Category Archives: counseling science

December 8, 2009 · 1:54 pm

End of semester thoughts


Looking at a stack of papers I need to grade and yet not feeling the energy to do so. Late night classes take more out of me than I care to admit. My physiology class ended with student presentations and a look at bipolar disorder. As we concluded the class, I asked them to remember that,

  1. Even with all the advances in neuroscience, we must humbly admit we still know little how we are fearfully and wonderfully made.
  2. It is good for counselors to keep learning about the body and at the same time hold what they know lightly. Tomorrow may bring evidence to the contrary
  3. Yet, what we know about the body can be helpful. We ought not to look down upon our ignorance but remember that doctors do not always explain or walk with patients
  4. There are great medical interventions available, but (and that but shouldn’t diminish what I said before it),
  5. Over and over we saw that the basics (maintaining balance in life, self-care, mindfulness) are so important to health, perspective, etc. No, they aren’t magic interventions. Yes, they pay-off over time rather than immediately.

On this last point I am pondering a bit and so let me be hyperbolic. Most people who come to see me for paid counseling come because they think (naively) I have some expertise that will shed light on their situation and a solution to their problems. They want me to do something. Why else pay that kind of money? And yet much of what I have to offer isn’t rocket science. Beyond a few fun techniques, what I have to offer is a listening ear, a willingness to walk with the other person in their travail, and encouragement to keep going back to the basics. Most people like the first two but balk at the last one. Why do we balk at going back to the basics? Two reasons: (1) we want something that will fix the problem NOW, and (2) we’ve tried the basics and they didn’t seem to work (see reason 1).

Examples of what I mean.

  • If you are a parent and you go to a counselor to deal with your young child’s behavior problem. More than likely, you will get some counselor telling you to use some reinforcement strategies. And what do many parents say? “I tried that and it didn’t work.” Chances are they did try it and either they didn’t keep at it or they didn’t realize they were doing something that reinforced the wrong thing, or they had a misguided view of what success should look like
  • A couple is struggling with fighting. They go to the counselor who encourages them to return to the basics of respectful talk. Usually, they will feel like they have already tried it–and it didn’t work. Chances are… You get the picture.

In physiology, we see that care for the body includes mindful meditation (My friend and former professor says a substitute word would be “watchfulness”) on the world as God sees it, developing and maintaining good circadian rhythms, watching food intake, exercise, maintaining healthy relationships and social supports. In every mental illness, these things are shown to decrease the severity of symptoms and delay relapse.

Here’s the problem: we forget the basics and because they don’t give immediate results, we go searching for other fast-acting mechanisms. For example, I want to feel safe. Instead of engaging in centering prayer over the long haul, I fall prey to the temptation to act in such a way to avoid all possible danger–thereby increasing my fears of danger.

If I don’t exercise (and I don’t much) I rarely get immediate feedback that my body is falling apart. If I don’t eat right, I don’t immediately gain 10 pounds. If I don’t pray, I don’t immediately get embittered. So, I assume that these basics aren’t all that important. Or, I know they are important but since they don’t pay off now, I don’t do them. I only do what demands I do it to avoid a crisis.

How do we stay on track with the basics? We need another person(s) willing to keep us on a short leash. As a kid I ran because I had a friend who was going to wonder where I was. As a doctoral student, I played basketball at 6 am because my peers would  ask me where I was. I lost some weight a couple of years ago because my wife and I worked together. Notice that the social accountability is a key facet to help us build the disciplines long enough to see that the pay off is more than can be delivered by an exciting new technique.

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December 1, 2009 · 12:04 pm

Chronic pain and the Christian faith


Last night’s Counseling & Physiology class covered the topic of chronic pain. There are a number of syndromes and disorders that cluster around pain as the presenting problem: Chronic Fatigue, Fibromyalgia, Irritable Bowel Syndrome, Rheumatoid Arthritis, Osteoarthritis, back pain, etc. Depending on which research study you read, some 9-17% of the population struggles with some form of chronic pain.

