Category Archives: christian counseling

March 12, 2008 · 1:39 pm

Integrative Psychotherpay IX: Schema Focused Interventions


McMinn and Campbell go into detail regarding the 2nd domain of their 3 tiered model of persons/change in chapter 8 of Integrative Psychotherapy. While the first domain addresses symptoms, this domain (schema) looks beneath to deeper roots than habit and thought. “Schema-based interventions dig deeper than symptom-based interventions, looking to general core beliefs rather than specific automatic thoughts” (p. 243). Schema interventions address the heart of soul and deeply held beliefs (perceptions) about the self and the world that persist beyond specific situations.

So, they open their chapter with this assertion: “…it is often the currents beneath the surface of consciousness that have the most power and bring the most troubles in personal adjustment and interpersonal relationship.” (p. 240). They point to perceived parallels in Romans 7 (Sin causing me to do what I do not want to do) and Freudian theory regarding unmet needs to be both talking about underlying–yet controlling–currents in our lives. A wide view of sin (both active choice and result of living in a fallen world) incorporates both views without making one attack the other.

On page 242 they revisit a vignette of a unhappily married, 24 year old woman. She was afraid she didn’t love her husband and was afraid of being “doomed to misery if they stayed together.” In the vignette, “Denise” is told by her elder that she was facing a spiritual problem that required more prayer and bible reading. The authors fault the elder for having bad psychology (premature advice, no rapport) AND bad theology (that spiritual disciplines can always solve the problem of sin). They faulted the elder for not recommending a fuller orbed treatment of therapy or meds and for not considering a wider variety of underlying issues (her family of origin, communication issues, interpersonal anxiety, hidden secrets, biological predisposition, etc.)

So, is a better answer to Denise’s problem to trace her automatic thoughts back to her core belief? Not so fast say McMinn and Campbell. Linearity is nice but too simple. So, they turn to a discussion of schema.

Schema is not synonymous with core belief despite the fact that it is used that way (mea culpa in this post). Defined by the authors, “a schema is simply a structure that contains a representation of reality” (p. 247). They remind us that since we are actively interpreting our world, we shape our schemas and we shape our lives to fit our schemas. They further describe schemas with these statements (fleshed out in the book)
1. Schemas affect how we interpret and construct the world
2. Schemas are adaptive and maladaptive
3. Schemas can be activated and deactivated
4. Schemas are connect to modes (while schemas are cognitive they lead to a way of being, a personality, a motivational bent, an emotional and physiological bent)
5. Schemas can be categorized in how they interpret self, world, and future (p. 260 has a list of 18 schemas with accompanying core beliefs)
6. Schemas have a historical dimension (they point to literature describing 4 different early life experiences as key historical causes: toxic frustration, trauma, overindulged, and identifying with the pathology of a parent)
7. Schemas have an interpersonal dimension (they are not developed in a vacuum)
8. Schemas are influenced by original sin (faulty thinking doesn’t just come from bad environments. Those raised in great homes also struggle with faulty thinking because they are tainted from the Fall.)
9. Schemas have a cultural dimension (some schemas are culture-based and the authors warn against trying to change these)
10. Schemas have a faith dimension (schemas may shape perception of God; One’s theology shapes schemas)

To make this real, they refer back to “Denise.” Since Denise’s schema contains distrust of the world, she quickly interprets her husband’s cooking her favorite meal as an attempt to make up for his dis-trustfulness and so is defensive and irritable. Of course, this schema “predicts” distrust and then finds evidence of it when Don is hurt and doesn’t try to be nice after her attack of him.

So how does Integrative Psychotherapyaddress maladaptive schemas? They suggest “Recursive Schema Activation” (p. 270) over against class CT tactics that challenge core beliefs with logic. Merely engaging in logic battles minimizes, in their view, that core beliefs, “are embedded in a complex array of motivations, behaviors, emotions, and physiological responses” (p. 217). By “recursive” they mean to emphasize that we change through experience, dialog, repetitive activation and deactivation of the schema.

