Christian Psychology v. Biblical Counseling: A. J. McConnell Reacts to Allchin and Throckmorton

Greek_uc_psi.svgI am in the middle of a series comparing and contrasting Christian psychology and Biblical counseling. Using a case of school refusal as a prompt, I have featured the conceptualizations of Biblical counselor Tim Allchin, and Christian psychologist A.J. McConnell as points of comparison to my description of how the case turned out. Today, A.J. McConnell sums up his views in this reaction to Allchin and me.  Next week, Dr. Allchin will provide a similar reaction to McConnell and me. After Allchin’s reaction, then I will wrap up the series.*

Overall, I have enjoyed reading the varying perspectives presented on this topic in both the responses by Dr. Tim Allchin and Dr. Warren Throckmorton as well as the comments provided by other readers in the comments section. Before I comment on Dr. Allchin’s and Dr. Throckmorton’s approaches, I wanted to briefly respond to a few of Dr. Throckmorton’s critiques on my conceptualization.
Dr. Throckmorton wrote:
“I have concerns about advocating techniques a client doesn’t ordinarily believe in or engage in as a technique….While there is research which links stress reduction with meditation, I believe Christian prayer should be a voluntary and spontaneous response to God rather than a prescribed technique of counseling.”
I agree with your statement and would never recommend or prescribe a technique that is contrary to a person’s belief system. If a Christian requests that I integrate Biblical principles with my knowledge of psychological interventions, I always first assess what spiritual disciplines they use in their daily life. This usually leads to a discussion on how they can use these disciplines as an adjunct with other interventions.
Dr. Throckmorton also stated:
“I must add that counseling is about much more than advice or guidance in moral decision making.”
I also agree with this statement. Not every issue brought into a counseling session is a moral issue. For example, I believe that an individual pursuing treatment for anxiety is looking for practical strategies they can use to stop having anxious thoughts and/or physical manifestations of anxiety. Similar to how a medical intervention can help anyone regardless of their religious beliefs, psychological science has provided several effective interventions that can help reduce anxiety or other mental health concerns.
My response to Dr. Allchin:
I enjoyed reading Tim Allchin’s conceptualization of the case example and respect his point of view. I found myself agreeing with many of Tim’s general interventions. Specifically, I agreed on the following points:

  1. I agree about medications not being the first option in this case. There are cognitive and behavioral interventions, for example, that can be used before even considering the need for medications. As Dr. Throckmorton discussed in his response about the role of PANDAS and separation anxiety, I would recommend the parents speak to the child’s pediatrician in order to rule out any underlying medical factors to this problem.
  1. I also agree that establishing a relationship with the child and family is vital for effective therapy. There are several research studies that indicate a strong therapeutic alliance is one of the strongest, if not the strongest, factor in effective outcomes in therapy. In other words, having a good relationship between a therapist and the child is just as important, and even more important, than the specific interventions used.
  1. I also agree with some of the examples of using a physical redirect as a replacement for anxious thoughts or behaviors. An example of a principle associated with behaviorism indicates that a behavior you are trying to extinguish needs to be replaced by an alternative behavior. Identifying alternative behaviors or physical redirects is a common strategy used by counselors.

