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Panic Attacks: Listen to the

Messenger

Article January 2006

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Charles Sigler
Grove City College
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 Panic Attacks:
Listen to the Messenger

by Chuck Sigler

The message on Sarahs answering That night, Sarah awoke at 2 a.m. seized
machine jolted her like an electric shock: by fear that she was going to lose control as Luke
Sarah, call me as soon as you hear this message. did and kill herself. Jeremy stayed home from
Luke is dead. He killed himself. work the next day to be with her, and initially
Sarah and Luke had served as short-term she was less fearful and anxious. Then in the
missionaries in Haiti a few years ago. They late afternoon, she listened to her voice mail
became friends while in the mission field but and heard Lukes voice on it. She then
drifted apart after returning to the States. Sarah experienced another episode of heart
returned home, started a new job, and married palpitations, dizziness, breathing trouble,
her fianc, Jeremy. Luke returned to his church tremors, and fears of losing control and killing
and became involved in a local ministry to the herself. This pattern of symptoms continued
homeless. over the next few weeks.
Its a shock to hear that someone you Sarah and Jeremy began to make
know has died by taking his or her own life. accommodations in their nightly routine that
With Sarah, the news struck deep. As she hung became a part of their lives for several months.
up the phone, two thoughts came to her: What Jeremy hid the kitchen knives, as Sarah asked,
was going on with Luke that he did such a and only brought them out of hiding for her to
thing? His faith had always seemed so strong. use when cooking. And at Sarahs suggestion, he
And If this could happen to someone like carried his set of weights, weighing several
Luke, it could easily happen to me. hundred pounds, from the basement to their
Fear and anxiety gripped Sarahs heart. bedroom. Every night before they went to sleep,
She felt dizzy and light headed. She had trouble he moved the weights in front of the bedroom
breathing. She trembled and shook. Her heart door, so Sarah could not wake up in the middle
pounded like a drum. She feared that she was of the night in a panic and run from their room
losing control, going crazy. When Jeremy came before he could stop and calm her. With these
home thirty minutes later, Sarah threw herself precautions in place, she was eventually able to
into his arms. It was another fifteen minutes fall asleep for a few hours.
before she could tell him what happened. Within the next two weeks, Sarah had five
_______________________________________________ additional panic attacks along with problems
*Chuck Sigler is the director of Anselm Ministries. sleepingeven with the weights blocking her
He also teaches Biblical Counseling and Sociology of door. She became restless and irritable and was
Deviant Behavior at Grove City College. easily fatigued. She had problems concentrating.

