[Last revised August 5, 2024 at 2:03 pm]
A Call for Better Biblical Counseling
As biblical counselors we wholeheartedly believe that the Bible is inerrant and sufficient. However, our theology of Scripture does not necessarily mean that our current iteration of biblical counseling is inerrant and sufficient. Our humble movement is at its best when we operate from the standpoint that we need to improve our own counseling theory and practice to be better in alignment with Scripture. One of the ways we can seek to make our biblical counseling better is by seeking to improve our understanding of specific mental health issues so that we can better apply the Bible. One specific issue needing to be given more attention in the biblical counseling movement is our approach to Obsessive-Compulsive Disorder (OCD).
Why Do We Need Better Biblical Counseling for OCD?
The reason I believe we need to be concerned to give better biblical counseling for OCD is because Scripture calls us to govern our bodies as part of our sanctification, but oftentimes biblical counselors neglect the physical body while ministering to those with OCD.
Scripture Calls us To Govern Our Bodies as Part of our Sanctification
As we strive to faithfully counsel sinners, sufferers, and saints from the Scriptures we are not interacting with disembodied souls, but rather embodied souls. The immaterial mind and the material body exist together, in an inseparable union, and both aspects influence each other. Because we are people of the book we need to recognize that the sufficient word of God compels us to steward and govern our bodies in accordance with the reign of Christ in our heart.1 Consider that Paul calls believers in Romans 6 to, “12 Let not sin therefore reign in your mortal body, to make you obey its passions.13 Do not present your members to sin as instruments for unrighteousness, but present yourselves to God as those who have been brought from death to life, and your members to God as instruments for righteousness.”2 One of the most striking observations that we need to consider from Romans 6:12-13 is that Paul implies sinful habits can live in the believer’s body, even after a change in governing authority has occurred in the mind. Experiencing change in our bodies, as part of sanctification, is something that God expects to be true of every believer.
Not only is experiencing change in our bodies commanded (Romans 6:12-13), it is possible. By God’s grace, the mortal body is not in a fixed state. Our bodies can undergo change as part of our sanctification, and we must take responsibility for this change. We know this kind of change is possible because Scripture never calls us to do that which is impossible. Therefore, bodily change as part of one’s sanctification is implied as being possible, and it is commanded as something necessary to pursue, in Romans 6:12-13.
In support of what we know to be true from Scripture, neuroscience has also confirmed that the brain can undergo change through a process of what is known as neuroplasticity. The idea of neuroplasticity is that the neurons in your brain can forge new connections, resulting in new wiring in the brain.3 This is an exciting insight because it points to the reality that our biblical counseling, which aims to minister to the whole person, is involved in the rewiring of the brain, thus working towards accomplishing the work of Romans 6:12-13 of presenting “your members to God as instruments of righteousness.”
We Often Neglect the Body in Biblical Counseling for OCD
The good news is that the notion that OCD is biologically involved is well attested within the biblical counseling movement. Medical doctor and biblical counselor Dr. Charles Hodges states, “There is objective medical evidence that those with OCD have differences in their brains that may account for the difficulty they have in moving on from an obsessive thought. […] OCD appears to have a genetic component.”4 Likewise, Dr. Michael Emlet states that the examples of genetic studies, autopsies of the brain following the influenza epidemic, and brain scans, “suggest that some types of OCD may be more biologically based.”5
Unfortunately, the wider biblical counseling movement has struggled at times to consistently provide counsel that adequately accounts for the biological issues involved in counseling one with OCD. In my opinion, this inconsistency largely exists because our understanding of the body’s role in the counseling process is often deficient or altogether missing. When the body is removed from the equation as something which needs to be sanctified in the OCD experience all that is left is that which is spiritual. As a consequence, our solutions and counsel can be shortsighted and flawed because they do not address the whole person.
Typically, this flawed approach results in the counselor negating the psychological diagnosis of OCD, redefining OCD in purely biblical terms (such as fear and worry), and then applying established biblical counsel for those presupposed heart issues. Unfortunately, this methodology can leave the one suffering in a crippled state because the body is left unaddressed.
As a result of a deficient theology of the body in the OCD experience we are prone to drift towards a kind of counseling which is sometimes referred to as ‘emotional voluntarism.’ Emotional voluntarism is the idea that our emotions solely reflect what we truly believe, and therefore, we can overcome our emotions by applying the gospel through voluntary mental work.6 While it is true that the one experiencing OCD symptoms must embrace a sense of agency and responsibility in their fight against OCD, and it is true that there is significant voluntary heart work which must be pursued, the disorder is not something which can be overcome solely with changing one’s deeply held beliefs. Emotional voluntarism makes change difficult because it presupposes that the immaterial heart is exclusively the problem needing to be addressed within OCD.
I believe that our biblical counseling for OCD can be better if we adequately account for the body’s role in the OCD experience, which in turn will keep us from treating OCD with emotional voluntarism, or as an exclusively spiritual problem.
Purpose & Outline
We, as biblical counselors, can provide better counseling to those with OCD symptoms, and that is my primary goal in writing this article. To achieve this, I will divide my article into two sections. In the first section, I will propose three key improvements for biblical counselors that must be pursued in counseling those with OCD. These improvements are:
- 1.1 – Gaining a deeper understanding of what living with OCD is like as a bodily experience.