This means the client’s troubling schemas are activated and deactivated in the context of the therapeutic relationship, over and over again, all the time helping to foster the client’s ability to stand apart from the core beliefs and reconstruct a new, healthier identity–an outcome know as decentering. In decentering the clients begins to understand the nature, power and origins of the maladaptive core beliefs while simultaneously developing more conscious control over the schema deactivation process. (p. 272)

What is really different here from classic CT? McMinn and Campbell don’t want to talk only about a client’s schema, but to activate and experience the schema, and then decenter from it in order to understand and control it. They do not believe they can eliminate a damaged schema. Classic CT wants to correct maladaptive thoughts. IP wants attempts to recognize the impossibility of that and yet gain control and reduce the power of these maladaptive thoughts via therapeutic relationships.

My thoughts? Okay, lots to munch on here. I like how they recognize the limitations and arrogance of classic CT in correcting our struggle with deception and sin. Just as we don’t try to stop sexual temptation but fight to kill those things that lead us further along, we can’t stop initial fearful thoughts but work to stop our acting on them. What we do with our thoughts (take them captive) matters. And the authors here recognize that such efforts are not merely logical but experiential. I generally agree with their thoughts regarding how schemas color our world. We are active in shaping our interpretations of self and other and our world is active in shaping us. We are neither completely responsible for the content of our perceptions or completely victim of our perceptions. However, we are responsible for our actions and attitudes per the Scriptures. The Scriptures do not excuse us because we were mistreated. But there is grace.

I have two pet peeves. First, the example of bad pastoral care is not followed by bad example of stereotyped christian psychological care. Both are problems. I wish they did more to call out their own kind. Second, they continue to see sin primarily as only original sin. This, I think, does much to minimize active will, motivation and choices in everyday living. By listing the faith dimension of schemas last, they may unintentionally give it only a small slice of the pie when in fact it is a part of every other part of a schema. Each of the other 9 statements about schemas are clearly shaped by our spiritual beliefs and actions.  

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March 7, 2008 · 11:44 am

On-line Models of Counseling Course


Biblical Seminary offers several completely on-line courses these days. Check out our homepage for short videos on each course: www.biblical.edu. Let me highlight one in particular. My colleague Bryan Maier is offering one this Spring entitled, Models of Counseling. Here’s his syllabus: http://www.biblical.edu/pages/equip/classes-course-syllabi-spring.htm

If you ever wanted to explore the key secular and Christian models of counseling from a Christian/biblical perspective, this course is for you. The good part is you don’t have to travel to Biblical to take it. Bryan is a great teacher with a good sense of humor. I think you would enjoy it.

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March 5, 2008 · 5:35 am

Integrative Psychotherapy VIII: Symptom reduction of anxiety


If you recall from prior chapters, McMinn and Campbell propose a 3 tiered model (IP) to address symptom, schema, and relationship issues. In chapter 7, they explore symptom focused interventions for anxiety (while not denying or addressing relational or schema matters of anxiety disorders). The authors provide a description of 5 types of anxiety problems (panic, phobias, OCD, PTSD, and GAD) and typical Cognitive Therapy interventions for each. For example, they describe panic as a “fear of fear” and explore interventions designed to interrupt the cycle of “internal physiological events” and “fearful appraisal of physiological sensations.” Such interventions include cognitive challenges or reframes, breathing and relaxation, and exposure (in vivo or imaginal) coupled with relaxation training. 

After providing this review of anxiety and common interventions, they move to a very brief discussion of fear from a spiritual perspective. The opposite of fear is love (not courage). They conclude that fear is, “a great spiritual problem” (p. 236). But, they quickly say, “we should not attribute anxiety problems to spiritual weakness.” They argue that doing that sets up an inappropriate simplistic model (you are anxious because you are immature) and ignores the complexities of fear. They fear it may also send the message that only people with anxiety cause their problems, when in fact we all live “outside of Eden.” So, our bodies, our communities, our wills are all tainted with sin. But, they say, “it is damaging and unrealistic to assume direct and immediate connections between a particular problem and spiritual maturity.” What should we do? “Our best response is to recognize our own brokenness so that we can, in humility, become people of compassion and understanding, willing to walk alongside others through the difficult passages of life.” (p. 236)

My thoughts? This is a classic CT review of anxiety. I’m not sure I saw much of their theological model of persons in this chapter. However, I have to remember this is a chapter designed only to address the symptom reduction aspects of therapy. The authors did not intend to look at relationships and schemas. In the real world, we can’t separate out schema and symptoms and deal with only one and not the other. I understand why they do highlight interventions in each domain in the book, but it comes at a cost (realism). I do wish they would have included a chapter on putting it all together by following a particular case. I also wish they would keep following anxiety problems through the other 2 domains of the model, but they didn’t.

