Counseling People Struggling with Obsessions and Compulsions

July 9, 2014

Counseling People Struggling with Obsessions and Compulsions
Dave Dunham

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Dave Dunham

Counseling People Struggling with Obsessions and Compulsions

Katelynn was trapped in her apartment over a long weekend. She was convinced that there was blood outside her door which was going to contaminate her.

Sasha was overcome with dread that she was going to yell out foul language during worship service, or while reading Scripture to her child. James was so consumed with the fear that he might be lying that he could never give a straight answer, only “maybe” would do.

These are real people. All of them have varying degrees of what is sometimes labeled obsessive-compulsive behavior (OCD). Caring for each of them requires incredible sensitivity, patience, and biblical counsel.

Freedom from Obsessions and Compulsions

OCD involves both obsessions and compulsions. Obsessions, properly defined, are intrusive, unwelcome, distressing thoughts or mental images. Compulsions are behaviors performed in a vain attempt to exorcise the fears or anxieties caused by an obsession. It’s necessary to understand both elements clearly if counselors are going to be helpful.

Vital things to remember about those who struggle with OCD is that they typically understand their obsession is illogical, and they also typically receive no pleasure from doing their compulsions. Attempts to help them should be exceedingly sensitive. The absurdity of the compulsion or the obsession should not be the focus of the counseling sessions. Rather, good counselors will attempt to be sensitive to the frustration and despair that a person with OCD may feel. They will also want to consider a number of issues related to causation.

Sensitivity is crucial for a number of reasons, but not least because there is a real possibility of biological causation as one important factor. Some counselor may too quickly overlook or dismiss the biological, believing it will remove personal responsibility from the individual. But the science pointing to biological factors should be taken seriously.

Biblical counselor Michael Emlet has pointed out several possible connections to biology. In his helpful booklet OCD: Freedom for the Obsessive Compulsive, he points readers to research that found OCD was more frequently present among identical twins than among fraternal twins. Furthermore, he points out that children with strep throat may develop a sudden onset of obsessive compulsive behavior which is relieved through treating the strep with antibiotics.

Jeffrey Schwartz too has demonstrated, through the use of PET scans that individuals suffering with obsessive-compulsive behavior actually present a sort of “overheating” in the basal ganglia (see Brain Lock). The frontal regions of their brains are overacting. An insensitive counselor will dismiss the biological, but a good counselor will encourage their counselee to seek appropriate medical attention to determine if any organic or biological causes may be contributing to or exacerbating their condition.

To counsel someone struggling with OCD without considering the biological factors is to fall prey to a kind of reductionism. Not only does such an approach feed the criticisms that is at times leveled against biblical counselors, namely, that they do not take science seriously, but it is also equally as reductionist as some secular approaches, only from a different angle. Some secular models of help do not treat the whole person, but rather reduces them to their biology. Such approaches have one tool in their tool belt: medicine. On the other hand, a biblical counselor unwilling to consider possible organic factors that may be involved in a case is reducing a person to their spiritual nature, a sort of gnostic approach to counseling that is neither Christian nor fundamentally helpful.

Working with James

Working with James has required this kind of careful analysis. James is a seemingly strong believer. He has a great grasp of the Scriptures, studies them often, and is concerned deeply about his obedience to Christ. He cannot, however, shake the feeling that he is going to lie. We discuss principles governing truth and falsehood. We discuss how it can be sinful to demand a level of certainty that God does not allow. He understands and can articulate these truths, but he has a real disconnect when it comes to applying them to his own life.

As two strong believers we are struggling together to work through this issue, it seems that getting a full physical examination might be next step for him. This doesn’t mean that James doesn’t also have heart issues that he needs to work through. He does, and we are doing that too. Some of his progress, however, may be stalled until we can determine what’s going on under the surface of his phobia; it might be a biological issue. Biblical counseling aims to treat the whole person as a whole person, so we want to carefully consider all the factors: spiritual, emotional, relational, psychological, and biological.

With James, progress has been slow. Every step forward has been met with another challenge. The list of phobias he has seems to grow. I am reminded often of 1 Thessalonians 5:14. Paul’s words to the church in Thessalonica have become a motto for Biblical counselors everywhere. He writes:

“And we urge you, brothers, admonish the idle, encourage the fainthearted, help the weak, be patient with them all.”

These words remind us of the importance of case-specific-counseling. Each individual needs a response that is relevant to their struggle. The idle need to be admonished, Paul says, but the fainthearted need encouragement. Different approaches are needed for different circumstances. The one thing that ought, however, to govern all cases is patience. This has been evidently true in counseling those who struggle with obsessive-compulsive behavior.

Obsessions are slavery, and those who have repeatedly given in to their compulsions only tighten their grips. Breaking those chains is not a quick process. Counselors must plan for the long-haul; they must focus on long-term discipleship not immediate repression of behavior.

