Category Archives: counseling science

PTSD: A New Theory? An Old Treatment


Researchers Liberzon and Abelson at the University of Michigan have published an essay articulating a new way of conceptualizing what is happening in the brains of those with Posttraumatic Stress Disorder. While you can’t read their essay for free, you can read this good summary here.

What is their new theory? the neurobiological problem of PTSD is “disrupted context processing.” In simple terms, I fail to respond to the “stimulus” in its proper context when I am triggered by old experiences in a new setting. Even more simply, when I wake up on full alert in the middle of the night after smelling wood-smoke in my sleep I initially fail to recognize the context (my neighbor burns wood) and immediately think my house is on fire (as it once was). Thankfully, the alertness is less than it used to be and I don’t always get up to check on my house.

The authors suggest that 3 separate and current brain models are inadequate in their scope of understanding the brain’s activities in PTSD. From their perspective the “fear model” (Fight/flight learning), the “overactive threat detection model” and the “executive functioning model” work best when integrated into one unified theory with their new label. And, in true humble researcher fashion, they request help in testing this model to see if indeed it can carry the freight.

An Old But Essential Treatment?

It is good to have a better handle on what is happening in the brain when someone experiences PTSD. Neurobiological research is growing by leaps and bounds. It is hard, frankly, to keep up. And yet, let us not forget an old but essential part of PTSD treatment, the person of the therapist. Humans are designed to be in relationship. PTSD has a way of shattering connections with others and thus the treatment must reverse the disconnect. Being present and bearing witness to trauma will always be the first and primary intervention every therapist must learn. Our temptation is that we want to move beyond the bearing witness phase into change phases. While this is understandable (we want others to get better as fast as possible), we sometimes want this for our own reasons–to avoid the pain we experience in sitting with traumatic experiences of others.

Let us remember that we therapists (and pastors, friends, etc.) are the primary intervention when we are present with those who suffer, when we become a student of their suffering. All other treatment activities stem from this foundation. To use a different analogy, consider Dr. Diane Langberg’s meditation, “Translators for God” (Day 26 of In our Lives First). In this meditation she describes the experience of being translated in a seminar. The translator must fully understand both languages in order to accurately communicate the speaker’s words into the heart language of the hearers. Counselors are translators for God and for healing. And yet, if they do not deeply learn the heart language (pain and trauma experience) of the client, they will not be able to connect the client to healing and to the God who heals.

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Filed under christian counseling, counseling science, Post-Traumatic Stress Disorder, ptsd, trauma, Uncategorized

Can Mental Health Practitioners Predict Future Violence?


Yesterday, a gunmen killed five and wounded at least eight others at the baggage claim for a Florida airport. Initial news reports allege the shooter had recently experienced psychotic-like symptoms. I am sure that in the coming days we will learn more details about the shooting and about the recent history of the shooter. Among the details there will be plenty of questions. Did anyone know this might happen? Could someone—especially in positions of power (FBI? Mental Health?)—have prevented it by reporting or removing access to guns?

Of course, it is easy to ask these questions and develop opinions after the fact. And yet we need to ask them if there are possibilities to learn from possible mistakes. What follows attempts to give the public a brief but better understanding of risk assessment when mental illness and violence combine. (NOTE: this is not a comment on the above sad situation or those cases where violence is unrelated to mental health.)

A little history of predicting future violence

Violence risk assessment is part of the sub-division of forensic psychology and psychiatry. Expert witnesses are used in court proceedings to report on the existence of mental illness, the probability of imminent dangerous behavior, and the options for most effective/least restrictive treatment required to reduce illness and increase safety.

How do clinicians make these opinions? In the not-too-distant past, expert witnesses usually used their wisdom shaped by years of experience. Much to the chagrin of experts, it turns out that clinical intuition isn’t all that effective. For some professionals, it is little better than chance! (Interested readers can check out Monahan’s 1984 oft-quoted research quoted in this rebuttal article.) Other options include actuarial methods (collecting risk factors just like an insurance company does to determine how much to charge your 18 year old son for car insurance) and test data. Both of these methods seek to eliminate feelings in the decision-making process. Actuarial data can certainly help us. Knowing someone has a history of violence and criminal behavior helps us predict future behavior. Knowing someone has schizophrenia may slightly increase risk of violence, but no more than it would for those who have problems managing impulses. And this would not be a reason to lock someone up (though it may be a reason to limit access to handguns). Assessment tools filled out by the person suspected of violence have a couple of problems with them but the main one is that very few of the most violent have been identified in treatment as possibly benefiting from assessment. And when we do give these assessments, the data rarely is clear—this kind of response means they will be violent, this one means they will not. We’re far better at identifying “faking good” or “faking bad” results than we are in determining whether the results mean future violence.

