Category Archives: christian counseling

What good is a diagnosis?


At the recent AACC conference Dr. Michael Lyles, a board member of AACC and practicing psychiatrist, stated the following,

A diagnosis is only a word on a page if it doesn’t serve a function.

What kind of function was he thinking about?

  1. Does it explain a set of symptoms?
  2. Does it point to a treatment plan?
  3. Does is help differentiate between overlapping symptoms?

I’m a firm believer that our current DSM diagnostic system is at once both flawed and useful. It is flawed in that DSM diagnoses don’t address causes or do much to point to treatment. It is useful when used carefully to help differentiate between overlapping sets of symptoms–even as it needs considerable overhaul to do a better job. Take differentiating between Major Depression and hypothyroidism instigated depression. The two look identical. But using a multiaxial diagnosis, a person could rule out Major Depression if they were able to make a positive diagnosis of low/inactive thyroid function.

So, until we have a better nosological system (i.e., a replacement for the DSM), I will continue to use it. In years to come we will, however, recognize it for the blunt instrument that it is.

Right Diagnosis…Wrong Focus?

Consider the following case study (not a real person, devised from several stories) as an illustration for the problems we have moving from current diagnostic categories to proper treatment.

Tom is 27, married, father to one young daughter, working part-time as a youth pastor and going to seminary full-time. He comes to counseling on the encouragement of his primary care doctor. One month ago during final exams and an overly busy ministry schedule, Tom began experiencing rapid heartbeat, shortness of breath, feelings that he was losing his mind, and chronic fear of dying. After experiencing 4 panic attacks in rapid succession, he began worrying that something was terribly wrong and that he was about to die. His doctor first ruled out a physical origin for these symptoms, taught him breathing and distraction exercises to interrupt the buildup of panic, prescribed an anti-anxiety medication, and recommended he make an appointment with a therapist. During the first session, Tom details his history of stress, reports he has been able to forestall 2 more panic attacks but admits he still struggles with fears of dying, lacks assurance of salvation, and feels flooded with guilt that he worries so much. Upon further exploration, Tom believes the bible teaches him that he should not fear if he has “perfect love”. He has read all of the verses about anxiety and feels condemned for his struggle.

Tom meets criteria for Panic Disorder, without Agoraphobia. This is a highly treatable problem and within a few short sessions, Tom is likely to gain mastery over his body in that he will no longer evidence panic attacks. This, of course, is not the same as saying he will stop experiencing worry, guilt over his chronic worry, or start having assurance of his salvation. Logic, disputing worries, distractions, exploring and altering core beliefs may help reduce the symptoms that brought Tom to his doctor and counselor. A good Christian counselor may also be able to reconnect Tom to Scripture in ways that help him experience God’s care for him in spite of his fears (e.g., hearing the gentle voice of Luke 12 vs. a harsh rebuke).

But has the diagnosis been properly made? Yes. Tom met the criteria for an anxiety disorder. No. Tom’s counselor also helped him discover a deep layer of shame that may have been the source of his anxiety. Without the latter, the former is not altogether helpful.

So, should the diagnosis be an anxiety disorder or shame? Until we have shame as some form of a diagnosis, I’m okay with maintaining the anxiety disorder as a good description of external symptoms. But, Tom and others like him will need wise counselors who can dig a bit to discover diverse multiple shaping factors (e.g., biopsychosociospirtual) that lead to a common expression of symptoms.

What good is a diagnosis? I concur with Dr. Lyles: not much.

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Self-care or stewardship?


Last night, Dr. Tan (Fuller) spoke on the topic of self-care. During the presentation he interacted with Dr. Sally Schwer Canning’s short essay in a previous Journal of Psychology & Christianity issue (2001, v 30, p 70-74). Dr. Canning raised some concerns about self-care and “balance” language. We all know that we can get out of balance and that we do need to do things to care for ourselves. However, there are times, Dr. Tan said, that we are put out of balance by God. He reminded us of Paul’s statement that he was overwhelmed to the point of despairing of life. He was ship-wrecked and more.