It is possible to resist urges. In fact studies have proven that after fifteen minutes of refusing to indulge a compulsion the urges often dramatically decrease. That is not the same, however, as suggesting that the urges just go away. Psychologist Jeffery Schwartz often tells his patients that the urges may never go away completely, but he insists that this should not be their goal.

The biblical counselor’s goal for a counselee is not that they would be totally temptation free, but rather that they would consistently increase in faithful responses. Victory is not the absence of struggle, but the growing response of faithfulness in the midst of the struggle. As Alasdair Groves so eloquently puts it:

Struggle is not a bad thing. Instead, struggle is the glorious work of God as he redeems and sanctifies fallen hearts. Most men take a negative view of struggle because it is painful, exhausting, and they know they should not love the sins they are tempted to love. Struggle, however, is God’s ordained way of working righteousness into our lives, transforming men into people who radically own it when they say “No” to temptation. (Journal of Biblical Counseling 27:1, 22-23)

Celebrating Victories

The goal is to say “No.” Saying “No” consistently, however, takes time and spiritual discipline. It also takes a counselor who is committed to patient reiteration of biblical truth. It takes a counselor who encourages the small evidences of hope. Celebrate the little victories more than you condemn the occasional failures. With both James and Sasha that has meant reminding them that they have demonstrated the possibility of resisting their urges. The occasional failure does not undo all the work that God has already done in them. We look often at Romans 6 after a bad week.

In Romans 6 Paul speaks of believers who “submit their members to sin as slaves of unrighteousness” (v. 13). Because OCD feels like a slavery, and because they understand that giving in to compulsions is a form of submitting to slavery this is a relevant passage for them.

The major point to direct them to, however, is Paul’s main point: you don’t have to do it. Paul’s whole point in Romans 6 is that the believer is “free from sin.” We may submit to sin, but we don’t have to. We can instead submit to God.

Furthermore, we discuss the work of the Spirit in their lives and point to the evidence that they can do this. They have done it many times. The goal is to encourage them towards increasing faithfulness. Their failure this week is not a complete failure, it’s a setback. We can still move forward. Only a patient counselor, however, will see this reality. The impatient counselor focuses on every failure, every setback, every false message that the counselee encounters. The impatient counselor is looking for the “cure,” the complete removal of temptation and struggle, but God does not promise us or our counselee such things. We must, then, rethink our definition of “victory.” We must be patient with the counselee.

Scripture-Informed Counseling

The Scriptures not only informs the way we counsel, but they inform the counsel we give too. Obviously what marks out biblical counseling as distinct is the fact that it takes its direction from the Bible. So our counsel derives from the Scriptures. It is the Scriptures that offer significant hope, even to those who struggle with obsessive compulsive behavior.

The primary means for treating mental disorders like OCD has largely been medication. But medication may not prove effective and is often accompanied by serious side effects. The dramatic side effects of so many medications make them often very undesirable. Patients are torn between which symptoms are worse: those derived from their OCD or those derived from the medication given to treat it. The Scriptures, in turn, offer a different approach to treating obsessive compulsive disorder.

The Scriptures tell us we can change by means of “renewing the mind” (Romans 12:2). In counseling James, Sasha, and Katelynn, we have naturally focused on their thoughts and what alternate truths combat the false messages their brains are sending them. We try to look for root issues and points of connection to other issues.

The OCD may in fact be a symptom. In one case study Dr. Steve Viars explained how one counselee’s obsession with driving on odd number streets was actually an attempt to self-atone for lustful thoughts (see Counseling Hard Cases).

In Katelynn’s case, her contamination fears manifested most clearly when she was involved in stressful social contexts. Fear of man dominated her so much the she was overcome with severe social phobia. She would leave parties and replay every scenario, every conversation, critiquing and berating herself for her supposed failures. Her cleaning compulsion was actually an attempt to divert her attention, to repress her thoughts.

As we began to address her social phobia biblically the need to act out the compulsion decreased significantly. Giving biblical truth to reshape and reorient the counselee goes a long way towards bringing remission to their obsessive compulsive behavior. This is what makes biblical counseling distinct from other approaches.

No struggles are ever simple. Treating those who struggle with OCD is a process that requires sensitive, patient biblical counsel. Biblical counselors should take science, sanctification, and Scripture seriously. As they do, such counselors will be exceedingly useful to those they counsel.

Join the Conversation

In your counseling of people struggling with obsessions and compulsions, who do you take seriously science, sanctification, and Scripture?


One thought on “Counseling People Struggling with Obsessions and Compulsions

  1. I liked the quote about struggle being a glorious work of God redeeming and sanctifying hearts. I also appreciate the connection between compulsive behavior and fear/approval of man. So true.

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