The best assessment to date requires that we have adequate history, survey of known risk factors, interviews, and test data. But as I said above, if the person suspected has not been in treatment or has done well to present as being merely disturbed but not dangerous, what can be done?

One More Complication

In our current society, we believe deeply that individuals have the right to self-determination. This means they have the right to refuse treatment. This right trumps nearly every other value. It doesn’t matter if the treatment would really help. The person is permitted to refuse. The only exceptions are involuntary commitments to address imminent danger to self or other. And as soon as the danger passes, the treatment can be refused again even if the treatment might avoid a relapse.

Bottom line for Practitioners

We can do better in responding to risk factors that might lead some to violence. We can learn more about these factors. We can equally promote confidentiality and privacy for our most distressed clients and yet be quick to warn others when signs of imminent violence are present. We can ask better questions. We can use non-cognitive approaches to get a better picture of their internal experiences. And yet, we can only work with the information we have. Contrary to popular belief, we are not prophets. In addition, most of our outpatient clients are not even remotely dangerous (in 27 years of clinical work, I have only needed to report two clients for imminent risk to others).

What we can do is assert the need for better and more available treatment options.

Family members are really the frontline of help for most distressed individuals. They are more likely to hear the murmurings that might indicate violence. This requires greater public education about the nature of mental illness and violence risk assessment and the kinds of ways to respond. Church leaders can also be better educated as to what kinds of options are available for those parishioners who are struggling with similar kinds of emotional distress. Let us be willing to lead the way in educating our communities and churches about mental health challenges and healthy responses. If we did a better job surrounding those with severe mental illness (and isolating them less) we would likely have less mental health induced violence.

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Filed under counseling, counseling science, counseling skills, News and politics, Psychology, teaching counseling, Training, Uncategorized, Violence

3 negative consequences of having too many options


I prefer having choices to make over not having the option to choose how I spend my time. And yet, just like any medication you might take, the freedom to choose brings with it some potentially dangerous side effects. I’d like you to think about 3 and then consider a couple of modifications about how you make choices.

Consider the differences between choosing a mate today versus 50 years ago. According to Daniel Jones (listen at the 17 minute mark), in previous generations people chose mates from close proximity–from their block, building, or neighborhood. Now, we have endless choices if we are willing to use the Internet.  Consider the differences in choosing professions. In the past, your father was a farmer, you became a farmer. Now, not only can you pursue any career, you have to choose from endless post-secondary educational schools on your way to that career.

How can having choices/options lead to negative consequences?

  • Dissatisfied. You are always wondering if there is something better out there. Again, consider Daniel Jones as he discusses online dating sites,

“…it turns you into a flaky person who is always looking for something better, that can become a kind of mania…if you have a moment of boredom, you think there are 12 more possibilities in your inbox…”

Later in the same interview, Jones tells us that the issue of today is “not labeling relationships. Based on his college student interviews, many young people today are loathe to identify someone as their partner or lover. They tend to resist labeling someone as a boy or girlfriend. The failure to accept normal labels not only lead to potential of chronic dissatisfaction but also confusion–if you don’t know when a relationship begins, ends or what it is founded upon. It would seem that commitment to a relationship would suffer if it never is named as such.

Dissatisfaction leads to comparing self against others and both lead to depression.

  • Anxious. Coupled with the tendency towards feeling dissatisfied with life, more choices lead many to anxiety. What if I made the wrong decision? What if the next person I meet would make a better spouse? What if I’m missing out on something important? Continual choice and/or rumination over choices increases the sense of importance for the choices we have.

Anxiety leads to chronic stress and chronic stress begins to break down our immune system.