In contrast, there are also areas in which I disagree with Allchin regarding this case. Here are a few examples:
Dr. Allchin wrote:
“What does the Bible say he needs to “put off” regarding fearful behaviors that lead to disobedience?”
Separation anxiety is a disorder and I do not believe that it comes from a spirit of disobedience towards God, the school, or the child’s parents. A child with this condition is experiencing a significant amount of fear that they do not know how to respond to appropriately.
Dr. Allchin also wrote:
“I would seek to help them identify emotions, behaviors, habits, beliefs, and heart motivations….. Biblical counselors seek to determine Action Steps that help a child function in a way that pleases God.”
Again, I perceive these quotes as indicating the problem is a “heart” issue rather than an issue of mental health. I did not get the sense in reading the case description that the child or family were exhibiting any oppositional, defiant, or other behaviors that would lead me to suspect any issues with their core belief system. Therefore, I would not focus on “heart motivations” or steps a child needs to do to “please God” in this situation.
On a side note:
I appreciate the role of Biblical counselors in our profession. They bring a unique perspective that is certainly applicable to many mental health concerns and they use the Bible as a strong resource to help others in need. However, Biblical counseling is not always appropriate for everyone. I would also make the same statement in regards to Christian Psychology and the western approach to Psychology in general. One reason why I chose psychology rather than becoming a pastor or a Biblical counselor is because I feel God called me to serve others as a psychologist. My role as a psychologist is not to convert people to Christianity. I’ll focus on that mission in my personal life. I work with many individuals that do not share my personal beliefs. My approach to everyone I work with, regardless of their religious views, is to respect them and not unnecessarily judge them for the choices and decisions they have made. I have worked with several individuals that have explicitly voiced their hatred towards the church, God/Jesus, and/or have expressed a belief in atheism. Their beliefs do not change how I approach them in counseling or treat them as a person when they are in my office. I feel that my professional role allows me to interact with a broader population. I enjoy the diversity and challenge when I meet people with other perspectives on life. It doesn’t compromise my faith or my relationship with Jesus. It helps me understand the world. I’m curious to how Biblical counselors would address these types of situations.
Response to Dr. Throckmorton’s conceptualization:
I am happy to hear that there was a successful resolution to this case example. The use of a paradoxical intervention was intriguing and one I may consider in the future if I encounter a similar situation. I have used paradoxical interventions in other situations involving working with families; however, this is not usually my first approach when addressing an issue of separation anxiety. My preference is a Cognitive-Behavioral approach given its strong research efficacy in treating this diagnosis. There is always a risk when using a paradoxical intervention that it will backfire and not have the intended outcomes that are desired by the therapist.
I appreciate Dr. Throckmorton’s willingness to review and consider new information in regards to this case example, as illustrated by the discussion of the role of PANDAS and its psychological impact on children. Personally, I have not researched any information on this topic but your post has reminded me of the importance of staying updated on scientific research findings in order to provide competent services to the individuals that we serve.
A quick note on other comments Throckmorton made about the 95 theses:
Similar to your opinion, I also disagree with Dr. Lambert’s theses statements #45 and #46 regarding the use of diagnostic labels in the DSM. These diagnoses are real conditions. Some are mentioned in the Bible. Other diagnoses are not. This does not make the DSM invalid. My specialty is in neurodevelopmental disabilities and I cannot recall symptoms of an autism spectrum disorder, for example, being discussed in the Bible.
I also take issue with Theses #72 and #73 regarding state licensure:

  1. The process of requiring a state license to counsel is not required by the Bible, is used by the state to enforce counseling practices founded on secular therapy, and is unnecessary for those wishing to grow in God’s wisdom to counsel.
  2. The only authentically Christian motivation for pursuing a state license to counsel is the missional desire of making Christ known to all people in all places, especially in those places where the authority of the state allows only licensed individuals to talk to troubled people.

These statements suggest that a professional counselor’s primary role is to convert others to the Christian faith. As Christians, we do not demand these expectations from Christians in other professions. We also do not expect other Christian professionals to not pursue a state license to practice medicine, nursing, law, accounting, teaching, etc. Most states require mental health professionals to obtain a license in order to practice. This provides a level of accountability and protects the public from harmful practices. Having a state license does not compromise a person’s faith. I find these statements to be judgmental and they place unnecessary guilt on an individual that has decided to pursue state licensure. If a Christian does not pursue a state license, it limits their ability to serve others. If this was the case, Christians would primarily only be able to provide counsel to others if they walked through a church door seeking help.

Thanks to Dr. McConnell for his participation in this series.
To read all posts in this series, click here.
*Even though I will wrap up this part of the series next week, I intend to start a new one featuring critique of Heath Lambert’s 95 theses.

Today Show on PANDAS

Back in the spring, I wrote an article on Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS). The disorder has opened my eyes to the potential role of bacteria in mental illness. Recently, the Today Show did a segment on PANDAS with a remarkable case of a boy attending school at nearby Carnegie-Mellon University. Watch and learn.


 

I also blogged at length about this condition. Part one dealt with the condition and part two with a potential paradigm shift in mental health and part three developed an interactionist perspective.

PANDAS article in the Christian Post

The Christian Post has published my feature on PANDAS – Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococci.
There are some great quotes from Susan Swedo, MD, who is often credited with discovering the relationship between psychiatric symptoms and strep throat. I don’t say much about it but I also report some new research regarding the mechanism of action for the strep antibodies in the brain. Crosswalk.com will put it up next week.

