Why We Need Science in Counseling: Another Look at a Case of School Refusal

Last week, I started a series comparing and contrasting biblical counseling and Christian psychology. I presented a case of school refusal and asked a biblical counselor and a Christian psychologist to comment. Today, I discuss how the case turned out and offer a few observations.
From the initial post, here is the case:

A mother and her second grade son attended the first session together. The father was at work. A meeting with them revealed that the youngster was afraid to remain in his school classroom. The boy attended a local public school and had never been afraid to go to school before. However, within the first month of school, his pattern was to enter school and remain in his classroom. After just a few minutes, he bolted from the room to the school office seemingly in terror and asked for his parents. This had been going on for about a month nearly every day. He remained in school on days his class attended field trips or out of class activities (e.g., library days). The parents had tried alternating morning rides to school and his father had carried him back into the classroom on multiple occasions only to have the same result. He bolted from the class looking for his parents.
On examination, the boy had male typical interests, played rough and tumble sports, was tall for his age, and was socially popular. He had never displayed separation anxiety beyond the norm prior to this year. In all respects except the fear of remaining in his classroom, the boy and his family (one older female sibling) seemed entirely normal and unremarkable from a mental health standpoint. The parents were leaders in their Christian church and the boy happily attended Sunday School and had professed a belief in Jesus as his Savior.

Monday, biblical counselor Tim Allchin addressed the case. Tuesday, Christian psychologist A.J. McConnell did the same. To get the most out of this post, you should read those posts before you read this one. Today, I will briefly react to Allchin, then to McConnell, and then I will describe what happened. Finally, I want to discuss why science must be a part of counseling work.

Tim Allchin and Biblical Counseling

Allchin advocated a multi-faceted assessment of emotions, thoughts, behavior, physical health and compliance with biblical morality. He said his interventions would also be multi-faceted depending on what he learned in the assessment process. With the exception of assessment of biblical compliance, this is similar to how many Christian counselors proceed.
To highlight my differences with the biblical counseling approach, I will list one of Allchin’s statements and then reply to it.

Allchin: “My working assumption would be that some sort of traumatic experience is likely the genesis of this behavior.

While a traumatic experience could be involved in such a case, I try not to conduct assessments with strong assumptions about cause. I worry about the effects of confirmation bias in such instances. Fear is indeed involved in school refusal but a traumatic experience is not of necessity at the root of the fear.

Allchin: “I would want the child and parent to know that even a child’s beliefs determine actions, resulting in feelings that either escalate or calm.

Sometimes people have fears for which there is no discernible cognitive or environmental trigger. They just arise. Sometimes beliefs and thoughts follow feelings. Biblical counselors and cognitive therapists may disagree with me, but if I have learned anything from social psychology, it is that the link between attitudes and behavior goes both ways. I have worked with clients who experience negative mood states and then try to make sense of them by catastrophic thinking. Their thoughts then push them into a downward spiral but sudden anxiety was the first step in that process.

Allchin: “…biblical counselors seek to determine Action Steps that help a child function in a way that pleases God:”

Because I don’t assume a link between biblical compliance and mental health, I didn’t do this. If a child is misbehaving in other ways, then I might focus more on situational compliance (e.g., following guidelines at home and school), but since the complaint of the parent and school is refusal to stay in class, I focused on that.

Allchin: “Additionally, I am going to have conversations about the following with a christian family is being counseled: What does the Bible say he needs to “put off” regarding fearful behaviors that lead to disobedience? (Repentance)” etc…

I did not do any of this. Again, since I do not believe mental health is of necessity tied to biblical compliance, I don’t have these conversations unless the client raises the matter. Most clients who organize their lives around their faith will bring these things up without prompting.
Overall, in my view, the biblical counseling approach is wrong to put emphasis on lack of biblical compliance, especially with childhood mental health concerns. It is too easy to feel false guilt tied to the belief that mental and emotional problems stem from lack of biblical compliance. This focus can also distract a counselor from more pressing problems in a client’s life.

A.J. McConnell and Christian Psychology

Dr. McConnell’s approach is quite comprehensive and reflects a broad training in assessment and psychotherapy. The only qualm I have about Greek_uc_psi.svgMcConnell’s religious techniques is one that I also have with biblical counseling and that is the use of spiritual disciplines as counseling techniques. 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. Techniques are judged by their utility in solving a problem. If clients are anxious and they view prayer as a kind of incantation or method to achieve a change in mood, how will they judge prayer if their anxiety persists? If prayer is a means to express something to God, it can never fail. If it is a technique, then it can and does fail. I have concerns about advocating techniques a client doesn’t ordinarily believe in or engage in as a technique. I will have more to say about this aspect of biblical and Christian counseling in my series wrap up post.