While these various forms of pain are quite different, there are some commonalities. Chronic and diffuse pain sufferers frequently experience some form of inflammation, fatigue, sleep disruption, negative mood, and poor memory (its hard to pay attention to new information when you are weighed down by pain). We don’t really know what causes what but we do know that these symptoms form a vicious cycle. If you don’t get restorative sleep, you experience more fatigue, you are more prone to negative thought patterns, your pain levels go up, memory goes down…and thus you don’t sleep well the next night, and so on. Researchers describe this vicious cycle in terms of “allostatic load”–the deleterious effects of chronic stress hormones without restorative sleep.

Because of the diffuse nature of pain (vs. focal) and the lack of obvious objective evidence of that pain (a big red spot, a swollen limb, etc.), chronic pain sufferers and their families struggle to understand whether or not the pain is real and what they are truly capable of doing. How do you measure pain levels? It’s pretty subjective! Thus, it encourages more “I should be able to…” thinking in all parties. Those not suffering chronic pain do more damage by implying that the person is just looking for attention, is just being lazy. Those suffering pain who either deny the pain and try to do too much or refuse to engage the world and withdraw from it do damage to themselves–real physical damage.

As with all physiological problems, one’s mood, one’s perceptions, one’s focus, one’s stress levels impact severity of the problem. While chronic pain is not just in one’s head, how one responds to chronic pain may help alleviate or elevate the pain sensations. Ironically, many pain sufferers resist counseling because they fear that others will believe that their symptoms are all in their head. Those who refuse to acknowledge the psychological factors in pain sensation and management miss out on important means to cope with the pain and to lower pain perceptions.

Chronic pain sufferers must accept the need to adjust their lifestyle to accommodate more rest. They must fight to get the best restorative sleep possible. These are probably their primary practical responses–even above medical treatments (and I’m not knocking medical treatments nor saying that just getting sleep will solve the problem).

One of the biggest challenges for pain sufferers is the matter of hope and faith. When we suffer problems, we often hope they will go away. And when they do not, or only get marginally better, it is easy to slide into despair. Despair usually is the result of things not going the way we hoped or expected they would. Part of dealing with chronic pain is grieving what is lost in order to accept–even enjoy–what strength and health we do have. Without hope, we lose what self-efficacy we once had, thus not doing the basic care-taking activities within our grasp. Interestingly, one of the clearest signs of this struggle is the massive dropouts in pain management research. Frequently, dropouts number about 50% in these studies. This means that before a study gets too far along many are dropping out because they assume the new treatment isn’t going work.

Faith is not that things will go my way right now but that God is in control, cares/protects me, and is working for my ultimate redemption–even when the opposite seems to be true. Faith is acting in a manner consistent with said assumptions even while grieving over real losses. Such faith enables us to be mindful of our thoughts so that we do not practice into beliefs counter to what we have come to know as true.

The chronic pain sufferer who grieves well (asks God for relief, stays in community with others, seeks relief through human means yet has an attitude of waiting on the Lord, and yet still willing to explore and confront hidden sin in self) begins to see that in the midst of the pain, God is there and providing momentary help. Such a person need not act as if the pain were nothing but will look for and rejoice in 5% improvement, 10% more comfort, etc, rather than demanding complete healing as the determinant as to whether God is present with them in their distress.

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November 11, 2009 · 5:59 am

Stress & Christian mindfulness, part 2


In the last post I reviewed some simple definitions of mindfulness, including some of the Buddhist ideas behind a version of mindfulness. In this post I want to consider how mindfulness, when reconsidered in the light of Christian thought, can be a valuable part of counseling practice.

A thought about mindfulness and the brain

Let me detour to one more thought about biology and mindfulness. What happens in the brain when a person is practicing mindfulness? Thought and feeling patterns result in neural activity in the brain (or is it the other way around?). Repeated neural activity creates stronger connections between neurons (increased synaptic activity and denser connections with neurons in the same neighborhood. Repeated activity leads to greater blood flow and activation in particular regions of the brain. Neuroscientists call this neuroplasticity.