Genetics and environment: Interaction in a different key

In previous posts, I wrote about PANDAS, the streptococcus related autoimmune disorder which involves obsessions, compulsions and perhaps more broad anxiety and movement problems. Discussion has been vigorous about the role of pathogens in creating mood and mental health issues.
Genetics as an influence is another biological factor often considered as a causal factor in mental health and behavior. Today, Brain Blogger discusses the influence of genetics and depression in a post with the provocative title, “Stressed by his short allele.” Brain Blogger is an interesting read in that he attempts to bring neurological research to a lay audience in a magazine format.
Regarding depression, stress and genetics, BB writes:

Individual differences in the genetic makeup of the serotonin system have been shown to increase one’s vulnerability to depression, anxiety and other psychiatric conditions, particularly if individuals are exposed to stressful events in their lives. Studies are showing that certain people (those that have the short allele of the serotonin transporter gene) have a greater biological reactivity to stressful events, including a larger hormonal response to stress and a greater brain reactivity to threat. In other words, both the hormonal and brain systems (amygdala) involved in fear and anxiety are more active in response to stress in those individuals who have a certain genetic makeup (short allele). This genetic difference may also account for individual differences in personality; those people who have a short allele for the serotonin transporter have been suggested to exhibit more “anxious” personality traits. This means our differences in gene function may bias our brains and our personalities to create a tendency to be more “negative,” “anxious” or reactive to stress.

Bringing together the PANDAS research with the observations regarding short serotonin gene alleles, one can envision several scenarios. A child with a stubby allele gets strep throat. This child is unfortunate in that the antibodies created to seek and destroy the strep bacteria find and bind with dopamine receptors in the basal ganglia. At that point, the cells designed to kill strep bacteria which are supposed to be hooked up with strep antibodies find this unholy alliance of strep antibody and dopamine receptors and launch their holy war of immunity. Dopamine cells fall in friendly fire thus sending the dopamine-serotonin balance into disarray. This child, being completely unaware of this of course, begins to feel nervous and irritable (mood change). This creates stress in the family and parents who may also have stubby alleles get stressed too. As BB notes, the short-allele brain already primed to be more reactive in the event of stress (the illness itself, the mood change and reaction of parents and sibs) goes into full fledged alert, generating lots of chemicals which basically provide that child with thoughts suggesting something is wrong here (anxiety and depression).
We can also imagine a child with a full sized allele going through the same thing. When the dopamine-serotonin balance is disrupted via an autoimmune disorder, one may see the typical rapid onset of PANDAS symptoms but these will likely not turn into a chronic problem. Furthermore, it is possible that the symptoms will be less intense or that the child will be more easily soothed with even modest parental inputs, thus preventing an escalation of panic.
Active readers will probably imagine a few hundred more scenarios.
I recently spoke with Susan Swedo at the NIMH who provided invaluable information regarding PANDAS. She agreed with me that we are at the beginning of this line of research and thinking. There is no doubt that psychological trauma is stressful and thus impacts mental health. However, the mechanisms of extended impact may be much different than psychodynamic theorists imagine.
The more of this kind of information we can get to patients the better in my view. It is helpful for people to understand the tricks their brain is playing on them when they get the intuition that they must engage in a compulsive action in order to relieve anxiety. Or when everything is really going well and they constantly fear the worst. Our active, monitoring minds play tricks on us and we are learning more about how those tricks are constructed in part via pathogens in the environment interacting with a genetically prepared host.

PANDAS, Part 2 – A paradigm shift in the treatment of mental disorders

Consider this case:

Jonny, (not his real name), is a third grader with a new problem – he cannot stay in class. After starting the year well the first week, he missed the almost the whole second week of school with a sore throat and a cold. When he came back to school, he was a different kid. He told his teacher he had to go home because he missed his mom. In fact, he wouldn’t stay in class. His parents would bring him to school, he went in the school but refused to go in the class room. He was sure something awful would happen to his parents if he did. When his dad came to school and convinced him to go in the classroom, Jonny bolted from the room in tears as soon as his dad left his view. This went on for a week with no progress. In desperation, Jonny’s parents called me for a consultation.