In the name of self-care, we sometimes put up inappropriate boundaries.

Both Tan and Canning suggest that “stewardship” may be a better image for us to us? How are we stewarding the gifts and resources we have, even when life is out of balance?

What do you think? Does stewardship get the same point as self-care?

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Speakers vs. teachers?


At AACC National conference in Branson this week. Good to see a number of old friends and colleagues. Have heard a few good ideas as well. At conferences like these there are plenary and breakout sessions where I can get continuing education. The plenary sessions include widely known individuals and the breakouts may also feature well-known counselors as well as “regular” people like me.

Here’s what I notice when I come to a place like this: there are speakers and teachers and usually a person is either one or the other. The speaker is someone who often displays a great sense of humor, knows how to tell stories, and can move and motivate the audience with information that may not be that new but is packaged in a captivating way. Teachers, on the other hand, tend to deliver new content, provide step-by-step description of interventions and give the audience some new way to think or act. Now, teachers can motivate and be humorous and speakers can deliver new content. But commonly these two types of speakers are very different in style.

Have you noticed this difference in conferences you attend and do you gravitate to one more than the other?

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The Five Minute Antidote for Anxiety


I’m an anxious person by trait. It is a common trait, especially in graduate school (in combination with narcissism. I say this also in self-disclosure; both features support successful completion of doctoral studies). Anxious people tend to spend considerable time ruminating through “What if…” questions along with should, coulda, woulda thinking. We worry about our past failures coming to light and whether we’ll be up to the challenge the future presents.

Sound pretty negative way to live? It is. The only way we differ from depressed people is that we still have some thought that our worry might save us from disaster. As you can imagine, such worry robs us of joy. It keeps us from enjoying the present or seeing God’s gracious hand on our lives. And we compound our problems by then shaming ourselves for failing to follow God’s command, “Do not be afraid.”

The Five Minute Antidote

Part of the problem with anxiety is that we are trying to control/manage every possible outcome in order to avoid future disaster(s). Fearful people know that the answer to their anxiety will not include,

  • Just not caring anymore. We’ve tried that…it doesn’t work.
  • Making sure we get it RIGHT. Tried that too. Didn’t work.

So, what might work? Try this on for size,

What is God’s plan for me for the next five minutes?

Most of us have no clue what God is planning for us next year or even next week. But, I suspect most of us can discern what we need to do right now…for the next five minutes,

  • I need to make dinner
  • I need to read this assignment for school
  • I need to attend to my child’s homework
  • I can call a friend who is grieving

We usually know the one thing we can do for the next five minutes. Do that with as much focus as you can. Here’s what you are likely to discover: your anxiety decreases, or at least does not increase. When we stop the ruminations or internal conversations, our anxieties decrease and our ability to be present increases. So, when you find yourself in an anxious stew, try to ask yourself, What is one thing I can do for the next five minutes or What does God want me to do for the next five minutes? Consider this your method of living out Psalm 131, where you are are stilled and quieted like a weaned child, content with what He has for you for the next five minutes.

Oh, did you think this will solve all your anxiety problems? No, of course not. But where God does give you something to focus your attention, call that a success. Part of the Christian life is repetition–repeated worship, repeated repentance, repeated obedience, repeated trust. So, do pray for God to remove your “thorn” but look for five minute relief. Notice when it works and then ask God for another five minute focus on the thing he has for you RIGHT NOW.

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Is All Counseling Theological?


Why do we have to study theology? I don’t need that to be a good counselor?

These are words I have heard from students studying counseling and/or psychology in both university settings and seminaries. What would you say?

Biblical and theological training in professional programs?

Most Christian institutions offering counseling or psychology graduate programs require some level of theological engagement. Otherwise, why exist? Some do so via specific course work while others embed the theological or biblical material into classic counseling courses. At Biblical, we do both. We require traditional counseling courses such as Marriage & Family, Helping Relationships, Psychopathology, Social & Cultural Foundations, etc. In these courses we explore counseling theory and practice from an evangelical Christian psychology perspective. We also require students to complete courses like, “Counseling & the Biblical Text” and “Counseling & Theology: Cultural Issues” where they engage biblical texts and theological study as they consider how it forms counseling theory/practice and shapes the character of the counselor.