Thus affective and cognitive patterns can indeed change your brain. Think about this. What patterns of thought do you engage in on a repetitive basis? Do you have a habit of fantasizing? Mulling over bitter or jealous thoughts? While some of these may come naturally to you, what you do with them may actually change or strengthen neural connections in the brain–for better or for worse.

Is mindfulness healthy or relativistic?

Mindfulness, no matter whether you take a religious, consciousness, or relational approach to it, includes the stepping back from shoulds, oughts, and other judgments. One might think that this would be dangerous for Christians. Within Christianity, there are rights and wrongs, truth and lie, righteousness and unrighteousness. The Bible is, among other things, the single guide for Christians to determine how to live for God. SO, it begs the question whether Christians should be wary of anything that seems to let go of shoulds and oughts?

Another view of shoulds and oughts

In my experience, those suffering from anxiety and depression suffer from a disorder of judgments. They are flooded by shoulds and oughts. Their self-talk does not seem to come from the Lord but are already laced with prejudice. “You should have been more vigilant against danger AND you weren’t. You’re a failure.” “You shouldn’t be rebellious BUT you are always a screw-up.” “I shouldn’t have to suffer this way AND God must not care for me.” Notice that most of these forms of judgment are careful consideration of the facts and experiences but well-formed opinions that may be based on only a smidgen of the actual events in their present circumstances.  Notice that these forms of ruminative thinking come in disguise as careful, logical thinking. They are not. What they are narratives–well-practiced narratives–that have an already formed conclusion that we repeat regardless of the actual facts of our lives.

Mindfulness, then, is stepping back from these narratives. Mindfulness is a practiced discipline of just noticing and describing events so as to process them more carefully instead of automatically repeated a script or mantra. Mindfulness provides the opportunity to discover “what is” rather than compound suffering by focusing on what we just assume. Consider Dan Siegel (The Mindful Brain, p. 77)

When the mind grasps onto preconceived ideas it creates a tension within the mind between what is and what “should be.” This tension creates stress and leads to suffering.”

While I’m sure I would vigorously disagree with Siegel on what a preconceived idea is, on what can be healthy “should be’s”, and much more, he has a point worth considering. Have you ever engaged in a fantasy conflictual conversation with someone you are about to meet. You play out yourself winning, being mistreated, standing up for what is right, and so on. Notice how such conversations aren’t useful. They only increase your level of stress because your brain responds to the inner drama as if it were really happening, when it has yet to happen. In this way, Siegel is right. We create tension that leads to suffering.

Using mindfulness in Christian Counseling

I’m running out of room here and won’t be able to do justice, in this post, to the most practical part of mindfulness. [Isn’t that just like us academics. We spend all our time pointing out problems but we never solve anything!]. Mindful practice may include time practicing being present in one’s surroundings. The counselor may encourage clients to take in their surroundings. While many thoughts may race through the brain, the mindful person may choose to not follow them but “drink in” the creation beauty around them–things growing, art, or anything that is a delight to the senses. This form of discipline must be practiced in de-stressed times so that it will be available during a crisis–just like a basketball player practices free-throws over and over so as to make the shot when there is only 1 second left on the clock.

Such work is the work of taking every thought captive. and resting (a la Psalms 131) without grasping after things “too wonderful” for us.

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November 10, 2009 · 5:25 am

Stress & Christian mindfulness, part 1


I’ve written about mindfulness in the past and based on numbers of folks coming to my blog looking for information about Christianity and mindfulness, I thought I might write just a bit more here. My intention is to write in two parts. Part 1 will cover some basics about stress and the idea of mindfulness. Part 2 will explore how Christian counselors might think critically about the topic and consider its use in their practice.

If this is not a term you are familiar with, you may wish to explore the goodly number of books in your local store discussing the topic. Why the interest? There is clear evidence that mindfulness has positive health benefits by reducing our stress responses to the chaos in our lives. Mindful individuals appear to have greater amounts of patience, able to avoid impulsive responses to stress, process rather than react to emotions, have greater capacities to be curious, open, accepting, and loving.