In reflecting upon the implications of PANDAS, I am remembering cases where autoimmune reactions associated with Strep may have been relevant. The case above is one of the more striking school refusal cases I encountered since there were no prior incidents of anxiety or phobia. The remission was equally striking. I saw them for three sessions and the boy’s phobia decreased dramatically.
My strategy was to ask the school if the boy and his mom could do his school work together in a room at school. I reasoned that there was some sudden onset of attachment anxiety. At the time, I wondered if for some reason the mother experienced attachment distress and communicated this in some way to the son. I wondered if the school refusal behavior was a communication to the father that perhaps Jonny wanted more time with dad. There were some corroborating findings. In this particular Autumn, dad was somewhat more busy in his work and gone a bit more. From a systems perspective, I had a working hypothesis that mom wanted the son to help bring dad home more and get more involved in the family. Dad was indeed too busy to attend sessions, so I worked with what I had and prescribed this change at the school. The school personnel cooperated and found a suitable room for mom and son to conduct school work.
Under these conditions, the youngster stayed at school and did his lessons. As predicted, mom and son soon got their fill of attachment and began to bicker some about various things. By the beginning of the second week, Jonny thought he could try the classroom again. After a couple of false starts, he was back in the classroom for good by week three.
Within a systems/solution focused framework, I had “prescribed the symptom” with the assumption that dramatically increased closeness would require a change in the mother-son relationship. Mom reported that she began to complain more to her husband about the school visitations and he was home a bit more. Somehow a more workable balance was restored to the family system. Mom and son found that when it came to closeness to each other, some was good, but more was not better.
Or did Jonny have untreated strep throat which eventually led to obsessions regarding attachment to his parents?
I will probably never know. I am very willing now to entertain the idea that the intervention I prescribed was not the source of the quick benefit. Rather, PANDAS or something like it may have gone into remission with the passing of time.
If the boy never again had related symptoms in the presence of streptococcal infection, he would not meet the NIMH criteria for PANDAS. The criteria are:

-Presence of a tic disorder and/or OCD;
-Pediatric onset of symptoms (age 3 years to puberty);
-Episodic course of symptom severity with sudden onset or acute exacerbations that are in:
-Temporal association with group A Beta-hemolytic streptococcal
infection (indicated by a positive throat culture for strep and/or elevated anti-streptococcal antibody titer); and
-Association with neurological abnormalities (hyperactivity/fidgetiness/restlessness, or adventitious movements such as the choreiform movements of Sydenham).

Even though Jonny might not have had PANDAS, it seems plausible that his reactions could have been triggered by his prior illness. The research program regarding PANDAS provides a new paradigm to consider with regard to the etiology of at least some psychiatric disorders. What other sudden onset autoimmune disorders could be related to bacteria or a virus? Mental health professionals are socialized and trained to attribute disorder to faulty family dynamics and/or trauma. I believe we should expand our thinking to include assessments of total health and environmental status. Careful observation was behind the discovery of PANDAS and may uncover additional syndromes. Susan Swedo et al describes this process:

…a subgroup of the patients experienced an explosive “overnight” onset of obsessions and compulsions followed by a relapsing-remitting symptom course. Closer observation revealed that the neuropsychiatric symptom relapses frequently occurred after episodes of streptococcal pharyngitis or scarlet fever…Longitudinal observations of the OCD subgroup and the patients with Sydenham’s chorea clearly demonstrated a temporal association between streptococcal infections and obsessive-compulsive symptoms.

In light of the PANDAS research, Swedo and colleagues recommend the following medical response in light of the research regarding PANDAS:

1. Laboratory testing: Children with an abrupt onset or exacerbation of OCD or tic disorder should have a throat culture obtained. If the symptoms have been present for >1 week, serial antistreptococcal titers may be indicated to document a preceding streptococcal infection. (Titers should be timed to catch the rise at 4–6 weeks.)
2. Use of antibiotics: Antibiotics are indicated only for the treatment of acute streptococcal infections as diagnosed by a positive throat culture or rapid streptococcal test. Clinical trials are underway to determine whether prophylactic antibiotics will be useful in the management of children in the PANDAS subgroup, but at present, they are not indicated. In the only placebo-controlled trial reported to date, penicillin administration failed to prevent streptococcal infections (14 of 35 infections occurred during the penicillin phase of the crossover trial), and thus there were no between-group differences in neuropsychiatric symptom severity.
3. Management of neuropsychiatric symptoms: Children in the PANDAS subgroup respond to treatment with standard pharmacologic and behavioral therapies. Obsessive-compulsive symptoms are treated best with a combination of medication (typically, a serotonin reuptake-blocking drug) and cognitive-behavior therapy, and motor and vocal tics respond to a variety of pharmacologic agents.