- 1.2 – Educating ourselves with the best available medical research on OCD to better understand the role of the body in the OCD experience.
- 1.3 Considering the insights of experts who are knowledgeable in OCD treatment to further refine our counseling practices.
My hope is that by improving our biblical counseling in these areas, we can offer more compassionate and biblically grounded support to those dealing with OCD. In the second section, I will present what I believe to be the three essential pillars of biblical counseling for OCD. These pillars for counseling OCD are:
- 2.1 – Provide a vision of the future in which the one struggling is flourishing.
- 2.2 – Push the counselee to deny their compulsive behaviors.
- 2.3 – Help the counselee disempower their intrusive thoughts.
These three pillars are not intended to be exhaustive. They are a primer and a framework intended to help generally guide the counselors thoughts and to find a sense of direction in the counseling room.
Section 1: Three Improvements Needed for Counseling OCD
1.1 – Better Biblical Counseling for OCD Entails Better Understanding the Experience of OCD
Formal Definition & Introductory Data
Obsessive-Compulsive Disorder (OCD) is defined as “a disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions). To get rid of the thoughts, they feel driven to do something repetitively (compulsions).”7 For the sake of clarity it is important to understand that with the OCD experience, the compulsive behaviors are intended to alleviate the psychological and bodily distress which accompanies the presence of intrusive thoughts.
In terms of prevalence, OCD is estimated to affect 2% of the global population (1 out of every 50 people), which includes about 6 million Americans. In terms of severity, OCD is crippling. The World Health Organization (WHO) lists OCD among the top 10 most debilitating illnesses of any kind. This data suggests that OCD is widespread and must be taken seriously.8
However, this definition and data do not fully capture the lived experience of those with OCD. To provide better biblical counseling for those struggling with OCD, it is crucial to consider their lived experience.
OCD as a Lived Experience
For those of us who do not live with OCD, it is often viewed through the lens of pop culture. We might think of individuals who are unusually particular about organizing their socks or keeping their house spotless, but this is not OCD. The reality of OCD is much darker. For those who struggle with OCD, everyday tasks can feel overwhelmingly distressing and the OCD experience often leaves individuals feeling as though they are being swallowed up by the disorder. To help illustrate the actual lived experience of OCD I want to compare the experience of OCD to accidentally running a red light, or at least thinking you did.
Consider what happens in your mind and body the moment you accidentally run a red light. In an instant, your heart rate spikes, your pulse begins to thump in your neck, and your stomach drops. All your senses are on high alert, experiencing total sensory overload. You might even think, “Did I just cause an accident or harm someone?” This red-light response is normal because it occurs in a genuinely dangerous situation, and is designed by God to protect you and others.
Now, imagine experiencing this exact response every single time you drive through a green light, despite knowing it’s safe. This is often what OCD feels like when those who suffer with it experience an intrusive thought and feel the intense impulse to complete a compulsive behavior.
They know at one level everything is fine and that the compulsion would be unnecessary to complete. However, on another level, they feel as though things are not okay. In fact, they feel as though they are in imminent danger, as if they just ran a red light. Unfortunately, these distressing moments can happen dozens of times each day for the one struggling with OCD, not just occasionally. Intense emotional and bodily distress occurs each time an intrusive thought arises, especially if the compulsive behavior meant to alleviate it is resisted or determined to be impossible to perform.
Those who experience OCD frequently detail that it is a grueling experience which wears them down spiritually and physically. How mentally fried would you be if you lived this life day after day, year after year?
To provide better biblical counseling to those with OCD, we need to understand the lived experience of OCD deeply. We must strive to comprehend the complexities of their struggle without assuming or suggesting we have experienced something similar. Prematurely assuming or claiming to understand someone else’s struggle can undermine our counseling efforts, particularly when counseling someone with OCD. In order to fight against this possibility we as biblical counselors need to understand the OCD experience from the first-hand account of our counselees. In order to gain access to this data our counselees have to disclose it to us through good questions and gaining trust.
In addition to getting good data from our counselees we need to learn about the OCD experience from the available medical research and by engaging with experts in the field of OCD. By God’s grace there is a plethora of research available and we have access to those who have unique insight through years of experience.
1.2 – Better Biblical Counseling for OCD Means Interacting with Medical Research
Why Should We as Biblical Counselors Care About the Medical Science of OCD?
At the outset of this article I stated that the Bible calls us to govern our bodies (Romans 6:12-13) as part of our sanctification because we are embodied souls. It is this most basic understanding of human anthropology, affirmed in Scripture, that should lead us to be careful students of medical science and research. We constantly need to do the hard work of discerning which issues of the body fall into the scope of Romans 6, and therefore can be repented of, and which issues of the body are part of being born with a sin cursed body, and therefore cannot be repented of. Unfortunately, too often we as biblical counselors only interact with medical research for the purpose of critique. We say things like “we’re not against science, we’re just against bad science.” While this may be true in theory, in practice, there are very few medically-informed resources available to biblical counselors which functionally affirm the use of good science.9
To a degree, we should be skeptical of medical science/research, because even medical science isn’t safe from biases and misinterpretation. Many of the conclusions drawn from scientific studies and research can be driven by a materialist worldview which presupposes the absence of an immaterial heart at play in the human condition. Further, we should also be suspicious of the medical research surrounding OCD because a vast majority of the medical research for OCD is in the field of neuroscience, which is still in its infancy in terms of what we actually know about neurology.