  • Fatigued (cognitive and emotional). We find ways to simplify life. A colleague of mine has a system to know what to wear each day so as to avoid the “What am I going to wear today” question. We (try to) put our keys in the same place to avoid the stress of looking for them every time we leave the house. When we live with too many open choices and options, we burn more glucose and our brains become less efficient. We numb our feelings or we become edgy.

Fatigue leads to poor decision-making (impulsive, reactive, unthinking). This is why we blow diets more at 10 pm than we do at 9 am. This is why those with addictions are more likely to use later in the day than early in the morning. When we are emotionally and cognitively fatigued, we are prone to feel greater anxiety and dissatisfaction. The “gift” of choice continues to give.

Can We Do Anything About This?

Now, rest assured that I am not advocating for life to return to a place of no choice (arranged marriage, one career path, etc.). Choice has enabled me to learn about myself and given me many wonderful experiences that as a boy growing up in Vermont I never imagined. But are there ways we can minimize the common negative consequences of too many choices?

  1. Examine your view of God’s will. I meet many people who fear making a choice God does not want them to make. They fear they will somehow end up on plan B of life as punishment from God. While there are many very black and white decisions (should I cheat on my taxes? Is it okay to kill my annoying neighbor?) most decisions are not that clear. What if most of your decisions are neither right nor wrong? Whether you go to university A or B, marry person A or B is less of concern for God than we might think. Typically God seems more interested in our motives than some of our daily choices. Consider seeing God’s will as guardrails on a road rather than a pinpoint decision.
  2. Limit your decision-making time. It can be a habit of some to mull over future decisions long before the decision needs to be made. Do you find yourself worrying about the challenges of next week? While it might seem wise to think through your decisions in a thorough way, anxious rumination is not helpful. Limit when you think about big ticket future decisions. For example, if you are considering a career change, set a specific time during the week to search out available options. Then, when you find your mind mulling over options outside that set time, you can say to yourself, “I’m going to think about that during the scheduled time, not now!” When you do make a decision, use the same technique to limit when you review/evaluate that decision, thereby limiting time for “what ifs.”
  3. Challenge post decision “if only” regrets. I made a major career decision 17 years ago. I chose to become a seminary professor over an Ivy League appointment. For the first few months at Biblical Seminary I found myself wondering if I had made the right choice. I imagine this was the result of financial struggles (the other job paid double) and the overwhelming stress of creating grad courses from scratch (the other job was something I had ample experience to do). So, I could easily see that I chose the harder job for less pay. That became the truth I believed for a bit. But, the real truth is that I chose a job that had immense freedom and opportunity for growth. I would not have been able to travel the world as I do now. Of course, I couldn’t know all that then. So, work to challenge your assumptions about the future. Yes, like me, you will grieve when doors close. But remember, God is at work in providing a future for you, even in tough locations and times.

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Filed under Anxiety, biblical counseling, counseling, counseling science, Psychology, Uncategorized

Free Counseling Journal For Counselors


For my counselor readers, I want to let you know of a free counselor journal. Click here for free access with search capacity. It is published by NBCC and is open access to anyone who wants to try to stay current on counseling literature.

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PTSD “A Disease of Time”


David Davies, part of the staff of “Fresh Air” on NPR, has conducted an 35 minute interview with David Morris, a journalist who was embedded in a unit in Iraq and who suffers from PTSD resulting from an explosion he survived. David has written a book, The Evil Hours: A Biography Of Post-Traumatic Stress Disorder. If you want to better understand the experience of PTSD and its impact on a person, you should listen to this show (or read the transcript). For therapists, Morris discusses his experiences with Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). He also describes the use of propranolol when repeating trauma stories.

Here’s a couple of my take-aways:

  • PTSD is a disease of time.

“…in some ways, PTSD is a disease of time. And a lot of people – PTSD is many things, but one of the things it is a failure to live fully in the present. And I think what happens a lot of times with traumatic – survivors of trauma is they have these compulsive returns to awful events, and they are unable to live in the now.”

  • The best treatment never removes all symptoms of PTSD

“The best we can do is work to contain the pain. Draw a line around it. Name it. Domesticate it, and try to transform what lays on the other side of that line into a kind of knowledge, a knowledge of the mechanics of loss that might be put to use for future generations.”