14 The Journal of Biblical Counseling Spring 2006

2006, The Christian Counseling and Educational Foundation
All rights reserved. No portion of this publication should be reproduced, copied or utilized in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system, without permission in writing from The Christian Counseling
and Educational Foundation. Inquiries should be made in writing, addressed to CCEF, 1803 East Willow Grove Ave, Glenside, PA 19038.
Her family doctor gave her some samples of breathing. She trembled and shook. Her heart
Ativan and made Sarah promise to see a pounded like a drum. She was afraid that she
recommended psychiatrist.1 She took an Ativan was losing control. And the panic attacks were
that night and was able to fall right to sleep. recurrent. Sarah worried about going crazy. She
Sarah was afraid to be alone during the day demonstrated significant behavioral changes
and spent as much time as possible with family related to the attacks (the nightly rituals with
members. In the evening, Jeremy and Sarah the weights and kitchen knives). Sarah is on the
continued with their rituals with the knives and verge of a panic disorder diagnosis but is one
the weights. Sarah continued to have two or week short of the required four weeks with the
three episodes of anxiety and panic per week, above symptoms to be diagnosed as such. Shes
usually in the late afternoon or early evening. restless and irritable. Shes easily fatigued. She
Jeremy cancelled several planned social has problems concentrating and continues to
activities because Sarah was worried she would have sleep problems.
have a panic attack in public. Three weeks after While its too early for a diagnosis of
her initial attack, she saw a psychiatrist who generalized anxiety disorderSarah would
warned that her panic attacks could develop have to struggle with these symptoms more
into an anxiety disorder if she didnt do days than not for at least six monthsbut
something. He advised her to use the Ativan according to the psychiatrist, shes on her way to
immediately after each panic attack and that that diagnosis if she doesnt do something.
she take Paxil daily. 2 He advised her to return in Sarah is a poster child for panic attacks.
two weeks to review how she was adjusting to Shes knocking on the door of panic disorder
the medication. The psychiatrist also suggested and is headed towards generalized anxiety
that she begin to meet with a counselor. This disorder. She has received prescriptions for
brought her to you. Ativan and Paxil to take for her troubles. The
Ativan seems to be helpful, but she hasnt begun
Diagnosis to take the Paxil yet.
This case study presents some potentially What happens when Sarah decides to use
tricky issues for the biblical counselor. Sarahs the medication recommended to her by the
symptoms are evidence of what the DSM-IV- psychiatrist? The Ativan helps her in the
TR describes as a panic attack.3 She rings all the immediate aftermath of her panic attacks.
diagnostic bells for a psychiatrist to make When she takes the Paxil and it reaches
tentative diagnosis of panic or anxiety disorder. therapeutic levels in her blood, the cluster of
Making a diagnosis is a pivotal decision that symptoms associated with her anxiety decreases
summarizes how the psychiatrist understands and even disappears. The panic attacks become
the presumed disorder and guides the clinician less frequent and eventually stop; and Sarah
to select disorder specific treatment, often sleeps through the night without interruption.
involving psychotropic medication with people The knives are back in the kitchen; the weights
like Sarah.4 The heart of the DSMs method of are in the basement again. These reactions now
diagnosis is a checklist of specific behaviors seem silly and a bit embarrassing. She begins to
identified as diagnostic criteria which 1) believe that she must always be drugged in order
delineate the specified category of mental to be normal and that her problem is
illness; 2) identify the observable symptoms of fundamentally biochemical. The medications
the pathology (but not the disorder itself); and seem to have solved her problem. But have
3) provide guidelines that enhance agreement they?
among clinicians making diagnoses.5 Sarah has reservations about taking the
Sarah demonstrated five of the thirteen Ativan, but it does seem to work when she uses
diagnostic criteria listed for a panic attack in the it. Her symptoms of panic and anxiety diminish
DSM. Only four criteria, or behaviors, that or disappear. Shes able to sleep and does feel
develop abruptly and reach a peak within ten calmer for awhile. But she comes to you and
minutes are needed to make a diagnosis. Sarah asks about the psychiatric labels the psychiatrist
felt dizzy and light headed. She had trouble discussed with her: panic disorder and anxiety

The Journal of Biblical Counseling Spring 2006 15

disorder. What do these mean? What should I happened to Luke could happen to her.
do? Should I continue with the medication? Do The bad fruit of the heart reacts to the
I really have a mental illness, a panic or anxiety situation: Sarahs immediate outward response
disorder? (fear) to her interpretation of this situation was
How do you help Sarah? the cluster of symptoms that contributed to
There are at least two entry gates you can her own diagnosis of being anxious and afraid
use to work with Sarah. First, you can explore and the psychiatrists later assessment that she
and address the thoughts, feelings, and had a panic attack. Her ongoing worry about
behaviors that contribute to her reaction of fear, losing control and hurting herself (bad root)
panic, and anxiety in the wake of her friends brought on more panic attacks.
suicide. Second, you need to address her Sarahs initial reaction eventually
questions about medication. subsided, but since fear had taken root in her
heart, Sarah wakes up during the night feeling
Entry Gate #1: Biblically Framing Sarahs anxious. She is again fearful of losing control
Fear and killing herself. Again she institutes the
Even though medication relieves most of accommodations with the knives and the
her symptoms, Sarahs life is still ruled by fear. weights. She again experiences the cluster of
She continues to take Paxil each morning. She behaviors and feelings that eventually are
has decided not to accept a position at a labeled as panic attacks. As fear and anxiety
Christian school because the schools insurance respond to the fertile soil of Sarahs heart over
coverage would not cover enough of her the next few weeks, they contribute to a
medication expenses. While never much for downward spiral of consequences.
arguing, Sarah is noticeably more passive with
others. She consults her older, sometimes Heart Idolatry, Stumbling Blocks, and the New
controlling, sister more and more about Heart
decisions she has to make. She tries to change We can further specify the dynamic of her
the subject or generally avoid conversations fear by applying the two-fold idea of heart
related to death, anxiety, suicide, and Luke. She idolatry and its stumbling block as seen in the
walks away when she cant avoid the subject. Ezekiel 14. Heart idolatry is a key metaphor in
Increasingly, she evaluates her actions and how biblical counseling views the problem of
words against their potential to generate anxiety entrenched sin in our lives. Idolatry becomes a
or fear. She agonizes over whether or not to say concept with which to comprehend the
certain things to other people and then worries intricacies of both individual motivation and
afterwards when she does say something and social conditioning. The idols of the heart lead
whether or not she had said it in the right way. us to defect from God in many ways. 7 But the
Periodically, when she misjudges a situation, her concept of heart idolatry can also be understood
anxiety is strong enough to warrant taking an as the tendency for believers to wander away
Ativan. Although less incapacitated with her from God.
medication, the inescapable influence of fear in We see a pattern in the Old Testament:
her life is clearly evident. God repeatedly addressed His people when they
But now lets examine how to biblically wandered after idols. This resulted in Gods
frame the cycle of thoughts, feelings, and judgment on them (Isa. 1 & 2; Jer. 11; and Ezek.
behavior that Sarahs reactions manifest.6 Sarah 20). God directly identified their judgment as a
follows a clear cycle of bad root and fruit as consequence of their original idolatry. He called
seen in Jeremiah 17:5-10 and Luke 6:43-45. upon them to repent or face destruction. Gods
The heart of the situation: The shock of intention throughout this intervention process
hearing about Luke triggered a heart-based is for His people to turn and resume their
reaction: fear and anxiety took root in her heart. relationship with Him and to stop wandering
Sarah realized that someone whose faith she into their idolatries:
perceived as stronger than hers had taken his
that the house of Israel may no more go
own life in a moment of despair; and what