Is all counseling theological?

Yes. And David Powlison in the most recent CCEF NOW magazine (2-4) talks about this very fact. Here are some choice tidbits,

…counselors deal with your story. In fact, they become players in that story. By word and deed, even by their line of questioning, they inevitably offer some form of editing or rescripting, some reinterpretation of your story.

Counseling is inescapably a moral and theological matter. To pretend otherwise is to be naive, deceived, or duplicitous.

…all counseling uncovers and edits personal stories…. All counseling must and does deal with questions of true and false, good and evil, right and wrong, value and stigma, glory and shame, justification and guilt.

All counseling explicitly or implicitly deals with questions of redemption, faith, identity, and meaning.

Thus, if value-free counseling is not possible (the very questions we ask lead clients in one direction or another), then it stands to reason that every counselor ought to explore the theologies (doctrines, interpretations, beliefs, etc.) he or she brings into the counseling room. Who is God? How does God operate? What is the purpose of the Bible? Does it have anything to say about my life, my attitudes, my relationships? What is sin? What is my purpose in life? What does God think about my suffering? And on we could go.

But counseling is NOT theologizing

But lest you think that Christian counselors spend a great deal of time plying clients with the right answers, on sin hunts, or catechising clients, let us remember that exhortation rarely makes for good counseling. In fact, most clients are well aware of their sins–even those who do not call themselves “believers.” And those who have correct theology are not less likely to have trouble in their relationships or less likely to struggle with racing thoughts or depression or less likely to get caught in addictive behavior.

Instead, good christian counseling consists mainly of,

  1. loads of stimulating questions designed not to get the “right” answer but to awaken the client to how they think, act, believe, relate, etc.
  2. Short observations to stimulate more critical understanding of the personal narratives being written, and
  3. Collegial exploration and practice of new narratives, perceptions, and behaviors.

Wait, just what is Christian about these three points? Couldn’t unbelieving counselors agree with this list? Sure they could. What makes these three activities Christian is the submission of both counselor and client to core convictions and practices of Christ followers.

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Guest post over at Christianpost.com


The website, www.christianpost.com has picked up one of my recent blog posts about whether our bodies can cause us to sin. Never heard of the site before but nice to be noticed. You can see the post here if you missed it on my site: http://blogs.christianpost.com/guest-views/can-your-body-cause-you-to-sin-11696/

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Forgetting Abuse? Some thoughts on motivated forgetting


Could someone really forget something as horrifying as a rape or sexual abuse? How come some people say they never stop reliving a bad experience while others say they have forgotten and cannot remember what happened? How do we best understand these two, seemingly, opposing reactions?

In a previous post I began a short series on the controversies of repressed and recovered memories. In that post I made a few general comments about the nature of memory. It isn’t a particular structure or substance or even stored as one discrete movie but rather is a whole brain process connected to context, mood, and self/other-perception. Memories do not exist outside of narrative or story (unfortunately for those with traumatic histories, these narratives are usually quite jumbled up making it difficult to tell the story well). In general, stories help us remember and remembering tells a story.

In this post I want to address the matter of forgetting abuse. Is it possible? The short answer is yes. Common to forget all of it? No. Common to forget portions? Yes. And even more common to have the experience of a new memory even without ever having forgotten the abuse (this I will address in the next post). It is possible to forget, to no longer have access to one’s own history. But, the bigger question is “how” and “why” rather than “if”.

Complicating factors

Laboratory studies re: memory cannot replicate the experience of sexual abuse or trauma. Thus, we have some rather weak experiments or post hoc, retrospective studies. What these studies point to is that (a) most people don’t forget entire episodes, (b) some forgetting does happen, and (c) some confabulation or memory error also happens (e.g., eye-witness accounts are more frail than we imagine them to be). But even when we get a good study, we find it hard to apply the information to real life. For example, one retrospective study located a number of child abuse victims decades after their ER visit to a hospital. A goodly number denied ever having been abused. While the study could reveal some form of forgetting, we might also be witnessing lying and/or alternative interpretations.