While these words of caution are necessary, we also need to be careful to not be so critical and cynical of medical research surrounding OCD that we miss valuable data. It is possible that we get so distracted by the shortcomings of medical science and research surrounding OCD, that we miss that information which is helpful.
Moving Forward with Imperfect Medical Science
In my view, in order for us to be better biblical counselors for those who struggle with OCD we have to learn how to move forward with incomplete, inconclusive, and even potentially flawed medical research. The purpose of interacting with the best available science is that it will help ensure that we begin to distinguish which issues are physiological and which are spiritual, and then counsel accordingly to both the inner-man and the outer-man. As we commit ourselves to better understand the complexities of the mind-body dynamic in the OCD experience, our counseling will be refined and focused on exactly where the wisdom of God’s Word intersects with the heart issues of OCD and how the Bible guides us in providing biblical counsel to spiritual issues with a biological component.
Medical Research for OCD
The current biological etiology for OCD revolves around the study of genetic contributions, dysfunction in functional neuroanatomy, and abnormalities in neurotransmitters. The widely believed theory in the scientific community is that these three biological factors are all at play to some extent in those with OCD symptoms.10
The research which is of particular interest to biblical counselors is the research pertaining to neuroanatomy and neurotransmitters. What makes this research of significance to biblical counselors is that modern neuroscience has revealed that the brain has significant plasticity, meaning that the biology of our brains can be acted upon and altered by our thoughts and behavior over time.11 This plasticity is widely believed to be pivotal in the formation of OCD symptoms and also the relief of symptoms. Essentially, this means that the brain can be conditioned to develop significant biological issues, and it can also be conditioned toward healing. The science of neuroplasticity should perk our interest considering Romans 6:12-13 calls believers to govern their bodies toward righteousness.
Neuroanatomy
One resource I’ve found helpful in further understanding the neuroanatomical functions of the brain, as it pertains to OCD, is the work of Dr. Andrew Huberman, a neuroscientist and professor in the Department of Neurobiology at Stanford University. Huberman explains that brain imaging research targeted at better understanding OCD has revealed dysregulation in the cortico-striatal-thalamic circuit loop in the brains of those who struggle with OCD.12 This finding is significant because these parts of the brain underlie our thoughts and actions.13
Here is a brief description of how these brain regions function and how dysfunction presents in those who suffer from OCD:
- “Cortico”: The cortical region of the brain, particularly the orbitofrontal cortex (OFC) and anterior cingulate cortex (ACC), are responsible for decision-making and assessing the significance of stimuli. In OCD patients there is often hyperactivity in these areas of the brain. This hyperactivity is believed to distort and exaggerate the perception of the emotional value of stimuli. As a result, things may be perceived to be more dangerous than they really are, which contributes toward obsessive thoughts.
- “Striatal”: The striatum is located in the basal ganglia of the brain and is comprised of the caudate nucleus and the putamen. This portion of the brain plays a significant role in regulating attention and planning movement. Dysfunction in this portion of the brain is believed to distort one’s ability to filter out intrusive thoughts and regulate compulsive behaviors.
- “Thalamic”: The thalamus is the portion of the brain that acts as a relay station between the cortical region of the brain and the basal ganglia. Hyperactivity in this area of the brain is believed to cause an excessive amount of signals being transmitted, further enabling the cycle of obsessions and compulsions.
How do we as biblical counselors synthesize and make sense of this research as we counsel those with OCD? In 2018, researchers from the University of Michigan Medicine released a study which included a large pool of 500 OCD participants and also collaborated data from 10 other studies. This research concluded that the brain’s of those suffering with OCD show abnormalities in error processing and inhibitory control.14 Perhaps the most helpful summary of this research came from Luke Norman, Ph.D, the lead author from the study. Norman explained that the results from the study “show that, in OCD, the brain responds too much to errors, and too little to stop signals […]”15 In short, the brain of an individual experiencing OCD symptoms has a tendency to amplify the volume of perceived errors while simultaneously struggling to hear the brain’s signal to stop.
Further evidence supporting this conclusion comes from a study by Dr. Susanna Ahmari at Columbia University. Ahmari artificially stimulated the cortico-striatal circuitry in mice, inducing OCD-like symptoms, such as excessive grooming. This research underscores the role of this circuitry in OCD behaviors by showing that OCD symptoms can be brought on by manipulating stimuli for the brain.16
I share this research in order to illustrate that the consensus from medical research over the last few decades consistently concludes that OCD symptoms are biologically based in our neurology.
Neurotransmitters
In addition to neuroanatomy, it is important to consider the role of neurotransmitters in OCD. Neurotransmitters are chemical messengers that transfer signals within the brain and across the nervous system. Research on OCD typically focuses on serotonin, dopamine, and glutamate, with glutamate receiving the most attention recently.
