Five Lessons Learned from Counseling "Severe" Cases

| April 10, 2018

I can still remember many of them. Etched in mind are counseling sessions I have had with individuals, many of whom were professing Christians, who were wrestling with challenges that many counselors would label “the severe cases.” These were individuals who had appeared by all accounts to lose touch with reality, were experiencing delusional thoughts or were hearing and/or seeing things that others were not also experiencing. Clinically, the term “psychosis” is often used in such situations, but aren’t there also spiritual components to such experiences? Given that psychotropic medication is often indicated and helpful in such situations, is this simply an area where a pastor or biblical counselor should just relinquish the complete package of aid to a medical doctor or other mental health professional? It can be so challenging, particularly for the pastor or layperson to know how to care for a person in these situations, particularly a brother or sister in Christ. And what if a true believer is wrestling with what could be diagnostically classified as psychosis (perhaps Schizophrenia, a psychotic bipolar disorder, or other such issue)? Is this diagnosis an absolute practical excommunication from the body of Christ gathered? In the end, resources outside the church can often be helpful, but this does not mean that the church or pastor needs to simply relinquish all aid. I want to look at five lessons, suggestions really, for counseling in such cases.

1. We Are Body and Soul

I recently wrote about this in another post related to anxiety, but it is a proper and practically necessary theological category to understand that human beings are body and soul. As such, the material part of us, our body, is subject due to sin, the fall and the curse, to brokenness and decay. There are certainly times where the diagnostic symptoms above can rightly be attributed to spiritual issues or attacks—we certainly see that in the Scriptures (i.e. think of the Psalmists seeming shifting emotions). However, there are clear cases where the human brain does not operate as it does in the average human individual, and as such, the experienced reality of an individual is altered. They may believe they are hearing voices, or seeing hallucinations, or are suddenly reacting to stimuli that are not actually there. In these situations, it is usually clear that biology is a necessary consideration, and in a proper, preferably wholistic way, medication treatments are necessary.

However, in saying that we are body and soul, we must not assume that a person with Schizophrenia who is a born again believer is no longer a human being with a soul that can be spiritually nourished. Deep biological ailment does not negate the care of the soul. I fear that often times in these situations, otherwise staunch dichotomists become practical monists in their understanding of human anthropology because of the extreme intricacies of caring for someone who has lost touch with reality. What I mean is that if a caregiver (pastor, layperson, etc.) is not careful, he or she will negate the soul, or assume it is driven only by a biological ailment in situations like these, which can result in a lack of intentionality to nurture a believer spiritually.

Bottom line: we must be careful not to rule out true biological roots to these problems, but we must also not forget that the soul of a believer is not singularly ruled by his or her biology.

2. Love Rejoices in the Truth

First Corinthians 13 reminds that us that in true love, truth is crucial. Severe challenges like psychosis require a steady eye on truth. Yes this means theological truths, but it also means daily, moment-by-moment reminders of what reality actually is. Often times, the individual with one of these diagnoses or struggles will have an extremely difficult time remembering the true from the false (beyond the cut and dry breaking of the ninth commandment) including who to trust, what content can be assumed as true, what the past was, what the current reality is and more. Medication is often helpful in these situations, but walking alongside a brother or sister in these areas requires a ready willingness to “rejoice in the truth with them” by not only reminding them regularly of the truths of Scripture, but also gently helping them to test their own perceptions of reality with more truthful actualities. In some cases, it will be necessary to help a sufferer to distinguish between intentional lying and unintentional lapses or breaks with reality. This must be handled delicately, and helping the brother or sister in Christ to see that you are trustworthy—sort of an “earning of the right” to walk alongside them—is a necessary foundation for success.

In this post, I am predominately addressing those situations where concerns for safety (of the individual, but also of the church body) are not a concern. Namely, situations where the challenges that an individual faces are known to be non-hostile and where the brother or sister is known (vs. being a new face, or someone “off the street”), at least by a few trusted members and where safety concerns regarding potential violence are not an issue. This concern is often a real concern and must at least be mentioned. However, we must also be careful not to assume everyone struggling with these types of challenges is “living on the street”, “definitely violent”, etc.

3. Difficult diagnoses do not rule out Sanctification, the Fruit of the Spirit or the call to obedience.

Much more research could be undertaken on this point, but we must be careful not letting a mental health diagnosis prevent us from assuming (although it might look slightly different) that a true believer isn’t being sanctified, cannot exhibit the fruit of the Spirit, or that they get a pass on the biblical call to obedience. Growth in obedience may be focused on areas other than what believers not struggling with such diagnoses might focus on, but biological challenges do not give a believer a free pass to disobey. We also miss the benefit of how the Lord is working in someone’s life if we fail to assume that He is. What if the Lord is forming peace in the life of a believer who hears voices, or fades in and out of present reality? Even if that formation looks different, will we notice? Won’t that believer also benefit from a close community in the body helping them to see his or her own growth? The Holy Spirit indwells every believer and is conforming him or her to the image of the Son. Spiritual fruit will nonetheless be seen, albeit in slightly different forms perhaps. Psychosis for instance, as challenging as it is, is not a cancellation of the work of Christ, nor the promise of Philippians 1:6.

4. Ordinary Means of Grace Don’t need to be replaced by Extraordinary Ones

We also must encourage those wrestling in these types of struggles to approach the ordinary means of grace. Preaching, prayer (even if regularly accompanied by others) and the sacraments/ordinances are a necessary food for the believer. Difficult mental health problems, while often necessitating many other relational structures and increased aid in some areas, do not nullify the usefulness of the ordinary means of grace. In the Word preached aright, Christ speaks to His people. Even a person struggling to hear and receive words; struggling to know delusion from reality; wrestling with basic tasks like self care—even these individuals who are Christ’s benefit from His Word. Retention may be less. Attention may be less. But, nonetheless, the ordinary means of grace are not to be thrown out in the midst of such challenges. It can be tempting to think that these situations require extraordinary means of grace. However, they require ordinary means of grace as a foundation upon which other tools can be helpful.

5. Love Is Patient

One of the attributes of Christian love is that of patience. Within the body of Christ, there will be an increased need for patience when a brother or sister is battling a more “severe” problem or diagnosis. Part of this patience may be the need for pastors, other church members connected to that individual, and family to get extra training, resources, books, etc. on how to serve that person. Part of this patience means having a flexible scale for how to measure progress and change, and part of this patience is going to require, on the part of the caregiver, a willingness to be challenged in their own sanctification as they walk alongside the brother or sister who is struggling.

One blog post is insufficient to even begin the process of considering how to care in these situations. It is certainly necessary that any person, a pastor or otherwise, who seeks to offer counsel in these “severe” cases seeks to study, get counsel and even obtain additional training in how to care in these situations. However, the purpose of this post is simply to advocate for the potential of spiritual growth in the believer struggling with one of these concerns. What can our God not do? For the brother or sister wrestling with one of these concerns, either in this life or ultimately in the life to come, the words of Question One of the Orthodox Catechism (1680) by Particular Baptist Hercules Collins, following on the tradition of the earlier Heidelberg Catechism, are so helpful:

What is your only comfort in life and in death?

Answer: That I am not my own, but belong — body and soul, in life and in death to my faithful Savior Jesus Christ. He has fully paid for all my sins with his precious blood, and has set me free from the tyranny of the devil. He also watches over me in such a way that not a hair can fall from my head without the will of my Father in heaven in fact, all things must work together for my salvation…