My bigger concern is the thin discussion on spiritual aspects of fear symptoms. Now, maybe they will pick up more when we get to schemas since schemas look at worldview and beliefs. But, while I agree completely with the last quote above, I think they make an all-or-nothing proposal. They are right that judgmentalism and simplistic understandings of fear are inappropriate. However, avoidance tactics found with panic symptoms do reveal implicit demands for control beyond what God intends. Symptoms both happen and are chosen. These demands that we make may be unconscious and may be completely understandable. And yet, I believe we can explore symptom maintenance and reduction AND talk about spiritual matters without equating spiritual maturity with the elimination of all problems.   For example, OCD symptoms such as worry that one has caused harm to another (e.g., hit someone while driving to work) can be best treated by cognitive challenges, imaginal exposure and response prevention. But as one attempts these interventions it is likely that conversations arise about the desire to avoid causing anyone harm. Now that is a deeply spiritual conversation–and I suspect the authors agree. Hopefully we’ll see some discussion of this in the next two chapters as they look at schema issues.  

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February 20, 2008 · 12:32 pm

Integrative Psychotherapy VI: Assessment and Conceptualization


In chapter 6 of Integrative Psychotherapy: Toward a Comprehensive Christian Approach, McMinn and Campbell take up the matter of case conceptualization. Thus far they have been discussing the foundations and features of their therapy model. Just before going into deeper looks and clinical applications of their 3 domains, they stop to look at the concept of assessment and case planning. Why does case planning matter?

“Assessment is the task of systematically observing what signs and symptoms a client experiences. These signs and symptoms are then understood through a particular theoretical grid, resulting in a case conceptualization (a framework for understanding the symptoms). Case conceptualization is an effort to understand the cause of the symptoms, the role the symptoms play in the person’s experience and treatment strategies to help the person improve.” (p. 145)  The authors acknowledge that this task of assessment and conceptualization are neither linear nor without bias. As they say, the very questions one asks determines to some degree the data one gets and how one interprets that data.

They pose 3 questions for the Christian counselor. Is evaluation acceptable for Christians? Isn’t Christian assessment mostly a matter of identifying sin? How is Christian evaluation unique? I’ll dispense with the first two assuming we agree the answers are in order: yes. no, not only. How is Christian evaluation unique? It doesn’t settle for simplistic biological, behavioral, or volitional explanations of symptom manifestations. That probably isn’t unique. What is unique then? The starting point about human nature.

The rest of the chapter describes key assessment and conceptualization practices. Collect data from multiple sources. Make a diagnosis (they describe the benefits and drawbacks of making a DSM diagnosis and how it is the start of assessment, not the end). Consider etiology (predisposing, precipitating, and perpetuating factors). Consider client factors (client perceptions, expectations, ability to work with a therapist, additional strengths and resources). The authors also want IP counselors to assess the specific areas of maladaptive thoughts, schemas, and interpersonal relationships. They provide sample lines of questions to explore each area. Finally, they suggest that the counselor consider whether the data they collect in each of the above assessment areas is likely to facilitate or inhibit therapy. This action may guide clinicians as to where to start (if at all) and what kinds of goals might remove a specific therapy interfering behavior

My thoughts? I like this chapter. It provides a concise reminder to the beginning counselor regarding the basic data they should collect. It does remind us that our interpretive grids impact the data we get and the interpretations we make. We are not so objective. In light of that, I do wonder whether the DSM diagnosis is a good place to start. By starting there does not the clinician tempt herself to think only in light of classic psychiatric models. I would rather see the diagnosis happen at the end. In this way, the clinician can report to the client whether it is helpful to consider the diagnosis. For example, a child may look ADHD, but by collecting the other data, it may be clear that the child has a primary trauma or anxiety type problem.

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February 8, 2008 · 10:00 am

The difference between counseling and discipleship?


Is there a difference between counseling and discipleship? If so, how would you articulate the difference? Is it merely a matter of intensity (counseling being more focused and intense)? I’m interested in your opinions as to (a) whether there is a difference, and (b) what that difference is.