Glutamate is the “most abundant excitatory neurotransmitter in the brain; it is critical to the communication of nerve cells with one another in practically every circuit in the nervous system.”17 Researchers have observed that there is often an abnormal amount of glutamate in the brains of those who struggle with OCD, leading many to conclude that an abundance of this excitatory neurotransmitter is involved in reinforcing OCD symptoms. As a result of this research there have been many psychotropic drugs utilized in the treatment of OCD which are geared towards regulating these neurotransmitters.
Huberman argues that the benefit of using psychotropic drugs to treat OCD symptoms may be that these drugs further activate targeted neurotransmitters, thus allowing greater neuroplasticity. Once the window of neuroplasticity is opened then the hard work of counseling can take root.18
Implications for Counseling OCD Given Current Medical Research
While the available medical research indicates there is a strong biological component at play in the OCD experience, the research does not prove causation. This is a point that medical researchers are often very transparent about. Despite the fact that the research doesn’t answer questions as to how exactly the OCD experience originates, it does indicate that the body is fully engaged once OCD symptoms have onset and become habitualized. As a result, biblical counselors need to provide counsel which aims at helping both the mind (immaterial) and the brain (material) of those with OCD.
As I wrap up this section of my article, I want to briefly outline some implications for how relevant medical research should shape our counseling of OCD in order to provide better biblical counseling:
- First, the medical research indicates that there are biological issues at play within the OCD experience which need the attention and expertise of appropriate medical professionals. It is necessary and wise to advise your counselees who show OCD symptoms to consult with their doctor in order that the image bearer before you can receive the best help available.
- Second, this medical research helps us see the scope of our biblical counseling. The best research available indicates that the OCD experience is both a battle for the mind and the brain, and that neuroplasticity is possible in the brain. Because change must happen at both the level of the immaterial-mind and the material-brain in order to overcome OCD, the scope of counseling those with OCD must aim at both spiritual and physical outcomes. For the sake of clarity, I am advocating that we must go beyond mind-oriented counsel such as “think this, understand this, be comforted by this, believe this, and be reminded of this”19 in our counseling of OCD. Also, we need to provide counseling homework that engages both the mind and the body so that the whole person experiences Gospel-transformation. If both the immaterial and the material issues are not dealt with in the OCD experience, the problem will not go away and the symptoms will not fade. For example, if the counseling homework we assign only targets the inner man, then the outer man aspect will be left unattended, unfortunately allowing OCD tendencies to thrive.
- Third, this medical research tempers our expectations for how quickly (or slowly) change is to take place. Because OCD gets engrained down into the body, growth and progress can be painfully slow. The biological hurdles of the OCD experience are significant and should lead us to be patient with our counselees. Many OCD patients know that their intrusive thoughts do not reflect reality or anything close to a rational thought. In fact, most OCD patients desperately want to experience change but they feel as though they are fighting against an enemy which is always one step ahead of them. The problem they are facing is that their brains are experiencing dysfunction due to abnormalities.
- Fourth, this medical research allows us as biblical counselors to be supportive of supplemental help offered by psychoactive medications. To be clear, I’m not suggesting that the use of any psychoactive medication (such as an SSRI) will fix the underlying causes of the OCD experience. However, I am arguing that a biblical counselor can be supportive of the help psychoactive medications provide because they may give the one experiencing OCD symptoms some breathing room in their physiology in order to do the hard work of counseling. Similarly, we know that Tylenol doesn’t fix a broken arm, but if you are being asked to carry something with a broken arm, some Tylenol may really help cloak the symptoms long enough that the task can be completed with less pain and distraction. As previously stated, an appropriate goal for using psychoactive medications is to create space for the hard work of counseling to take place.
- Fifth, and perhaps most importantly, this medical research in no way undermines human agency. The best science available in the realm of OCD does not negate the human will nor the clear command of Romans 6:12-13 to govern your body in pursuit of sanctification. In my view, clearly delineating how the biological issues are involved in the OCD experience are necessary in order to apply Paul’s command to render the body for righteousness with precision. In short, those who suffer with OCD symptoms must take responsibility for their actions and their growth in Christ.
Medical research, even when conducted by those who do not acknowledge God, is still a manifestation of His grace. However, we must diligently test all information, whether it comes from scientific studies or our biblical counseling literature, against the truths found in Scripture.
1.3 – Better Biblical Counseling for OCD Means Engaging with the Experts
The renewing of the immaterial mind is not only biblical (Romans 12:2), it is necessary in the context of OCD because the battle is first and foremost an inner-man battle. However, the concept of renewing the mind is so broad that the truth can feel hard to access and apply in the context of the OCD experience.
What Does It Look Like to Take a Thought Captive?
One Scripture that speaks more directly to the kind of mind renewal needed for OCD strugglers is 2 Corinthians 10:5, which says,, “We destroy arguments and every lofty opinion raised against the knowledge of God, and take every thought captive to obey Christ.” In this Scripture Paul is describing the nature of the warfare he fights to defend his ministry. Rather than using fleshly weapons (v.4), Paul is committed to fighting with spiritual weapons, like guarding his thought life by taking his thoughts captive to obey Christ. The truth of 2 Corinthians 10:5 gives us a helpful way to unpack the renewal of the mind spoken of in Romans 12:2. However, I also found myself wrestling with how to unpack the concept of taking a thought captive in my counseling of those with OCD.