16 The Journal of Biblical Counseling Spring 2006

 astray from Me, nor defile themselves fruit of the tree and the land will be restored.
anymore with all their transgressions, but The vicious cycle of sin and folly described so
that they may be My people and I may be clearly in Ezekiel 14 will be a thing of the past.
their God, declares the LORD God. A new cycle of godly fruit and abundance will be
(Ezek. 14:11) made possible by a new, obedient heart and
Spirit. We will be His people and He will be our
But as the history of the Old Testament
God. Our hearts will no longer wander away
illustrates, Gods people never seem to remain in
from Him.
relationship with Him. They keep wandering
These dual, opposing cycles of idolatry and
after things they desire more. Their hearts tend
godly fruit found in Ezekiel 14 and 36 illustrate
to wander; they crawl off the altar of self-
the Pauline contrast in Galatians 5:16-26 of life
sacrifice.
in the flesh and life in the Spirit. The works of
Within the book of Ezekiel itself, God
the flesh and the works of the Spirit are opposed
repeatedly calls for Ezekiel to prophesy
to one another; we wont do what we know will
judgment against the elders, prophets,
please God. What motivates us to do what we
shepherds, and people of Israel for their
actually do? We either have a wandering heart
wandering, idolatrous hearts. In Ezekiel 20 the
full of idolatries or a new God-given heart
elders come again to inquire of the Lord, but
surrendered to His Spirit within us. The choice
God refuses them again because of their idolatry.
is ever before us: forsake Him by serving other