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January 30, 2008 · 11:09 am

Integrative Psychotherapy III


In chapter two of Integrative Psychotherapy, McMinn and Campbell attempt to set our their foundation for psychotherapy. You’ll remember that in the last chapter they articulated their theological foundation. This chapter nicely divides into two parts: (a) A defense of the science of psychotherapy, and (b) a summary of what is “known” about the what works, when, and why.

They begin the chapter by admitting that there are many competing and dispirit theories/models of psychotherapy–many which have never been tested through empirical means despite lofty claims. They also acknowledge that many Conservative Christians have cherry picked certain studies that show that psychotherapy is ineffective and ignored many others that say the opposite. In other words, anyone can find a stat to prove whatever they want.

McMinn and Campbell remind their readers that they intend to build a Christian Psychotherapy model built on a robust Christian worldview and fleshed out with scientific methods to tell us, “what works, whey, and why” (p. 56). They lament that since both scientists and theologians aren’t known for their humility, a robust Christian psychotherapy model has not really been built. Collective wisdom is needed to accomplish the goal.

Then the authors turn to some of the details about the science of psychotherapy? Is it really effective? They summarize some of the effectiveness and efficacy studies (these are different: effectiveness: client survey; efficacy: lab studies of very specific interventions on one particular problem). Back in the 1950s Hans Eysenck published a number of studies reporting, “there was no research evidence to support the effectiveness of psychotherapy compared to no-treatment control groups” (p. 57). By 1980, however, there was ample evidence to the contrary. In fact, McMinn and Campbell report, “that the average effect size for psychotherapy is .82 indicating that the average treated is less symptomatic than 80% of untreated persons” (p. 58). They then compare that number with the effect size of certain medications on psychiatric problems (stimulants for ADHD: .91, SSRIs for Depression: .50, Atypical Antipsychotics for Schizophrenia: .25).    

Does any one model work better than another? The authors report the oft-heard conclusion: no one model seems more effective than another. And yet, at the end of this chapter they state their preference for Cognitive theory models (due to the research published about cognitive techniques) joined to aspects of client-centered models and other aspects of psychotherapy research. In olden days, we called this eclectic. They do not call it that, most likely due to the negative connotations associated with the word (it has often been used to cover up the lack of theoretical awareness of the clinician using the term).

Before they end the chapter, they consider whether length of treatment matters. They do not really do much with this question other than to point out that most therapeutic courses are much shorter these days. They also consider the question whether therapy benefits last. Again, they don’t cite the literature but state the that certain factors will make it more or less likely for the benefits to last.

They speak briefly about two more important matters in the consideration of the effectiveness of psychotherapy: (a) recognizing that common threads of the change process (insight, affective experience, stages of change, behavioral change, etc.) and point to the works of Prochaska and DiClemente, and (b) common factors in all models of therapy that seem to account for success. They cite date regarding these factors (and the percentages the factor accounts for for therapy outcome) as

  1. Client and extratherapeutic factors (40%). Such as intelligence, motivation for change, persistence, social support, resiliency, etc.
  2. Relationship between client and therapist (30%). This is why program emphasize relational skills over techniques or models
  3. Hope/expectancy (15%). How much hope does the client have in the possibility of change?
  4. Model/Technique (15%). Notice that the learning of special therapeutic techniques only account for a small portion of the outcomes in psychotherapy.

My thoughts on this chapter. Nothing out of the ordinary here. The chapter follows conventional wisdom about the science of therapy. The reader who wants to go deeper can look look at their bibliography and dig pretty deep. The reality is that though we think we know a number of things, the research on psychotherapy is complex and sometimes controversial. This is not to say that we know nothing. But we do have a long way to go. I might have liked to see some more discussion on what we as yet do not know but really want to. Further, I would have also liked a short discussion of philosophy of science. Why? Just as we need to be tentative about some of our theological underpinnings, so we ought to be a bit tentative about the modernist underpinnings of psychological research. I don’t think they are overstating their case yet, but the reader may view these two disciplines (theology and psychology) as one having only theory and the other only fact.

I do hope that they will take a look at the presuppositions of cognitive theory in the next chapter. How does that model influence what they see? 

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January 25, 2008 · 9:48 am

Opportunity for free career and resume consultation!