Stress and your body

It is well-known that small amounts of stress activate the body but larger amounts make us sick. But, did you know that the same biological response system that fights viral intruders activates with high levels of stress? Your immune system works in this manner (okay, my simplistic rendition): Your body senses an intruder. The microphages that come in contact with a virus act like little ants sending messages to their buddies to come and defend the colony. One of the messenger chemicals is interleukin-1. Your resulting fever is evidence that the body is working. But to work this hard, other bodily systems get such down. Your stomach and intestines stop or slow down their contractions, you lose your appetite, sexual drive, you have difficulty thinking clearly. These sick symptoms are more likely the result of your body’s defense mode than the virus that has intruded.

The SAME thing happens with high stress. Your pleasures centers shut down to conserve energy. Such activity decreases clarity of thought and pleasure and thus increases experiences of depression and anxiety. See how a vicious cycle of stress/distress leads to greater symptoms of depression/anxiety–a vicious cycle!

What is mindfulness?

Well, it depends upon who you ask. Definitions range from Buddhist forms of meditation, to being present in the moment, to being aware, to centering prayer, to having a nonjudgmental stance. So, for some it is a religious activity. For others it is a form of consciousness. And still others describe it as a relational “attunement” (e.g., a mother’s awareness of the meaning of her infant’s needs even before the cry; a service dog who picks up subtle clues that it’s owner is about to have a seizure). The truth is that each one of these fragments of definitions captures a little bit of what one observes in someone who is able to, in the moment, stand back from the chaos in their life and not react to it. Such people seem to be alert (not dissociated) to the moment, are being in the moment rather than reacting and doing something, are more likely to be describing events, feelings, perceptions, etc. rather than judging them.

In Dan Siegel’s The Mindful Brain (W.W. Norton, 2007), he lists a number of component parts to mindfulness:

  • Intention (rather than reactive), attention (aware), attitude (open, curious, non-judgmental)
  • Nonreactive to inner experiences (I notice my inner experience, but I am not merely my inner experience)
  • Observation, noticing, describing, labeling
  • Attending to sensations; acting with awareness
  • Either focused attention on the present or merely noticing all that passes through the mind

What about the Buddhist part?

There are two terms you’ll find when reading up on Buddhist meditation: vipassana (insight, clear thinking), samatha (concentration or tranquility). I’m not a Buddhist scholar but I do believe I’m in the ballpark about these next bullet points:

  • The goal is to get beyond (ab0ve) the experience of good and evil; of pleasure and pain to a higher level of experience
  • The goal is personal transformation and character development; awareness leading to the drying up of demands (desires?)

It is important to point out that Buddhism is not the only religion that espouses meditational practices. Christianity, from the beginning of the Church, has promoted the concept of meditation, albeit in significantly different form and purpose.

How ought we Christians to think about it?

Some might suggest that engaging in practices that encourage openness, neutrality (which is a misrepresentation of Buddhist practices) open oneself up to the occult. Others might be suspicious of hidden, subtle belief systems (personal transformation vs. Spirit-led transformation). These are legitimate questions. And yet I contend that we do not need to reject these concerns to acknowledge that God has given all humans the capacity to observe and grasp concepts that are true and right–even if we might staunchly disagree with their personal philosophies. This does not mean we take a concept into our life and practices without considerable critical thinking, but it does mean we are open to learning something that our own tradition has lost, ignored, or deemed unnecessary to healthy living.  I’ll attempt to do just that in the next post.

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October 26, 2009 · 9:13 am

PTSD and surgery mortality rates


Today I begin “Counseling & Physiology”, a crash course (6 weeks!) for my students to explore the mind/body connections and how counselors pay attention to the body even if not their primary focus.