How the School Refusal Case Turned Out

As both Allchin and McConnell recommended, I did a comprehensive assessment of the youth and family. I asked the teacher and parents to complete a Connors Rating Scale and also interviewed the father. My working hypothesis after the first couple of interviews was that the boy experienced separation anxiety and was particularly focused on his mother. The boy couldn’t articulate why he was worried about her, he just was. He even expressed his confidence that she was fine at home, but he still worried about her when he was at school. I found no evidence of bullying, trauma, or social stigma. In a way, the simplicity of the symptom made the assessment process more complicated.
Since my working hypothesis was that the boy was experiencing separation anxiety, I decided to try what probably seemed odd and counterproductive to the parents. Drawing from the family systems tradition, I told the mother that she should stay with the boy during the entire school day, including lunch. I secured cooperation from the school for mother and son to do his classwork in a private room at the school. The mother and son initially seemed relieved at the suggestion. School officials were glad that the boy would be at school.
That seemingly paradoxical move brought mother and son together for extended periods of time. My belief was that the technique might actually cause them to want distance. I also felt that the risk was low since I would probably learn in short order more about the problem if the technique didn’t work to promote going back to class.
It didn’t take long for both mother and son to want distance. By the second week, the boy asked to go to recess and lunch without mother. After about three weeks, the boy was back in the classroom with very few residual problems. Through the winter, the parents described occasional new and random fears (e.g., the dark, going to a new place) but these were overcome with some gentle coaxing or the promise of a small reward.
From my vantage point, the child’s religious life had little, if anything, to do with his sudden and unprecedented separation anxiety. Likewise, I couldn’t find much evidence that his thought processes or beliefs preceded his fears. Rather, it became clear that his fears came first and the emergence of them evoked efforts from his parents, his relatives, himself and eventually me to explain his fears. When I couldn’t find an antecedent event or thought pattern, I decided that a more behavioral intervention might help clarify the picture. As it turned out, the intervention achieved the result desired by everyone in the situation.

What Happened?

Reflecting on this case, I have come up with two very different theories about why this case turned out well. The first is very much tied to the intervention. In this theory, I think natural apprehension about the first day of school may have accidentally become associated with the classroom. When he went to class, he experienced an undefined worry which was reinforced by the relief of leaving the classroom. To reverse the accidental pairing of classroom and worry, I put the mother in the school situation which initially brought relief. As the days went by, the inevitable frustration and friction produced by near constant contact with his mom replaced his anxiety over separation from her. His worried thoughts became replaced with other thoughts that did not evoke anxiety. When he was able to leave her for a time, he felt relief which reinforced the separation. I also believe that the mother had her fill of him and whatever worries she had about his safety and well being at school were replaced with other preoccupations. I was surprised by how quickly things changed.
I did not get this strategy from my study of the Bible. I am not sure where I would go to look for it in the Bible.

Could School Refusal Have Resulted from Strep Throat?

Long after this case was resolved, I learned about another possible cause of sudden separation anxiety and impulsive behaviors – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). The disorder results from the action of the antibodies created by the immune system to fight Streptococcus bacteria. The NIMH website provides a good description of the action involved:

The strep bacteria are very ancient organisms that survive in the human host by hiding from the immune system as long as possible. It hides itself by putting molecules on its cell wall so that it looks nearly identical to molecules found on the child’s heart, joints, skin, and brain tissues. This hiding is called “molecular mimicry” and allows the strep bacteria to evade detection for a long time.
However, the molecules on the strep bacteria are eventually recognized as foreign to the body and the child’s immune system reacts to them by producing antibodies. Because of the molecular mimicry by the bacteria, the immune system reacts not only to the strep molecules, but also to the human host molecules that were mimicked; antibodies system “attack” the mimicked molecules in the child’s own tissues.
Studies at the NIMH and elsewhere have shown that some cross-reactive “anti-brain” antibodies target the brain—causing OCD, tics, and the other neuropsychiatric symptoms of PANDAS.

As explained to me in 2009 by Susan Swedo, the scientist who identified PANDAS, the antibodies attack healthy brain cells and interfere with moods and emotions.

The science is clear now. We not only have a direct relationship between the anti-strep antibodies and the anti-neuronal antibodies, but also have demonstrated that the antibodies interact with receptors in the brain that could produce the symptoms observed.