We either have a wandering heart full of idolatries

or a new God-given heart surrendered to
His Spirit within us.
gods or serve Him (Josh. 24:14-15). Even with
There seems to be no hope. Those within the
the clear impact upon our circumstances of
siege of Jerusalem (4:17) will rot away because
heredity, environment, and seemingly random
of their punishment. Against the house of
events, the choice remains as to how we will
Israel God will stretch out His hand (6:14) and
respond: from a new heart or a wandering heart;
make the land desolate and waste. The LORD
serving the Lord or wandering away to serve
is against the shepherds (34:10) and will
other gods. The allure and the assault of our life
require my sheep at their hand and put a stop to
experiences tempt us to crawl off of the altar
their feeding the sheep. The consolation God
upon which we presented ourselves as living
promises in Ezekiel 14:23 gives little comfort.
sacrifices to God.
We know that He does nothing without cause.
Sarahs wandering heart issues may not be
Nevertheless, the four judgments of sword,
obvious to her at first. She has to examine her
famine, wild beasts, and plague will be sent
fear. She needs to ask: What did she want and
against Jerusalem to kill its people and animals.
believe in the midst of the situation of hearing of
But then in Ezekiel 36, God makes a
Lukes suicide? How did she interpret the news
wonderful promise: He will cleanse His people
about Luke? How does she now interpret her
from all their iniquity and their wandering. He
symptoms of panic and anxiety and her
will replace idolatrous hearts with new hearts.
withdrawal symptoms?
The Israelites will again be His people and He
Sarah can recognize that the root issue of
will be their God. He will rebuild the ruined
her wandering heart is manifested as the bad
places and replant what was desolate. The
fruit (the stumbling block of her own fear
despairing cycle of repeatedly wandering off will
evident in symptoms of panic and anxiety). Her
be remembered with shame. God will place His
heart is not full of the confidence that comes
Spirit within them, causing them to obey the
with a heart that follows God. As God said to
statutes and rules of the Lord. The land that was
Ezekiel about the elders of Israel, in order to
desolate will be like the Garden of Eden. The
remove the stumbling block, Sarah must give up

The Journal of Biblical Counseling Spring 2006 17

her wandering and be reconciled to God. What likely address these very areas. In fact, cognitive
rules her heart? What has she come to treasure therapy techniques are quite effective with
or value in her life that has estranged her from anxiety and fear. What constitutes the biblical
God? Where has she wandered? What lives in nature of these changes is their ultimate purpose
her heartfear or God? and source. In biblical counseling, Sarahs
Engage Sarah in the process of examining ultimate purpose for changing is to be more
and monitoring her cycle of folly. She could Christ-like. The source of her change is the new
journal the times and frequency of her panic heart placed within her through Gods grace. In
attack symptoms, noting what she was thinking, effect, her goal is progressive sanctification, a
feeling, and doing. She could assess the intensity divinely wrought character change freeing us
of her anxiety in conjunction with her from sinful habits and forming in us Christ like
journaling. She can use one of several anxiety affections, dispositions, and virtues.8
scales available online or in cognitively-oriented Pecheur and Beck have suggested that the
self-help books, like The Feeling Good Handbook, change process in sanctification and cognitive
by David Burns. As she gains insight into the therapy are the same. But this cannot be true if,
pattern of her idolatry, she simultaneously as they themselves note, the major difference
identifies exactly how and what she needs to between cognitive-behavioral therapy and
change. sanctification is Gods active participation in the
But simple insight into Sarahs cycle of process of sanctification.9 There is a divinely
folly is not enough. Neither is finding wrought character change in sanctification.
satisfactory answers to such questions as: 1) God places a new heart within us. This new
Whats going on? 2) What does Sarah do? 3) heart seeks to form a Christ-like character. This
What does she think? and 4) What does she can be imitated, but not duplicated, by cognitive
want? Sarah has to do something: She has to therapy. The self-awareness of the cognitive
return to God and stop her wandering. She has approach that challenges ineffective,
to replace her fear with confidence in her God. unproductive thinking and behavior at best
produces a lost soul who responds to situational
Biblically Intervening in Sarahs Fear heat without stumbling over the stumbling
Sarah needs to specifically target her fears block. You drug the messenger (the panic
and strive to grow in grace and sanctification. attack) to avoid or ignore it. But through
As you and she recognize the inroads that fear biblical counseling, you learn to listen to the
has made into her life, she can learn to seek wise messenger (the panic attacks). You struggle to
counsel with the right issues and avoid doing so hear its message. You look to your own heart to
out of fear that shell do the wrong thing. She see how it has strayed from God. You seek to
can become more alert to whether a passive, find where you have replaced confidence in God
nonassertive response from her in a particular with human fear. And you seek Gods Spirit in
situation is the godly fruit of patience, kindness, helping you change. Godly change brings heart
or gentleness or whether it is a response that change. Heart change brings renewed
comes from her fear of conflict. In conversations confidence in God and replaces fear.
on topics that make her feel uncomfortable, she Concentrated efforts in spiritual
can verbalize that shes uncomfortable with the disciplines such as prayer, meditation, reading
topic instead of just walking away. She can be and memorizing Scripture, and reading and
selective in talking to others about the topics studying spiritual works are called for. Sarah
she avoids. She can talk to other people who needs to recognize that as she turns from serving
struggle with fear and anxiety and maybe other her idols and instead honors the Lord, He will
people who knew Luke. When she feels the deliver her from the hand of her enemies (2
need to say something to someone else, she can Kings 17:38-39). She needs to realize the reality
work to speak the truth in love, to pray ahead of Psalm 73: that God is good to those who are
of time about the encounter, and to leave it in pure in heart, and that she does not vainly strive
Gods hands afterwards. to keep her heart clean before Him. God has a
A secular counseling approach would also hold of her right hand. He guides her with His