In the next article, I want to develop these recommendations a bit with application to counselors in mental health and school settings.
Read part one in this series here

PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococci

I recently became aware of this condition where a variety of emotional and psychiatric symptoms arise due to an adverse reaction to the strep virus. I hope to raise awareness and note the import of understanding this condition for mental health professionals and consumers.
Years ago, I specialized in child mental health and saw cases of anxiety with no apparent precursor. Despite my psychodynamic training, it became clear to me that family dynamics played little to no role in the etiology of these conditions. However, in some of the cases, I could find no clear explanation. I suspect I was dealing with PANDAS. Some background:

PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. The term is used to describe a subset of children who have Obsessive Compulsive Disorder (OCD) and/or tic disorders such as Tourette’s Syndrome, and in whom symptoms worsen following streptococcus infections such as “Strep throat” and Scarlet Fever.
The children usually have dramatic, “overnight” onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions. In addition to these symptoms, children may also become moody, irritable or show concerns about separating from parents or loved ones. This abrupt onset is generally preceeded by a Strep throat infection.

How does Strep throat lead to PANDAS?

What is the mechanism behind this phenomenon? At present, it is unknown but researchers at the NIMH are pursuing a theory that the mechanism is similar to that of Rheumatic Fever, an autoimmune disorder triggered by strep. throat infections. In every bacterial infection, the body produces antibodies against the invading bacteria, and the antibodies help eliminate the bacteria from the body. However in Rheumatic Fever, the antibodies mistakenly recognize and “attack” the heart valves, joints, and/or certain parts of the brain. This phenomenon is called “molecular mimicry”, which means that proteins on the cell wall of the strep. bacteria are similar in some way to the proteins of the heart valve, joints, or brain. Because the antibodies set off an immune reaction which damages those tissues, the child with Rheumatic Fever can get heart disease (especially mitral valve regurgitation), arthritis, and/or abnormal movements known as Sydenham’s Chorea or St. Vitus Dance.
In PANDAS, it is believed that something very similar to Sydenham’s Chorea occurs. One part of the brain that is affected in PANDAS is the Basal Ganglia, which is believed to be responsible for movement and behavior. Thus, the antibodies interact with the brain to cause tics and/or OCD, instead of Sydenham Chorea.

In other cases, the child with PANDAS can become fearful, especially surrounding separations from parents. Mood swings have an abrupt onset and are more extreme than prior to the strep infection. There is a clear and dramatic change.
The best treatment seems to be antibiotics to address the strep infectiom. However, even after the infection is ended, the antibodies can remain in the child with negative impact.
I suspect many counselors have seen children with PANDAS without knowing it. The following description seems quite plausible:

Typically, a child with undiagnosed PANDAS may be taken to the Psychologist and/or Paediatrician for treatment of an onset or exacerbation of ADHD symptoms, oppositional behaviours or OCD. Stimulant or anti-depressant medication may be prescribed and/or a behavioural intervention or counselling initiated. As the infection passes and the strep antibodies reduce, the symptoms gradually subside and parents and clinicians believe that the intervention was successful. However then there is another strep infection, the symptoms return and the process is repeated. The problem is that the brain is being continuously damaged by the repeated attacks by streptococcus antibodies; and after each attack the recovery of damaged brain tissues may not be as complete as we would hope. Eventually the child may develop a chronic psychiatric disorder

This condition should cause health professionals to reconsider models of personality and psychopathology development. Counselors advising parents who have a child with PANDAS might be tempted to propose environmental theories for sudden anxiety states. However, such hypotheses would be far off. Counselors should take detailed health histories even with adult clients given how this biological causal factor gradually coould compromise mental health and lead to a psychiatric condition. Rather than hunt for psychic trauma, a bacterial trauma may be implicated.
This disorder came up on another thread regarding causes of same-sex attraction. There is no evidence as yet that a virus/bacteria could create a similar autoimmune reaction which would effect brain development or perhaps glutamate levels in the developing brain. However, it appears that behavior and emotional experience are effected in PANDAS. Is it a stretch to think other experiences (e.g., sexual attraction) might be altered in some similar manner?
Part 2 discusses a paradigm shift in treatment stimulated by PANDAS.