  • Honest reflections of the impact of PE and CPT (and why so many dropout from PE treatment)
  • Honest admission about the most common “treatment” of PTSD–alcohol (and evidence why so many end up abusing it!)
  • War traumatizes far too many but rape is 5x more traumatizing

[in discussing how helplessness/lack of control is a significant factor in the development of PTSD] “Yeah, the helplessness is one of the main predictors of who’s going to end up with PTSD and who doesn’t. And the idea that you have absolutely no control over your environment is very hard for people to deal with because, you know, you are basically completely helpless and unable to control your destiny and your survival….and that’s one thing I discovered in the book is I thought – you know, we sort of assume that PTSD is sort of the realm of soldiers and veterans, when in fact, the most common and most toxic form of trauma is rape.

…a soldier may have some control over his or her environment. They have a weapon with them; they can move; they can take cover. But oftentimes in the cases of rape, the victim is completely overwhelmed and trapped and cornered. And from the moment the attack begins, they are rendered almost completely helpless, which is interesting. And you see that in the diagnosable rates of who gets PTSD and who doesn’t. Rape survivors tend to have it almost 50 percent of the time, whereas your average war veteran – particularly for Iraq and Afghanistan veterans – the rate of PTSD diagnosis is more around 10 to 12 percent. So a rape victim – rape is, in a manner of speaking, five times more traumatic than combat.”

 

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How labels we use reveal self-deception


 

Someone sent me one of Ken Pope’s summaries of a recent essay about the differences in research findings when asking men if they have ever used force and held someone down during sex versus asking them if they had ever raped another person. You can read the original research he was discussing here, which is by some researchers at the University of North Dakota.

No, I’m not a rapist, but I have used force to make someone to have sex.

Let that previous line sink in a bit.  We’ll discuss it in a minute. But first, you might not want to read the article so let me tell you what the authors were interested in knowing. They wanted to know if there were differences between men who are hostile towards women and accept the label of rape and those who have used force but deny the label.

This allows us to test whether there are differences in men who do not identify with the “rape” label on sexual aggression surveys, although they have committed acts that would be defined as rape. Men who admit intentions to force women to have sexual intercourse only, but do not believe that this act constitutes rape, might not be primarily motivated by a desire to retaliate and overpower women. Their behavior could be guided by other factors in line with stereotypically masculine gender roles such as having a high desire for sexual activity, viewing sexuality as a competition and a way to gain respect among peers, and lacking consideration for women or viewing them as sexual objects. Therefore, we hypothesize that men do not endorse any intentions for sexual aggression will differ from the other two groups of men primarily on a dimension characterized by hostility toward women as the strongest loading factor. (emphasis mine)

What did they find?

As hypothesized, a sizable number of participants indicated that they might use force to obtain intercourse, but would not rape a woman. Men who indicate intentions to use force but deny intentions to rape exhibit a unique disposition featuring an inverse construct of hostility toward women but high levels of callous sexual attitudes (Check 1985). Given that hostility toward women involves resentment, bitterness, rejection sensitivity, and paranoia about women’s motives, we consider the inverse of hostility toward women in men that intend to use force to be indicative of an affable, trusting, and nonreactive affect toward women. When combined with callous sexual attitudes, we interpret this function as representing personality characteristics that might lend themselves to allowing men to not perceive his actions as rape and may even view the forced intercourse as an achievement. The primary motivation in this case could be sexual gratification, accomplishment, and/or perceived compliance with stereotypical masculine gender norms. The use of force in these cases might be seen as an acceptable mean to reach one’s goal, or the woman’s “no” is perceived as a token resistance consistent with stereotypical gender norms. While the ultimate outcome of either act constitutes rape, this pattern of results suggests that there might be different types of offenders with potential differences in underlying motivation, cognition, and/or personality traits.

So, not every rapist does so for the same motives (and therefore our interventions will need to be different). Some knowingly rape and are not self-deceived about their actions. Others who are willing to acknowledge “forceful intercourse” group reveal deceptions  (probably both in view of self and other) that enable rape to be considered something less than it really is.