How does one make taking a thought captive tangible? How does one know when they have successfully taken a thought captive? What are the nuts and bolts of taking a thought captive? What does it look like and feel like to take a thought captive?
Nuancing Awareness vs. Attention
One resource I’ve found helpful in discerning how to best help counselees take their thoughts captive comes from Dr. Michael Greenberg, a clinical psychologist specializing in the treatment of OCD. Greenberg is pioneering a variation of Exposure and Response Prevention (ERP) therapy called Rumination-Focused ERP (RF-ERP).
Greenberg argues that you cannot prevent yourself from becoming aware of a thought, but you can prevent yourself from giving attention to the thought.20 Greenberg goes on to quantify that giving a thought attention entails using your mental power and analytical skills to problem-solve.21 This important nuance guides our counsel for those with OCD because this nuance between awareness and attention gives us helpful language to use in order to help our counselees understand exactly what it looks like to take a thought captive. In short, our counselees need to understand that in order to take a thought captive they must be practiced in refusing to give intrusive thoughts any problem-solving attention.
It may be helpful to consider a case study in order to see how Greenberg’s nuance would be utilized by a biblical counselor trying to help his counselee take a thought captive.
Case Study: Ezra
Consider Ezra who struggles with contamination-OCD. Ezra’s intrusive thoughts typically occur when he touches something he perceives as contaminated or when someone else touches something of his with potentially contaminated hands. Ezra’s compulsive response to these intrusive thoughts is typically one of two things: (a) he immediately and methodically washes his hands for at least 20 seconds after an occurrence of contamination (like touching the kitchen sink), or (b) he discards items touched by contaminated hands. These are the rules Ezra lives by without exception because when these rules are broken, his mind and body catapult into a red-light response (severe mental and bodily distress).
Recently, Ezra was at his favorite Italian restaurant, and he observed his waiter committing an act of cross-contamination. The perceived violation was that the waiter picked up someone else’s dirty glass right before delivering Ezra’s plate of food. In the blink of an eye, Ezra had become aware of a problem as he experienced an intrusive thought: “I’ve just been contaminated because the waiter touched my food right after he touched someone else’s dirty cup.”
Ezra gave this intrusive thought an enormous amount of attention by compulsively thinking about how to avoid eating the contaminated plate of food. As is often true of Ezra, he played out the various solutions in his head: “I could tell everyone that I suddenly feel like I’m going to throw up so that I don’t have to eat the food,” or “I could tell the waiter he got my order wrong and ask for a replacement.” Ezra elected to go the route of saying he was sick so that he wouldn’t have to eat the contaminated food.
What Ezra needed to do at the Italian restaurant was to take that first intrusive thought captive. Ezra could not have prevented himself from becoming aware of a perceived problem as the result of an intrusive thought. Observations, like noticing your waiter do something you don’t like, are just a part of life and they are impossible to completely avoid. However, Ezra could have and should have taken responsibility for what he did next. What Ezra should have done is to refuse to give the perceived problem any problem-solving attention. He should have denied himself in terms of figuring out how to get around the occurrence of contamination. If Ezra had exercised this necessary step of taking his thought captive then the compulsive behaviors would have never been an issue.
Ezra needs to be encouraged by his biblical counselor to take the intrusive thought captive. Ezra needs to be challenged to not ponder, calculate, or consider how to alleviate the discomfort of the intrusive thought because analytical thinking in response to an intrusive thought only reinforces the legitimacy of the intrusive thought. Rather than feeding the intrusive thought by trying to solve the problem presented by the intrusive thought, Ezra needs to be counseled to carry on with whatever he was doing right before he became aware of the problem via the intrusive thought. For Ezra, this may look like continuing on in the conversation at the table and then eating the food on the plate in front of him. Ezra needs to do this while accepting the tension he feels from believing he is eating something contaminated.
God’s Grace From Unlikely Places
When I read Greenberg’s approach to distinguishing between awareness and attention, I realized this language provided an excellent way to vocalize the mechanics of taking a thought captive for those who struggle with intrusive thoughts and OCD. Our counselees need to understand that taking an OCD thought captive involves choosing not to engage in the mental gymnastics of solving the thought we have become aware of.
Greenberg’s perception, years of experience, and insight have proved to be invaluable assets to my biblical approach to counseling OCD. This experience reminded me that engaging with the experts can be a grace from God if it helps you make biblical truth more accessible to the people in your care. To be clear, I don’t believe that Greenberg has come up with something that isn’t already in Scripture (at least conceptually), but he has unintentionally articulated the minutiae of the mechanics involved in the biblical principle of taking a thought captive.
The idea that engaging with secular experts in order to make biblical truth more accessible is not without precedence in our biblical counseling movement. To hear Dr. Charles Hodges engaged in a helpful analysis and interaction with the work of world-renown OCD expert Dr. Jeffrey M. Schwartz click here.