Since learning about PANDAS, I have wondered if the school refusal case described in this series could have had the post-strep disorder. I didn’t ask about recent infections or strep throat as I would now. The sudden onset and then rather quick disappearance of separation anxiety and impulsive behavior fit the profile for other PANDAS kids I have known.
It should be obvious that I didn’t learn about PANDAS from the Bible. In future cases, knowing about PANDAS could alter my treatment strategies and solidify my conviction that a Bible based conversation about “perfect love casting out fear” might induce unwarranted guilt in a client with PANDAS.

Why We Need Science in Counseling

I understand why biblical and Christian counselors want to look to the Bible when they give advice to Christian clients. Although I don’t believe all good advice is in the Bible, I think the Bible as the rule of faith and practice, plays a vital role in developing sound advice.
Having said that, I must add that counseling is about much more than advice or guidance in moral decision making. Mental health professionals are called on to help treat mental and emotional disorders. According to Heath Lambert’s 95 Theses, these disorders are not the best descriptions of the problems people bring to counseling. Theses 45 and 46 state:

45. The Bible’s lack of technical and secular labels for counseling problems, such as those found in the Diagnostic and Statistical Manual of Mental Disorders, does not disprove Scripture’s sufficiency and authority for counseling because God uses his own, superior language to describe people’s problems (Rom 1:24-32).
46. The lack of biblical language in the Diagnostic and Statistical Manual of Mental Disorders demonstrates that the thinking of secular individuals is insufficient to grasp the true nature of people, the problems they bring to counseling, and the solutions necessary to bring about real and lasting change.

I will grant that DSM series has undergone numerous changes over the years. However, I don’t think mental disorders are simply linguistic inventions. Depression, panic disorders, eating disorders, etc., represent mind-body dysfunctions which require the help of science to understand and treat. I appreciate that Tim Allchin recommends good medical care, but in doing so it appears to me that he goes beyond the scope of the 95 Theses.  For instance, this statement seem to negate the importance of science:

10. The subject matter of counseling conversations is the wisdom needed to deal with life’s problems, and so counseling is not a discipline that is fundamentally informed by science, but by the teaching found in God’s Word.

Other statements in the 95 Theses document direct counselors to only use the Bible.

9. Because counseling problems concern the very same issues that God writes about in his Word, it is essential to have a conversation about the contents of the Bible to solve counseling problems.
11. When the Bible claims to address all the issues concerning life and godliness, it declares itself to be a sufficient and an authoritative resource to address everything essential for counseling conversations (2 Pet 1:3-4).
12. Christians must not separate the authority of Scripture for counseling from the sufficiency of Scripture for counseling because, if Scripture is to be a relevant authority, then it must be sufficient for the struggles people face as they live life in a fallen world (2 Pet 1:3-21).
13. The authority and sufficiency of Scripture for counseling means that counselors must counsel out of the conviction that the theological content of Scripture defines and directs the conversational content of counseling.
14. The Bible teaches that the person and work of Jesus Christ provide God’s sufficient power to solve every problem of humanity so, according to Scripture, he is the ultimate subject of every counseling conversation (Col 2:2-3).

In fact, it isn’t essential to have a conversation about the contents of the Bible to solve every counseling problem. Furthermore, I can think of situations where those kind of conversations have been counterproductive. I agree with A.J. McConnell when he wrote:

When Christians are told that Jesus and the Bible are all that is needed in counseling, this assumes that the person is in a mindset where they can accept Biblical advice and adequately apply it to their situation. In contrast, the nature of a disorder is that a person is suffering and they require counseling, medication, or a combination of both to become well.

Some Bible based conversations are so far off the mark that they evoke a false guilt which can be crippling. Some Bible based conversations lead bipolar people to go off their medication often leading to disastrous consequences. I feel sure that Tim Allchin and responsible biblical counselors don’t want to create those results but I am not convinced that biblical counselors who follow the 95 Theses closely would be able to avoid it. On that point, McConnell wrote:

Children and/or adults might feel unnecessary guilt from the church if they need to pursue professional assistance with a psychologist, psychiatrist, or other medical professional to treat a disorder. Most Christians and churches do not shame an individual for pursuing medical interventions for diabetes, cancer, hypertension, etc. The same approach should be taken for mental illness in order to reduce this unnecessary guilt. Overall, I recommend finding a specialist that aligns with your beliefs (2 Corinthians 6:14).

I hope this series has helped to clarify the range of opinions among Christians who work in counseling. Tomorrow, I hope to wrap up the series with reactions from McConnell and Allchin. And you can have the last word in the comments section.
To see all posts in this series, click here.