Spiritual Warfare or Mental Health Issue? How to Discern the Difference

As a Christian counselor who has walked alongside pastors and ministry leaders within the Church as well as Christians in the counseling room, one of the more common and challenging questions I hear is: “Is this person struggling with spiritual warfare, or is this a mental health issue?”

For Christians who take seriously both the authority of Scripture and the reality of clinical mental health, this is not a question with quick or simplistic answers. The truth is, people live at the intersection of mind, body, community, and spirit. When distress shows up, we must discern carefully: Is this the enemy at work, a psychological struggle, or sometimes a mixture of both?

A Biblical Foundation for Discernment

The Bible is clear that we wrestle with spiritual realities.

“For we wrestle not against flesh and blood, but against principalities, against powers, against the rulers of the darkness of this world…” (Ephesians 6:12, KJV)
“Be sober-minded; be watchful. Your adversary the devil prowls around like a roaring lion, seeking someone to devour.” (1 Peter 5:8, ESV)
“Submit yourselves therefore to God. Resist the devil, and he will flee from you.” (James 4:7, ESV)

At the same time, Scripture acknowledges human weakness and frailty. Elijah, after a major spiritual victory on Mount Carmel, collapsed in exhaustion and despair, crying out to God to take his life (1 Kings 19:4). David openly described anguish, sleeplessness, and despair (Psalm 6:6–7). Paul spoke of carrying “a thorn in the flesh” that tormented him (2 Corinthians 12:7–9).

These passages remind us that not every trial is purely spiritual. Sometimes, what looks like “a demon” may be depression that includes symptoms of isolation or constant irritability. What feels like “oppression” may be untreated trauma. Further, what looks like “just mental illness” may have deep roots in spiritual warfare.

The Clinical Perspective

As counselors and pastors, we cannot ignore the advances of psychology, brain science, and medicine. God has given us both Scripture and the sciences as tools to understand His creation. We live in a fallen world that has led to brokenness physically, socially, spiritually, and emotionally.

Signs of a Mental Health Concern

Mental health issues often display certain patterns that differ from purely spiritual struggles:

Consistency across settings: A person shows symptoms (such as depression, anxiety, hallucinations, mood swings) in daily life, regardless of whether spiritual activity is present.
Biological or genetic factors: Family history of bipolar disorder, schizophrenia, or depression often signals a medical/clinical component. We call this a genetic disoposition of disorders. We see high causation with these diagnoses with family genetics.
Environmental factors: Not only do we have genetics play into it, but life and how we are raise play into mental health. Adverse childhood experiences often lead to trauma, depression, and anxiety symptoms. Loss of a loved one leads to grief, overworked and undersupported can lead to significant anxiety, and substance misuse can lead to short- or long-term psychosis and paranoia because of the amount and types of substances used.
Response to treatment: Evidence-based clinical counseling or medication can and does lead to measurable and lasting improvement for individuals and their families.
Developmental roots: Trauma, abuse, or long-term stress often contribute to mental health issues.

For example, someone with Major Depressive Disorder may feel unable to pray, lack energy, and experience dark, intrusive thoughts. Obsessive Compulsive Disorder has a subtype called Scrupulosity, which includes obsessive behaviors towards religious practices of prayer, shame, and guilt from compulsions of not being “a good Christian” that is based on psychological problems. These should not immediately be labeled as demonic oppression; instead, it is often a legitimate psychological and physiological disorder that requires compassionate care. Though spiritual warfare could be a key to some of these environmental or developmental factors, too.

Holding Both Together: A Balanced Approach

Pastors and Christian counselors should not hesitate to refer when symptoms exceed pastoral care. Hallucinations, suicidal thoughts, prolonged inability to function, or dramatic mood shifts should be evaluated by a licensed mental health professional. This is not a lack of faith but rather good stewardship of the body God has given us.

When spiritual warfare is suspected, pastors should respond with prayer, fasting, Scripture, and accountability. The believer must be encouraged to put on the full armor of God (Ephesians 6:10–18). Deliverance ministry should always be conducted with humility, wisdom, and in alignment with Scriptur, but not sensationalism.

The challenge comes when mental health struggles and spiritual warfare overlap. A person with trauma may be more vulnerable to the enemy’s lies. Someone with schizophrenia may still need deliverance from real oppression. The key is not choosing one over the other but learning to minister wisely in both realms.

While we recognize mental health realities, we must also affirm what Scripture teaches about spiritual warfare. Satan aims to destroy God’s people, to deceive, accuse, and hinder the work of the church. How do you make sure you do not immediately dismiss the spiritual, yet also not assume there is a demon under every bush and negative experience?

Though not always easy to identify, certain patterns may suggest spiritual warfare and require pastoral discernment. I also want to note this is not my specialty, these two lists is adapted from Timothy Keller’s sermon listed at the end of this article:

Signs of Spiritual Oppression

Targeted resistance to spiritual disciplines: Extreme agitation, confusion, or hostility only during prayer, Scripture reading, or worship.
Patterns of temptation and deception: The enemy plants lies that directly contradict God’s Word, often leading to bondage in sin.
Unexplainable heaviness connected to spiritual activity: A person feels unusually oppressed before serving, preaching, or evangelizing.
Discernment of the Holy Spirit: Pastors and believers, in prayer, may sense a spiritual battle beyond the natural explanation.

Practical Guidelines for Pastoral Discernment

Start with prayer and Scripture. Ask God for wisdom (James 1:5). The Holy Spirit grants discernment beyond what human knowledge can provide.
Listen carefully to the person’s story. Often, mental health symptoms have clear triggers that can be identified with compassion and patience.
Rule out medical issues. Encourage physical exams and mental health assessments when symptoms appear biological.
Consider spiritual patterns. Is resistance only in relation to spiritual matters, or does it appear across all areas of life?
Collaborate, don’t compete. Pastors and counselors should partner together. Pastors bring theological and spiritual insight; counselors bring clinical expertise. Both are needed for holistic care.

Conclusion: Shepherding with Wisdom and Compassion

Pastors and Christian counselors have a sacred responsibility. When we mislabel depression as “demonic,” we heap guilt and shame on struggling believers. When we dismiss spiritual warfare as “just mental illness,” we leave sheep vulnerable to the enemy’s attacks.

The wise shepherd recognizes that God has made us whole persons—body, soul, and spirit. Sometimes the enemy attacks the mind; sometimes the body falters and the soul grows weary. In every case, Christ is sufficient. He is both our Wonderful Counselor (Isaiah 9:6) and our Deliverer (Psalm 18:2).

Our call is to walk in humility, leaning on Scripture, prayer, and the tools of wise clinical care, so that we may bring people closer to wholeness in Christ.