So, we have to admit at the outset we have a large supply of anecdotes of full forgetting, partial forgetting, and no forgetting, and an equally large supply theories and explanations based in part on experience and low power correlational studies. Now, anecdotes and poorly supported theories aren’t reasons to doubt the reality of forgetting trauma (or the reality of false recovered memories). They are, however, good reminders to be wary of applying some general knowledge as complete answer to any specific case. Each case of forgetting trauma needs to be evaluated on its own merits (more on this when I get to a post on clinical/practical interventions).

One more complication. Adults who reveal child sexual abuse experiences rarely have any corroborating witnesses or forensic evidence. They have their memories and that is about it. Families, offenders, and communities have much to lose to admit such abuse could have happened. Thus, outside therapeutic environments, adults have few opportunities to be heard or believed.

By what mechanism do we forget traumatic experiences

“Normal” forgetting happens in a variety of ways. Each of these may be a partial answer as to why someone might forget something very powerful.

  1. Distraction leading to failure to encode. If you are introduced to someone and immediately forget their name (happens to me ALL the time), it is because the information never got encoded (too distracted by preparing to say my own name??). Distractions may come in the form of attending to something very specific or not attending to anything at all. Some victims of abuse report that their memories are fuzzy because they could only focus on the flower pattern on the wall during the actual abuse.
  2. Other memory intrusion. A previous memory may interfere with the clear encoding of a new memory or a new memory may interfere with the recall of an old memory. Victims of extended abuse often report difficulty in remembering when it started and stopped, who was present, etc., especially when  the perpetrator also provided more normal love and attention. The memories (and their competing narratives) make it hard to remember.
  3. Motivated Forgetting. I like but hesitate to use this term. “Motivated” could sound like “willful” or “intentional.” And while some motivated forgetting is intentional, most just happens outside the conscious experience of the one doing the forgetting. If I have a conflict with my wife and I spend the next 5 hours rehearsing her supposed sins against me, I may have difficulty recalling my own misuse of words. I may not consciously say to myself, “I am going to do this so I won’t be able to remember my angry words to her,” but I am engaging in what I call “motivated forgetting.” Obviously, abuse victims would rather NOT remember what happened to them and would rather maintain a positive view of a loved one who did the abuse. Victims may encourage motivated forgetting through several means (again, without conscious decision): repeating a false narrative (“He didn’t mean to do that and I am at fault.”) created by themselves or others, using conscious decision not to think about an event, dissociating during abuse and then dissociating when not being abused, focusing on another possible threat.

Now, these forms of forgetting may not sound like they would lead to the complete forgetting of an event. And that would be true for the vast majority of abuse victims. But, I think we need to remember that it is possible given enough anecdotes of some who recover memories (apart from suggestion by therapist or others) on their own and that do get corroborated by others. Is it common? No. Can mental health professionals cause false memories? Yes (but that is for another post in this series!).

So, why do some remember minute details of trauma? They rehearse them (whether they want to or not). Why do some forget them? Their memories degrade due to forms of memory loss discussed above. Other factors are also likely: natural capacity to dissociate, age/development of victim, culture where abuse took place (e.g., a one-time event in a rather safe environment will have a different impact than repeated experiences where safety has never been present).

In my next post I want to take a few minutes to discuss dissociation, repression, and the experience of re-remembering child abuse later in life.

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Of Babies and Bath Water: Navigating the Controversies of Repressed and Recovered Memory


Recently I ran a conference about abuse within the church. In these kinds of venues (this blog and conferences) I am asked about a couple of related problems—the problem of false memories of abuse and the reliability of recovered memories of abuse.

While I intend to address these matters here (and in future blogs), I want to reiterate something that I think gets lost in most conversations about recovered and/or false memories.

Sexual abuse is real. The vast majority of adult reporters of abuse during childhood never forgot the details.

