties, excessive perspiration, and nausea in public places where their ability to leave unobtrusively is limited. How might they feel if there are no seats available near an exit at a worship service, or if a well-meaning usher directs them to a middle seat near the front of the church?

3. Expectations for self-discipline: The Bible clearly equates self-control with spiritual maturity. Most mental health conditions can negatively impact executive functioning—the cognitive capacities through which we establish priorities, plan for the future, manage time, delay gratification, and exercise conscious control over our thoughts, words, and actions. When children struggle with self-control in the absence of obvious signs of disability, we're often quick to make assumptions about their parents. One mother in describing her family's experience in looking for a church with two school-age boys with ADHD observed that, "People in the church think they can tell when a disability ends and bad parenting begins."

4. Sensory processing: Heightened sensitivity to light, touch, noise, and smell isn't limited to persons with autism spectrum disorders but is often also associated with anxiety disorders and ADHD. For someone with sensory processing differences, the hustle and bustle around entrances and exits before and after worship services, the volume of the music performed during the praise and worship time, expectations for greeting fellow attendees with handshakes or hugs, and the aroma of strong perfume or cologne worn by fellow attendees may all produce intense discomfort.

5. Social communication: Churches are intensely social places, and Scripture is clear that we were created to live in community with one another. Some people with common mental health conditions struggle to pick up on language cues essential to day-to-day interaction—body language, facial expression, eye contact, tone, and inflection of voice. They may fail to pick up on the "unwritten rules" for conduct and behavior common in many churches or misinterpret interactions with church leaders or fellow attendees.

6. Social isolation: Persons with common mental health conditions are less likely to have friendships and social connections that produce invitations, worship services, and other church activities. Persons with depression frequently withdraw from social activities, and many with anxiety disorders actively seek to avoid them. Kids experience more difficulty making or keeping friends who will invite them to Awana or youth group activities. Their parents often encounter great difficulty finding qualified child care so they can socialize with friends and neighbors or participate in small groups at church.

7. Past experiences of church: Many families impacted by mental illness carry with them the baggage associated with past negative experiences of church. Kids with mental illness often inherit their predisposition for their conditions from their parents. If mom or dad experienced a condition during their childhood and teen years affecting their church involvement, the likelihood that they'll seek out a church for their family as a young adult is markedly diminished.

Families touched by mental illness represent an enormous potential mission field literally living within the shadows of our steeples. A first step for pastors and church leaders seeking to minister to them is to identify potential obstacles to their participation in worship services and other activities most critical for discipleship within your church and consider how those obstacles might be overcome.