In addition to reading widely to better communicate biblical truth, there are several other reasons I would encourage my fellow biblical counselors to engage with experts in the field of OCD:
- Engaging with the experts is helpful because your counselees already are doing so. If I’m counseling someone diagnosed with PTSD, OCD, or depression, I assume that my counselees are Googling their problems and reading anything they can find. Being well-versed helps me know what to listen for and to safeguard my counselees from worldly thinking. At the same time, it helps me better translate and understand what is being said in the counseling room.
- Engaging with the experts helps you see symptoms that you may have missed and that even your counselee may have missed. Knowing what the DSM-V says about the symptoms of OCD is incredibly helpful in identifying symptoms that are part of the OCD experience that the counselee may not even realize they need to address. Michael Emlet argues that, “psychiatric diagnoses organize suffering into categories that prompt focused attention. Put another way, the DSM helps you identify patterns of experience. It makes you aware of human struggles you perhaps didn’t know existed and therefore encourages a caring and careful exploration of such struggles.”22
- Engaging with the experts helps you see solutions that may be in the Bible, but you’ve missed because of preconceived notions and tunnel vision.23 When I first started counseling those with OCD, my approach was very much focused on helping my counselees change their thought process and belief system. My hope was that their body and behavior would naturally align as they gained biblical insight. The more I read outside of my biblical counseling camp, the more I encountered ERP therapy, the most widely used therapy for treating OCD. In light of this information, I started to ask, “If this secular therapy works fairly well, WHY does it work?” I believe ERP therapy often yields great results because it re-habitualizes the body’s behavior, with the understanding that eventually one’s thoughts will follow. This approach works well in treating OCD because it mirrors certain biblical principles closely enough that it taps into God’s wisdom. The principle being: Make no provision for the flesh (Romans 13:14). Rather, do what God wants you to do, even when you don’t feel like it.
Understandably, there is a reluctance in the biblical counseling movement to interact with secular sources and voices as they pertain to counseling theory and practice. The reasons for this reluctance are many and not without merit. Rather than rehearsing the valid reasons why we as biblical counselors should be skeptical about secular voices, I hope that I have put forth a nuanced argument as to how we can benefit from engaging with secular voices without simultaneously tainting the well of living water.
Section 2: Three Pillars of Effective Biblical Counseling for OCD
Up to this point, I have explored how biblical counselors should seek to better serve those whom they minister to. As a reminder, this was the first goal of this article. For the remainder of this article, I intend to offer biblical direction in how to counsel OCD. In doing so, we will consider three pillars of effective counseling for those with OCD symptoms.
2.1 – Provide a vision of the future in which the one struggling is flourishing
Some OCD sufferers remember a better version of their life before the onset of OCD symptoms, while others do not because the OCD symptoms have so defined every aspect of their existence for as long as they can remember. Regardless of which camp your counselee falls into, it is almost certain that your counselee is feeling exhausted and exasperated. What your counselee needs more than anything is hope to keep pushing forward.
One of my favorite Scriptures to use in counseling OCD is Lamentations 3:31-33, which says, “For the Lord will not cast off forever, but, though he cause grief, he will have compassion according to the abundance of his steadfast love; for he does not afflict from his heart or grieve the children of men.” This Scripture, originally given to Israel, is accessed through the person and work of Christ for all who place their faith in Him. What we learn from this Scripture is a key truth about the character of God. The key truth is that God is not someone who forgets about the one who is hurting, nor is He someone who delights to leave the sufferer in a state of permanent suffering. He will prove Himself to be faithful in the promise to not cast off forever. To the one who is hurting, I typically say: “Your suffering had a start date, and it will have an end date. Even though you are not guaranteed relief from pain in this life, you are guaranteed relief in the world to come. Even still, isn’t it more likely than not that a good God will bring you relief from your current suffering? Think back to the thing that most troubled you five years ago. Is that problem still persisting today? Think back 10 years ago. Is that problem still persisting today?” The point is that God often grants relief from human discomfort and suffering. There are very few seasons of suffering in our lives which are terminal.
Another one of my favorite Scriptures in counseling OCD is Psalm 121:5-8, which states, “The LORD is your keeper; The LORD is your shade on your right hand. The sun will not smite you by day, nor the moon by night. The LORD will protect you from all evil; He will keep your soul. The LORD will guard your going out and your coming in from this time forth and forever. I love this Scripture because OCD strugglers live with a constant sense of imminent danger because of the constant flow of asking “what if?” never ends. Psalm 121:5-8 helps those who live in this state of unending panic know that because the Lord is their keeper, they don’t have to be their own keeper.24 The Lord is the one who protects, and the Lord is the one who keeps our counselees secure. This is a big truth for those who habitually feel crushed and overwhelmed by having to control everything all the time.
If God, in his infinite wisdom and goodness, denies our prayers for relief, the LORD is still good and His grace is still sufficient. As is true with counseling any other issue, regardless of whether or not it is spiritual or physical, there is a goal bigger than relief from the pressure we are living under. The goal is living in light of the truth that God’s grace is sufficient for the purpose of being God-pleasing even if our circumstances and suffering go unchanged.