Labels and what they may reveal

What labels do you use and what do they reveal about yourself and your proclivity to self-deceive? Here are some examples

  • I exercise (once in a great while)
  • I stand up for myself (I attack anyone who disagrees with me)
  • I used to struggle with porn (well, I look about once a month but I don’t think I will do it again)
  • I eat healthy (I’m obsessed with food labels)
  • I am good at doing my taxes (I underreport income)
  • I’m a Christian (I go to church but never really talk to God)
  • Let’s just call it sin rather than abuse (because I won’t accept my actions are abusive)
  • I need (I want/demand)

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Filed under Abuse, counseling science, deception, Psychology, Rape

Brooks on journaling about emotions


Friend Jeff McMullen pointed out a recent David Brooks op ed in the New York Times. (Read it here). While I’m not sure I agree fully with his journaling/not journaling point he says something very important about the timing of writing one’s emotions after a traumatic event. He says,

When people examine themselves from too close, they often end up ruminating or oversimplifying. Rumination is like that middle-of-the-night thinking — when the rest of the world is hidden by darkness and the mind descends into a spiral of endless reaction to itself. People have repetitive thoughts, but don’t take action. Depressed ruminators end up making themselves more depressed.

Then later, this important distinction between immediate processing of emotions and later processing,

We are better self-perceivers if we can create distance and see the general contours of our emergent system selves — rather than trying to unpack constituent parts. This can be done in several ways.

First, you can distance yourself by time. A program called Critical Incident Stress Debriefing had victims of trauma write down their emotions right after the event. (The idea was they shouldn’t bottle up their feelings.) But people who did so suffered more post-traumatic stress and were more depressed in the ensuing weeks. Their intimate reflections impeded healing and froze the pain. But people who write about trauma later on can place a broader perspective on things. Their lives are improved by the exercise.

David points to some research that exists that suggest CISD is unhelpful for some participants. Some are made worse. Yet, narrating one’s trauma in the broader context of a life tend to see a reduction of symptoms. The difference seems to be whether the focus in on life or mostly on the trauma. Trauma in perspective is the goal. Just reviewing trauma may in fact strengthen the traumatic reaction rather than weaken it.

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Traumatic Nightmares? Two Treatment Possibilities


Many who suffer from PTSD or other traumatic reactions also experience chronic nightmares. It is bad enough to have to deal with intrusive memories and triggers during the day but being robbed of peaceful sleep can send you over the edge, both in terms of physical and emotional health. Christian counselors may be tempted to ignore these nightmares (how can you stop something you have little control over?) or overly spiritualize the content of the dream.

But we ought not neglect the problem of nightmares. It is well-known that reductions in quality of sleep make all mental illnesses worse. Nightmare sufferers understandably avoid sleep but of course this creates a vicious cycle of insomnia, anxiety, and increased avoidance strategies.

There are two intervention options (among many) that appear to have fairly robust positive data indicating helpfulness. (For detailed descriptions of these two and others including the analyses of value, see this pdf): Prazosin (medication) and Imagery Rehearsal Therapy (IRT).

Prazosin is an anti-hypertensive (alpha blocker) that may work on the problem of too much norepinephrine in PTSD patients. It seems to improve sleep length and REM time. Interestingly, beta blockers have been found to increase nightmares rather than reduce them. I am no physician and so cannot evaluate the value of this medication for clients but would encourage clients with chronic, severe and re-occurring nightmares to talk with their doctor about whether Prazosin might work for them. The studies I have reviewed primarily examined the value of this medication for veterans with extreme nightmare problems. The most significant downside to medication treatment is that it only works when the medication is taken. Stop the medication, the nightmares may come back. However, some relief may be beneficial and thus the medication then has value.

Imagery Rehearsal Therapy (IRT) is a short-term therapy that does not work on the actual content of the traumatic experience or attempt to treat PTSD. Instead, it treats nightmares as a primary sleep disorder problem. There are variations on IRT but most versions last between 4 and 6 sessions and may be delivered in individual or group formats. Sessions include education about the nature of nightmares, sleep hygiene protocols, and the imagery replacement protocol. While some of the IR protocols are done imaginally, others ask nightmare sufferers to (a) write down the details of the distressing nightmare, and (b) write a new ending to the nightmare. As Bret Moore and Barry Krakow describe, the therapist does not dictate the new outcome of the revised dream but encourage the sufferer to “change the nightmare anyway you wish” (Psychological Trauma, v. 2, 2010). The nightmare sufferer then rehearses (multiple times) the new ending and is instructed to ignore the old nightmare.