Why say this first? Discussions of rare and extreme cases (i.e., repressed memories, recovered memories, and false memories) tends to create undue suspicion for all adults who choose to reveal their child abuse later in life. It is my experiences that conversations about false memories or recovered memories lead many to assume that a report of extensive or horrific abuse is probably false. So, let us remember that as we take up the matter of fully repressed memories of abuse, we are talking about a very small percentage of people.

But, the issue of repressed and/or recovered memories and the construction of false memories is indeed worthy of a careful review given the strong feelings on both sides of the recovered memory debate. In order to be as careful as possible, I want to consider a few topics that may help us understand the issue. First, I will explore foundational topics (memory, forgetting, repression, and dissociation). Then,  I’ll explore the how trauma is known to create confusion, self-doubt, and “motivated” forgetting. Finally, we’ll take up the practice of counseling victims of sexual abuse and the particular matter of dealing with memory retrieval in counseling. Strap in!

Just in case you NEED to know my opinion at the outset…

I find Partlett and Nurcombe’s 1998 summary of an APA report on the topic to be fairly comprehensive,

The plain point here is the consensus set forth by the Working Group:
1. Controversies regarding adult recollections should not be allowed to obscure the fact that child sexual abuse is a complex and pervasive problem in America that has historically gone unacknowledged.
2. Most people who were sexually abused as children remember all or part of what happened to them.
3. It is possible for memories of abuse that have been forgotten for a long time to be remembered.
4. It is also possible to construct convincing pseudomemories for events that never occurred.
5. There are gaps in our knowledge about the processes that lead to accurate and inaccurate recollections of childhood abuse.[1]

I would add one more point: most people (myself included) in this debate are motivated by strong feelings as well as “facts.” These feelings may be the result of experiences with those who appear to be abused or appear to be falsely accused.

Issue one: Memory and Memory Retrieval

Let me start by stating the obvious: this isn’t a neuropsychology primer on memory and I am not an expert in memory. However, there are a few things on which I think we can agree:

  1. memory is a whole brain biochemical process. While structures like the hippocampus are clearly involved in memory storage, no one structure handles all aspects of memory storage or recall.
  2. memory is multi-faceted. Researchers differentiate between recognition and recall memory, explicit and implicit memory, short-term, long-term, and working memories…and much more.
  3. memory-making is a process.  The formation of memory requires attention, perception, encoding, storage, and retrieval. Thomas Insel calls it a 5 act play. A person moves from perception to long-term encoding to retrieval and finally, expression of memory.
  4. relational and affective context influences memory formation and memory retrieval
  5. the act of recall may change memory,

The concept is simple: memories are not fixed; they are periodically retrieved, and modified each time they are retrieved. This process of strengthening a memory by retrieval is called reconsolidation. One profound implication of this concept is that what you recall is not only a reflection of what you first learned, but also a product of each time you have recalled the original information.

How does this relate to our issue of recall of abuse?

  • memories are both fragile and yet not so. You recall what the house you grew up in looks like, even if you haven’t seen it in 30 years. And yet, your recall may or may not be particularly accurate. You may remember a large house even when it is much smaller to your adult eyes.
  • repetitive recall along with high levels of emotion may solidify memory. Most of us know exactly where we were on the morning of September 11, 2001.  You remember this because you talked about it, played it over in your mind, and because of the powerful biochemical process kicked off when you heard of the first plane crashing into the twin towers.
  • Most child sexual abuse has little corroborating evidence, especially when revealed decades later. This leaves victims by themselves to sort through the narratives they and others tell about their history.  The result? Ample opportunities for both denials of actual abuse as well as false memory.

Return with me to my first point. Most child sexual abuse is never fully forgotten. Some memories may be lost, others distorted, still others intentionally forgotten. Memory, as we have seen here is not a structure but a narrative.[2] In most cases, the story being told has much merit, even if some important details are perceived rightly. Thus memory retrieval during therapy (something that WILL happen whether therapist or client wants it) plays a powerful role in the re-storying work of therapy.