Part of Biblical Seminary’s advanced counselor training certificate for those pursuing licensure includes a course on career and lifestyle development. Led by two seasoned (experience…not old) career and job change counselors, the course includes a special free-of-charge career clinic on February 11 staffed by the students.

Appointments are available every half hour or so, and they recommend that you bring a résumé. They’ll help with questions you may have about getting a job, work situations, and overall career goals. If you are out of the area but would still like to take advantage of this opportunity, feel free to request that here in a comment and I’ll email you privately to get contact info. If you fax your resume to us, we’ll see about getting you a phone conference. Slots are limited.

Here’s a link to the flyer location on Biblical’s website that will give you more details:
http://www.biblical.edu/pages/embark/flyer_for_career_clinic.pdf

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January 23, 2008 · 5:06 am

Integrative Psychotherapy II


Chapter one of McMinn’s and Campbell’s Integrative Psychotherapy begins with Christian foundations. Interestingly, chapter 2 (next week) is entitled Scientific Foundations. We may not want to make those distinctions. This chapter lays out their theological anthropology. They begin by asserting that a responsible Christian psychology is founded on the “bedrock” of a Christian worldview. “Christianity–informed by Scripture and responsible theological appraisal–is trump” (p. 25). This is a significant change from older integrative models that often describe their task as weighted equally on the pillars of psychology and theology.

The remaining portions of the chapter discuss what it means to be made in God’s image. They employ 3 ways of looking at imago dei: functional, structural, and relational. Functional: God’s image is revealed in human behavior (especially in our managing and stewarding behaviors). Structural: God’s image is revealed in our moral and rational capacities. Relational: God’s image is revealed in relationality and communicative activities. Psychology also addresses these areas (adaptive behavior, cognitive behavior, effective relationships).  These form the 3 domains of Integrative Psychotherapy.

Then they tackle the Fall. They acknowledge that many psychotherapists live in denial about sin. Taking sin seriously, they say, doesn’t have to mean forgoing empathy. Instead the view it through the lens of Augustine. Sin, they assert is both a state of being (therefore “free will and personal resolve are not enough” to change behavior) and an act. We sin and are sinned against. Why does this matter to counselors? Because we have a tendency to deny and distort due to the effects of the Fall. Sin mars and colors everything one and everything. A robust doctrine of sin enables counselors to recognize the brokenness in the world.

The authors conclude the chapter looking at the theme of redemption. “A doctrine of sin, viewed in the context of a God who loves humanity, is the Christian’s great hope because it opens the possibility of redemption–God buying us back from the bondage of sin through the atoning work of Jesus Christ, restoring a right relationship with those who were lost in their sin” (p. 44). Long sentence, but sums of their view of redemption.  This matters to the Christian counselor because it means there is hope for change, hope for healing, hope for redeeming broken things. This hope is not a general hope of change but founded, for them, in the revelation and incarnation of Christ. “And so a Christian approach to psychotherapy calls us to consider more than general revelation….In short, [it] involves an awareness of sanctification as we all seek to be transformed by the divine life revealed in and mediated to us by Christ” (p. 49).

My thoughts? McMinn and Campbell make a significant break with prior integrative models by acknowledging that the Christian worldview does provide a trump to all other competing reality claims. This does not need to set up an unnecessary sacred/secular divide but does remind us that the biblical data isn’t a sidebar to Christian care, but front and center. I’m glad to see them emphasize this without reservation. Too often folks talk about psychological truth as what is found in general revelation. This is problematic for two reasons. First it denies the rich psychological data in the bible. Second, general revelation has been misused to mean neutral data outside of Scripture. But, general revelation really is natural that points to the existence of the triune God.  

Its clear this text isn’t trying to be an advanced text in biblical anthropology. But what it summarizes is in keeping with classical theology. We’ll have to see how this works out in their model and practice. They write for the professional counseling student. To keep them interested they have little sidebar vignettes and practical tips. Some may like that but I find it a bit annoying because it breaks the flow of their argument. But, I suppose it does tell the student that what they talk about is not all pie in the sky.

Next week, I’ll summarize their scientific foundations in chapter 2.