Sound goofy? How is it that a person can just decide to have a different dream? However, the evidence that this therapy works is quite robust. Numerous studies with veterans and civilians indicates it is effective in reducing unwanted nightmares. Most treatment protocols suggest starting with nightmares with content unrelated to actual traumatic events.

Thus, Christian counselors ought to review these two treatments and consider learning the IRT protocol to bring relief to chronic nightmare sufferers.

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Filed under christian counseling, christian psychology, Christianity, counseling, counseling science, counseling skills, Post-Traumatic Stress Disorder, Psychology, Uncategorized

Should therapists talk about themselves to clients? Surprising information


How do you feel when your counselor begins to self-disclose during a session? When they do, is it helpful or a lapse in their judgment?

This is a common conversation in counselor training programs. Generally, most models of counseling and therapy discourage counselor-self-disclosure; some models do so more than others. The reasons for discouraging counselor self-disclosure vary from breaking the unconscious projection (analytic) to just confusing clients because we change the subject from client to counselor.

But a recent article in the April 2014 Journal of Counseling Psychology, suggests that self-disclosure might actually help more than we think. Henretty, Currier, Berman, and Levitt completed a meta-analytic review of 53 studies examining counselor self-disclosure versus non disclosure. And “overall” they found that clients have favorable perceptions of disclosing counselors.

Why? It appears that when a client perceives great affinity/similarity with a counselor, they rate that counselor higher. Also, when a counselor reveals something difficult or painful (a vulnerability?), it makes them more human to their clients. Some examples of this negative valence might include, “when you said that, I felt really sad.” Or, “Let’s talk about your anxiety, having suffering with it some years ago, I suspect you…”

Not so fast!

So revealing similarities with clients and being human make clients feel more similar and possibly more understood. This makes sense. Client/Counselor matching seems to correlate with better outcomes. However, before counselors go talking about themselves they ought to consider a few things.

  1. Why am I doing this? Is what I have to say for them or really for me? (Too often, we speak to talk about self)
  2. Is what I say really going to keep my clients focused on themselves or distract them to my story?
  3. Am I sure that what I say will show similarity? The truth is that we *think* we have a similar story but the times we are sure we know what our clients are feeling we are most likely to stop listening and then miss the client.
  4. How often do I do it?

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Filed under christian psychology, Christianity, counseling, counseling science, Psychology, Uncategorized

Mapping urban domestic trauma


Our community of practice continues with a presentation by Michael Lyles, MD who presented on the problem of trauma in urban settings. [Watch his talk here] He pointed out how we often think about violence and the connection with trauma in international settings but fail to connect the two in American urban settings. We see angry young men and women who seem calloused and do not value life. Yet, often what is happening is that we have hypervigilant individuals who choose to manage their trauma reactions by being alert and on edge and ready to attack before being attacked. When you bring together poverty, violence and a traumatized population, you develop a chronically traumatized person, meeting most criteria for PTSD but never getting diagnosed.

One study mentioned a few statistics about violence prevalence. 55% of urban children have experienced sexual abuse (compare that to about 15% of US population); 39% have witnessed domestic violence. 27% experienced physical abuse.

To highlight the problem he pointed out a 2o12 Philly Magazine report on trauma in our city. Between 2001 and 2012, more than 18,000 people were shot. During that time some 3800 murders. He noted that suicide rates run about 20% and that number goes even higher when you include “academic suicide”–dropping out of life. In addition, he pointed to the connections between trauma and adrenal overload, hypertension, diabetes, and other physical illness. He also pointed to the scarring that takes place in the amygdala.

He noted a good book to consider: John Rich, MD (Drexel University) Wrong Place, Wrong Time: Trauma and Violence in Lives of Young Black Men.

He ended his presentation considering the role of “Chief Musician” as found in the Psalms. These are folks who listen to the story, don’t debate it, set it to words/music that are appropriate.

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