In my next post on this topic, I will make some comments about forgetting, motivated forgetting, dissociation, and repression.


[1] Partlett, DF & Nurcombe, B (1998). Recovered memories of child sexual abuse and liability: Society, science, and the law in comparative study. Psychology, Public Policy, and Law, 4, p. 1273

[2] “Rememberings—whether valid or invalid—are communicated by means of narratives.” Sarbin, TR (1998). The social construction of truth. Journal of Theoretical and Philosophical Psychology, 18, p. 145.

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The Cost of Reconciliation: Adding Insult to Injury


It is time to get back into the swing of writing again. Regular readers will note I have take a vacation from blogging. During my time off I have enjoyed reading about Powell’s trip down the Colorado River, a couple of books about the DRC, and a counseling book which I plan to review this fall.

But, before I start my own writing, I want to draw your attention to this short post on reconciliation. I have just one added note to this post. The choice of becoming vulnerable must always be made by the victim. Any forced reconciliation continues the abuse and is false through and through.

The Cost of Reconciliation: Adding Insult to Injury.

What do you think?

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What is therapeutic presence?


If you go to a counselor, you’d probably prefer that person to be awake versus asleep, to pay attention to you versus check their smart phone, to respond to what you are talking about versus make non sequitur responses. As I’ve noted here before, it is probably better to have a counselor who cares about you than one who has a big bag of techniques–though most of us would prefer our counselors to care AND be competent.

Therapeutic presence is a way of talking about the act of being with our clients in such a way as to build safe, trust-filled relationships where clients can grow and change. I think most people can easily identify failures of therapeutic presence. Try these on for fun:

CLIENT: I’m just so depressed.

THERAPIST: You think you are depressed? Let me tell you about depression. I have a client who just lost job, family, church, home. Now, that is something to be depressed about. You just had a bad day, that’s all.

Or,

CLIENT: I don’t understand why God would take away this job from me.

THERAPIST: Well, theologically speaking, God does things for all sorts of reasons. He sometimes does this to cause us to trust him more, to reveal some sin, to give him glory.

Notice how both responses fail miserably to be either therapeutic or present with the person in the moment of counseling. Not hard to miss, right? So here’s a question: Why do so many of us counselors, even seasoned ones at that, fail the “presence” test?

My answer? When we fail to be present in helpful ways, it reveals a lack of preparation and a lack of attention to purpose.

Shari Geller and Leslie Greenberg (in Therapeutic Presence: A Mindful Approach to Effective Therapy. APA, 2012) define the building blocks of therapeutic presence as

    • how therapists prepare for being present (in personal life and in session)
    • the process (or therapist activities) of being present (aka purposing to be present)
    • the experience of being present

Sound like mumbo-jumbo? Here’s another way of putting it. What does a counselor need to do to be ready to be in tune with their clients? What do they do to stay in tune when with clients, and are they aware of when they are failing to be in tune? (If I am unaware, then I am likely to get out of tune.)

Here are some things counselors ought to be asking themselves:

  • Do I have adequate space to move from my private life to being present with my clients? Do I have enough space between clients? The answer is not always an amount of time, but what we do during the space between.
  • As I prepare for sessions, what am I meditating and praying about? For example, if I pray for clients to be free from something that has them bound up, I could accidentally encourage myself to push for change or to talk about a subject that the client is not able or ready to talk about. I’m all for praying for healing. I just think we have other prayers to pray as well. “Lord, help me to be with the client today and not focused on my own personal goals for them.”
  • Am I staying present with their mood, their cognitions, their silences in such a way that it is as easy to talk about what is happening in the session as it is to talk about what happened in the past or might happen in the future?
  • When I sense a disconnect, am I quick to invite dialogue and learn (vs. avoid or defend/explain away)?

Therapeutic presence isn’t everything. I could be present with someone and no healing might take place. But without therapeutic presence, I will only be a barrier to whatever growth is taking place. When I do it well, I imagine that I might see just a tiny glimpse of how Jesus was with the woman caught in adultery, the Samaritan woman, or with Peter after he had abandoned Jesus.

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