18 The Journal of Biblical Counseling Spring 2006

counsel and will receive her in glory. As she Our behavior, how we respond to the world, is
learns that there is nothing on earth for her to inescapably related to our heart (Ezek. 14:1-11;
desire but God, My flesh and my heart may fail, Matt. 6:21). Psychotropic medication
but God is the strength of my heart and my potentially kills the messenger of symptoms
portion forever (Ps. 73:26). (the bad fruit) that announce that fear has
How can we know these are the right taken root in Sarahs heart.
interventions into her fears and anxiety? Look The diagnostic criteria or symptoms of her
at their fruits: Do the symptoms decrease? Do anxiety disorder exist because Sarahs heart is
the panic attacks lessen and eventually stop? ruled by fear. When we encounter frightening
Does her sleep improve? Does she feel less events, as Sarah did with Lukes suicide, or
fearful and anxious? You will know a tree by its become fearful that we could harm ourselves or
fruits. others, we need to address that fear in order to
Sarah will find that as she comes through have lasting change in our symptoms. Taking
her panic attacks, she will become a more medication will only reduce the intensity of the
effective witness to others suffering through symptomatic bad fruit; it will not address the
panic and anxiety. As she describes her own root problem of fear. It will cover up the very
struggles and her growing victory over her fears, thing that needs to be exposed to Gods light.
she shows others that God is their refuge and Help Sarah weigh the pros and cons of
strength; a help in times of trouble. They need taking psychiatric medication before she begins
not fear. God is their fortress (Ps. 46). As she taking her prescriptions. In my experience, using
goes on with her own life, she will know that the psychiatric medication to cope with anxiety and
God who delivered her from fear will continue panic should only be done in a limited way or as

Psychotropic medication potentially kills the

messenger of symptoms (the bad fruit) that announce
that fear has taken root in Sarahs heart.
to deliver her from the Philistines of outward a last resort, if at all. In order for Sarah to feel
trouble and the inward temptations of her flesh better, to not panic, she has to be able to face
(1 Sam. 17:37; Rom. 7:24). and deal with her problem. But the medications
can short-circuit her understanding of what her
Entry Gate #2: Assessing the Need for symptoms actually mean. But far more
Medication important, consider the serious side effects to
If we were to use magnetic imaging taking both of the classes of medication that
technology (MRS, Magnetic Resonance were used to treat Sarahs panic and anxiety. In
Spectrograph) on Sarah as she experiences a addition to being habit forming and causing
panic attack, its possible we would see subtle withdrawal reactions (discontinuation
changes in her brain chemistry. However, that syndrome: anxiety/agitation, dramatic crying
by itself would not prove that the root cause is spells, and irritability), warning labels on these
biochemical, and that the treatment should drugs describe the increased risk of suicide
include medication. We are, to use Anthony thinking and behavior in children, adolescents,
Hoekemas phrase, a psychosomatic unity of and adults who take them. Patients on these
physical and immaterial; of the inner and outer drugs may interpret withdrawal symptoms as
person. The cascading pattern of physiological evidence of reemergence of psychiatric
reactions makes sense because of this symptoms and their need to resume taking the
psychosomatic unity of being. We should expect medication.10 The person becomes dependent
evidence of neurochemical, physiological on the medication and never addresses the
changes when we panic. The MRS would underlying heart issues.
demonstrate what we already know biblically. How many people actually achieve clinical