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January 16, 2008 · 5:35 pm

Integrative Psychotherapy: A Review 1


Consider this your forwarning that I am about to start weekly chapter reviews of Mark McMinn and Clark Campbell’s book Integrative Psychotherapy: Toward a Comprehensive Approach(IVP, 2007). I believe this book is important because it marks an important step forward in developing a substantial theoretical model for integrationist psychotherapy. Most of what has gone on in the last several decades has been primarily theoretical and not practice oriented. Both men are professors at George Fox University in Oregon. I know Mark personally as he taught several of my classes at Wheaton and helped me publish my first book chapters in a book he edited. Mark is a gentleman, prolific writer, and pretty good basketball player (he has/had one of the quickest releases around, making it hard to block his shot).

I’m not likely to fully agree with this book, but I expect that it will provoke some thoughts among my student readers.

Introduction: What is a Christian psychotherapy? Good question. the authors say that Christian psychotherapy must be based on “a model of psychotherapy that is faithful to both Christianity and psychology.” (p. 15).

They acknowledge some problems with prior attempts. They define integration in 2 dimensions: (a) integrating a Christian view of persons with psychological literature, and (b) integrating various approaches to therapy (they do not believe in any one pure approach to therapy).

They are not trying to propose the ONE christian model for psychotherapy.

What is to come? the first 4 chapters establish their theoretical framework. For example, they use the concept of the imago dei and its functional, structural, and relational aspects to build their model of persons and therapy). The next 7 chapters consider the practice of their model referred to as IP.

Well, strap on your seatbelts and come along for the ride each Wednesday. 

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December 19, 2007 · 5:48 am

Should you listen to your clients?


In chapter one of Workmen of God, Oswald Chambers has this to say about the work of curing souls (bold emphases mine):

Keep these three things in mind—reliance on the Holy Spirit of God, keeping in contact with people, and above all, keeping in contact with the revelation facts in God’s Book; live amongst them, and ask God how to apply them.

Another thing I want to mention—never believe what people tell you about themselves. There is only one person in a thousand who can actually tell you his or her symptoms; and beware of the people who can tell you where they are spiritually. I mean by that, never be guided by what people tell you; rely on the Spirit of God all the time you are probing them.

Let me read you this in regard to medical treatment—

Recent evidence in the law courts has pointed to a fact which the medical profession holds of great value—the necessity, not only of personal and private interview with a patient, but of the penetrative ability to get at the real facts and symptoms. In other words, successful diagnosis depends on the doctor’s acumen in cross-examination. “Cross-examination of a patient is almost always necessary,” says an eminent medical man. “They will give me causes, or rather what they think are causes, instead of symptoms. The rich patient is more troublesome in this respect than the poor, for he has had leisure in which to evolve a sort of scheme of his illness, based on ‘popular’ medical knowledge.

“Patients always colour facts, speaking absolutely instead of relatively. They never tell the truth about the amount of sleep they have had or as to appetite. They frequently say they have had nothing to eat. Casually you find there were two eggs at least for breakfast. A minute or two later they remember stewed steak for dinner. Perhaps the greatest need for cross-examination is that it gives an extended opportunity to the medical man to examine the patient objectively. The most important symptoms are generally those the patient never notices.”

If that is true in the medical profession which deals with men’s bodies, it is a thousandfold more true about spiritual symptoms when it comes to dealing with a man’s soul. Do beware, then, of paying too much attention to the talk of the one that is in trouble, keep your own heart and mind alert on what God is saying to you; get to the place where you will know when the Holy Spirit brings the word of God to your remembrance for that one.

If you are unacquainted with Chambers, you might think him rather harsh and condescending to those he ministers. To the contrary, he very much cares for the souls he serves. In fact, his next lines are some of my favorite. He confronts those who love to hurl bible texts at others without listening to the Spirit.

So, how might these thoughts from Chambers inform the counselor?

Listen to what is being said, even if not the actual words. It is not hard to hear the heart cry despite being dressed up in words that accuse the self or other for causing the misery presently experienced. Then, consider what the Spirit and the Word have to say to that heart cry (Chambers alludes here to John 14:25).  It is a delicate balancing act to listen to our clients describe their dream of a solution to their problems, validate that dream, and yet bring reality into that dream. Sometimes, we are called to help them see how their dream leaves themselves out of the solution? Sometimes, we are called to help them work where they have the power to make changes and let go of those areas where they do not.

So, listen, validate, and yet point to those areas where God is leading the client. Of course, this assumes that the counselor is in touch with the Spirit and not just in touch with their own mind.  

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