2.2 – Push the counselee to deny their compulsive behaviors
The medical research available for OCD suggests that the body houses the OCD experience and even lends itself towards perpetuating OCD tendencies. This basic medical insight for OCD instructs our biblical counseling in the sense that it helps direct our attention in the right direction as we explore biblical insight and help. Because OCD is as much an issue of the body as it is the mind, we must remember that one cannot simply out-think OCD. No amount of meditation, memorization, reflection, insight, or introspection can undo the OCD mess because OCD is not just a problem of the immaterial ‘mind.’ To push back the enemy lines of OCD, there also needs to be effort and attention given to address the biological/neurological side of OCD. In order to fight against the neurological hurdles of OCD, a counselee must learn to outbehave it by resisting compulsions. In short, you conquer OCD compulsions by starving them to death by being obedient to Christ.
Biblically speaking, this point of application should not surprise us. Romans 13:14 instructs us to not make any provision for the flesh. When someone with OCD tendencies moves from an intrusive thought to the corresponding compulsion, what they are doing is making a provision for a fleshly desire by keeping alive the pattern of indulging in what the flesh wants (Romans 13:14). As those with OCD deny themselves the luxury of performing various compulsions, the felt weight of the compulsions weakens over time. Doing this work of denying a compulsion is not to be taken lightly. Denying a compulsion can feel utterly impossible for those who struggle with OCD. Learning this new habit is going to take a lot of time and failure is part of the journey.
The necessity to fight against OCD compulsions is straightforward when the compulsions are clearly sinful. For instance, when someone feels compelled to throw away groceries because they were purchased on the wrong day of the week, it is obvious that this behavior is sinful as it demonstrates poor stewardship of God’s resources. However, when a person’s compulsions seem more odd than sinful, it is easy for a counselor to leave these behaviors unchecked and unchallenged. While many OCD behaviors, such as repetitive hand-washing and double-checking the stove, might seem innocuous and harmless, they are not. These behaviors are born out of fear, not faith, and therefore need to be repented of. Every time your counselee gives in to a seemingly harmless compulsion, they are perpetuating and further ingraining the lies that are underneath their compulsive behavior.
Case Study: Denna
Consider Denna for a moment. Denna is a woman in her late 30’s and she works at a dental clinic as an office manager. Denna’s intrusive thoughts are almost entirely connected to this idea that she could do something which could unintentionally bring harm to others. She has dozens of intrusive thoughts each day and almost as many corresponding compulsive behaviors which are constantly being performed.
For instance, Denna will never shake the hand, fist bump, or high-five any of her co-workers without using hand sanitizer before and after the interaction. She performs this compulsive behavior because she frequently has this thought play out in her head in which she envisions transferring possibly harmful germs to one of her dental hygienist friends and that they will in turn give the germs to a patient. Those patients will then go home, become violently ill, and it will all be Denna’s fault.
Also, Denna quadruple-checks whether or not she put patient records in the correct folder of the office filing cabinet. She does this because she frequently has the intrusive thought that if she mistakenly places files in the wrong place, thus frustrating her coworkers, it could eventually lead to her being fired.
Lastly, Denna insists that she is the last one out of the office each evening and that she personally locks the doors. Denna does this because she has this intrusive thought which involves a burglar entering the property when the office is closed because a door is left unlocked. Denna is so rigid with this particular compulsion that she will sometimes come back after hours just to double-check the doors.
As you survey these three examples of Denna’s OCD, none of her compulsions seem sinful. In fact, her compulsions all seem to revolve around protecting others and sometimes herself. Some may even look at Denna’s compulsions and think, “Wow, some of that is really to be commended!”
Regardless of how harmless Denna’s OCD symptoms seem, they need to be resisted and denied. If Denna allows herself to continue to perform needless compulsions, she is actually preventing growth. One of the best things a biblical counsel can do to serve Denna is to help her learn to tolerate the discomfort of denying her compulsions, no matter how harmless the compulsions may appear on the surface.
Any meaningful progress in fighting against OCD is inherently and incessantly uncomfortable. When you push your OCD counselee to deny their compulsions, in accordance with Romans 13:14, you are actually pushing them to do a work that engages both the immaterial mind and the material body. By God’s grace, their body is being reprogrammed as new habits are formed. As time goes on, Denna’s compulsions will weaken in their perceived intensity.
Reflecting on why Resisting Compulsions Matters
The effects of one’s personal sin and living in a sin-broken world have on one’s body are difficult to overstate. Because we are truly physically embodied, spiritual beings, we expect to see issues of the heart manifest themselves in the physiology of our bodies. The necessary work of every biblical counselor is to counsel the whole person. In order to minister to the whole person, and in particular the body of those who struggle with OCD, we must encourage our OCD counselees to resist their compulsions.
As has already been mentioned, resisting compulsions is the biblical work implied by Romans 13:14. Following the basic biblical principle of Romans 13:14 to make no provision for the flesh, is first and foremost a matter of obedience to the Lord. However, a secondary benefit of this biblical wisdom is that it engages the physical body in a way that taps into the biological side of OCD and undoes the havoc that is OCD.
2.3 – Help the counselee disempower their intrusive thoughts
Most people with OCD symptoms would love nothing more than to have greater control over their thought life. The motivation for this desire is the belief that if the intrusive thoughts can be stopped, then the accompanying compulsive behaviors can also be stopped. By analogy, stopping the intrusive thoughts is like cutting off the head of a snake. Unfortunately, the problem with stopping intrusive thoughts is that the more you try to put a thought out of your mind, the more persistent it becomes. Therefore, the solution cannot be just to not have an intrusive thought, but rather to disempower the intrusive thoughts when they appear.