The Journal of Biblical Counseling Spring 2006 19

 _______________________________________________
remission after their first treatment with an 1 Ativan is in a class of drugs called benzodiazephines and
antidepressant? According to Kate George, is standard treatment for panic disorders. Ativan works by
only 22.6 percent of patients achieve clinical suppressing overall brain function, initially experienced as
relaxation or reduction in anxiety and tension. Other drugs
remission after their first treatment with an in this class include: Xanax, Librium, Valium, and
antidepressant. Depression is a complex Klonopin. This class of drugs is potentially habit forming.
disorder with a number of predisposing genes as 2 Paxil is an antidepressant classified as a selective
well as multiple contributing behaviors. George serotonin reuptake inhibitor (SSRI). Withdrawal reactions
states, It is possible that depression will never (discontinuation syndrome: anxiety/agitation, dramatic
crying spells, and irritability) have been reported with
be reduced to a series of genes and molecular SSRIs. (Luvox, Zoloft and Prozac are also in this class of
mechanisms, and this complexity, combined antidepressants.)
with the infancy of these biotech programs, 3 The Diagnostic and Statistical Manual, 4th edition, with
means that a ground-breaking pharmacological Text Revisions.
therapy or the use of tailored therapies for 4 Stewart Kirk and Herb Kutchins, The Selling of the DSM:
depression is a long-way off and may never be The Rhetoric of Science in Psychiatry (New York: Aldine De
possible at all.11 Gruyter, 1992), 23.
5 Herb Kutchins and Stuart Kirk, Making Us Crazy: The
Symptomatic Relief or Permanent Relief? Psychiatric Bible and the Creation of Mental Disorders (New
York: The Free Press, 1997) 247.
Current psychiatric practice is quick to
6 Organize the case data within the root and fruit
prescribe medication for a myriad of problems in
structure of Paul Tripps hook questions in Instruments in
addition to the fear and anxiety described in the the Redeemers Hands (Phillipsburg, NJ: P&R Publishing,
above case study. This over-reliance on 2002), 188. See also Timothy S. Lane and Paul David
medication is a concern that biblical counselors Tripps article in this issue of the Journal, Order from
Chaos: When a Bad Marriage Gets Worse.
need to address. The immediate distress of
7 David Powlinson, Idols of the Heart and Vanity Fair,
anxiety, depression, mood swings, and other
Journal of the Biblical Counseling, 13.2, Winter, 1995, 35.
identified mental disorders makes it hard for See also Paul Tripp, Instruments in the Redeemers Hands
someone to resist the promise of symptomatic (Phillipsburg, NJ: P&R Publishing, 2002), chapter 4.
relief inherent with psychiatric medication. 8 J. I. Packer, Concise Theology: A Guide to Historic Christian
Sometimes a neurochemical makeover Beliefs, (Wheaton, IL: Tyndale House, 1995, c.1993).
presents a dramatic, positive difference in the 9 D. Pecheur and J. R. Beck, Cognitive Theory/Therapy
before and after of a persons life. But taking and Sanctification, Journal of Psychology and Theology, 6:4,
medication will not bring lasting change to Fall 1978, 239-253.
whatever the situational stressors may be. And 10 See A. F. Schatzberg, Antidepressant Syndrome: An
its efficacy will also dull or kill the message Update of Serotonin Reuptake Inhibitors, and P. Haddad,
Newer Antidepressants and the Discontinuation
being communicated to the person and the Syndrome; in the Journal of Clinical Psychology, 1997, 58
biblical counselor about the true root and heart (supplement 7), 3-4 and 17-22; and B. G. Pollock,
of the matter. Discontinuation Symptoms and SSRIs, Journal of Clinical
Psychiatry, 1998, 59, 535-536. Also refer to Peter Breggin
As we also saw, taking psychiatric and David Cohen, Your Drug May Be Your Problem: How
medication brings a series of complications in its and Why to Stop Taking Psychiatric Medication (Cambridge,
own right. Automatic deferral to the greater MA: DaCapo Press, 1999), 62-72; 153-156.
wisdom and expertise of a psychiatrist 11 From Depressiona bleak future? by Kate George.
prescribing medication is then not in the best Retrieved online at: imshealth.com. IMS Health is a
company used by the pharmaceutical industry to globally
interest of the person taking the medication. monitor pharmaceutical market intelligence.
Except in cases of extreme debilitation,
psychiatric medication should be avoided.
As with Sarah, in many situations where
medication is typically prescribed, it may not
even be necessary. What is necessary is that the
LORD God again lay hold of the heart of the
one who was estranged from Him through her
idols (Ezek. 14:5).

20 The Journal of Biblical Counseling Spring 2006