Biblically speaking, one of the the best place go in Scripture to learn how to deal with intrusive thoughts is 2 Corinthians 10:5, in which Paul says, “We destroy arguments and every lofty opinion raised against the knowledge of God, and take every thought captive to obey Christ.” As previously discussed, you must be able to quantify the actual mechanics of taking a thought captive for your counselee. I believe that the best way to achieve this is to encourage your counselee to distinguish between being aware of an intrusive thought and giving that intrusive thought problem-solving attention. For many, giving the intrusive thought attention is in and of itself a compulsion and is widely known as rumination.25 As explained earlier in this article, denying an intrusive thought attention means that the counselee has to strive to not solve the problem presented by the mere awareness of the thought. I think a case study may help flush this out.
Case Study: Shelby
Take Shelby as an example. Shelby is a woman in her late 20s who struggles with intrusive thoughts concerning whether or not she is a true child of God. Typically, Shelby experiences this intrusive thought whenever she perceives she has sinned or is somehow reminded of the fact that there are those in the world who think they are saved but really aren’t. When Shelby has these intrusive thoughts, she typically launches into an inner dialogue in which she defends her faith to herself. Oftentimes this looks like rehearsing the truth of the Gospel, reciting Scripture, or reminding herself of other biblical truths from 1 John. Unfortunately, Shelby inevitably gets caught in a mental loop when she begins to second-guess her defenses to this intrusive thought.
What Shelby needs to do is to ignore the intrusive thought altogether and not give it any oxygen. The more that Shelby compulsively thinks on the intrusive thought and tries to rid herself of it by solving the question it presents, the more she is legitimizing the presence of the intrusive thought. In order to ignore the thought, Shelby needs to resume the activity she was participating in when the intrusive thought presented itself. The idea is to ‘pick up where you left off and carry on.’ Notice how similar the counsel for Shelby is to the counsel given to Ezra in light of his intrusive thought in the Italian restaurant.
As you counsel someone with OCD it is imperative to not only explain that the intrusive thoughts need to be denied, but that you detail how to deny the intrusive thought. Further, it is imperative to give voice to how incredibly difficult it will be for the OCD sufferer to deny engaging an intrusive thought with problem solving attention. Realize that denying an intrusive thought is a skill that has to be learned over time.
It is also worth noting that Shelby’s story is fairly common and presents some complexities for biblical counselors. The complexity for biblical counselors is that Shelby’s compulsive behavior (rumination) looks a lot like doing the work of Philippians 4:8, “Finally, brothers, whatever is true, whatever is honorable, whatever is just, whatever is pure, whatever is lovely, whatever is commendable, if there is any excellence, if there is anything worthy of praise, think about these things.” It looks like Shelby is doing the work of Philippians 4:8 because she is assertively directing her mental gaze at biblical truths. However, I would argue that Shelby’s response to the intrusive thought regarding the certainty of her salvation is potentially not as helpful as it appears because Shelby’s reciting of biblical truths to herself has been swallowed up into an OCD compulsion. Therefore, Shelby should not do these things in response to an intrusive thought. For the sake of clarity, it would be fine for Shelby to do these spiritual practices any other time. The caution I am giving is particular to those ruminations and other compulsions connected to the occurrence of OCD symptoms and which appear to be spiritual.
In counseling Christians with OCD, you will see this kind of thing all of the time. What’s important to remember is that you have to be willing to call your counselee to cease from doing seemingly spiritually oriented things if those spiritually oriented things are being weaponized against them in their OCD experience. Again, this is not to suggest that you altogether call your counselee to completely stop doing a certain spiritual thing, but that you call them to cease from doing that spiritual thing as a compulsive action in response to an intrusive thought. Maybe a better way to make the point is like this: never condone or endorse a compulsion in response to an intrusive thought, even if that compulsion is something Scripture calls Christians to do as part of their walk with Christ.
Conclusion
My goal in writing this article was two-fold. First, I wanted to offer what I believe to be necessary steps that we as biblical counselors must take in order to be better equipped to minister to those with OCD. My hope is that I’ve pushed you to understand the plight of OCD more deeply, to meaningfully engage the available medical research, and to engage with the leading experts in the field. Second, I wanted to pass along what I believe to be essential components of how to counsel OCD biblically. My encouragement is that you help your counselee wholeheartedly believe that the Lord will not cast off forever, and to effectively counsel to push back the enemy lines of the OCD experience in both the obsessions and the compulsions.
On a personal note, I hope that this article faithfully engaged with the Truth of God’s Word, and I also hope that it accurately and intelligently interacted with the available medical research on the topic. I wholeheartedly believe that the biblical counseling movement is a grace from God, and I believe that we can continue to better our movement through hard conversations.
Grace & peace to all of you, friends!
Credits
The Holy Bible: English Standard Version. (2016). (all Scripture). Wheaton, IL: Crossway Bibles.
Photo by Milad Fakurian on Unsplash
Footnotes
gospelmercies.com 