Last week I saw this news item on my Medscape.com feed: “Veterans with PTSD twice as likely to die after surgery”

Here are some of the highlights from a research study done at the San Francisco VA and UC San Francisco:

  1. 10 year retrospective study of 1792 vets (ending in 2008). 7.8% had established dx of PTSD. On average vets with PTSD were 7 years younger than those without the diagnosis (you would think then, younger = higher survival rates). Surgeries studied were elective surgeries.
  2. 25% increase in mortality 1 year post surgery for vets with PTSD, even if surgery happens years after getting out of the service
  3. Mortality rates for these vets were higher than those with Diabetes
  4. PTSD is an independent risk factor for mortality
  5. DX of PTSD was associated with increased cardiac issues (may point to why the mortality rates are higher

Sobering research if you ask me. Let us not become lazy in our thinking. Emotional problems such as severe depression and anxiety (which PTSD tends to bring both together) have a substantial impact on the entire person, affecting every part of the person from cells to spirit. Neither let us believe that if the cells are involved in such a disorder that there is nothing that counselors can do. Clients can learn to manage and even defeat some of the symptoms of PTSD by taking control of their thought life.

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September 21, 2009 · 12:02 pm

AACC revisited


Not much time today for any significant posting on psychological assessment and/or the AACC world conference I’ve just returned from. 5 Days away from home leaves way too much other stuff to do!

However, here’s one small reaction question I pondered on the plane ride home: Which is better: a conference where I agree with most speakers, OR, one where there is wide diversity and quality of work (and some work that is downright bogus)?

I attend two different counseling conferences. One really scrutinizes speakers and makes sure they are in agreement with the organizing agency. The other seems to let any counselor teach if they can write a decent proposal and outcomes statement. The first one protects from outrageous presentations but most likely limits new voices and/or progressive ideas. The second one gives many ideas an opportunity but the listener bears the responsibility to figure out whether the speaker has any basis for their opinion.

Now, I don’t know this for sure, but I’m guessing the first one suffers from highly critical followers who make sure that no speaker ventures too far from home. And I also guessing that the second group has a large following that does not discern truth from simplistic pop psychology.

So, which is better? The first one rarely ruffles my feathers. The second one has speakers that make me want to scream but also  exposes me to new ideas and research.

As I said, I’m not sure which I prefer. Both tempt me to have arrogant thoughts…which reveals more about me I suppose.

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September 18, 2009 · 5:13 am

Engaging Biblical Texts in Trauma Therapy


Today I present my 1 hour CE training at the AACC conference. In this presentation I briefly review (a) complex PTSD and its typical symptom presentation, (b) material from my recently published work on best practices for using Scripture in counseling. Then I consider the particular application to therapy with trauma survivors. The goal is not get individuals to believe the truth but to experience it via the interpersonal relationship of therapy.

If you are interested in more, see the pptx slides I have up on my page “Articles, Slides, Etc.” (# 15 on the list).

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September 14, 2009 · 11:17 am

Psych assessment and the new semester


And so we begin the new semester today. I’m teaching Psychological Assessment tonight to our advanced professional counseling students (recent grads looking to complete licensure courses). Psych assessment covers a wide variety of formal and informal assessment techniques for counselors. Among them are the use and interpretation of psychological tests. It is my experience that most people with superficial exposure to psychological tests have one of two responses

1. Inordinate value of testing and what it can do

2. Inordinate suspicion of testing and what it can do

Most of these responses come from quick reactions to some personal exposure to tests. Those who give too much value to tests may have taken a test and had it “nail” them. For instance, someone takes the Myers-Briggs (MBTI), finds out they are an INTJ and that it explains why they nearly lose their mind around their boss who is an ESFP. Those who are suspicious of testing often have had a bad experience of testing (test mis-use, a negative evaluation or they have had a course that exposes them to the weaknesses of some test construction and research.

The truth is that tests do have both limits (some way more than others) and value. Never underestimate the power to abuse a test or the data that comes from one. A relative of mine once was turned down from a job because some wacko decided he had repressed issues from a simple drawing.

However, those who say that they can get all they need from a clinical interview fail to recognize the value of learning how one functions in comparison to a large sample of peers. And several data points like that can really flesh out a personality or learning profile.

I’d be curious to hear reader’s experiences with testing (their administration and/or interpretation). Did you have a positive or negative experience and why?

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September 9, 2009 · 11:45 am

ICAT as a new therapy model?


Take any psychotherapies class and you will get your usual dose of the classic models built on grand schemes attempting to explain the meaning of life and human behavior: psychoanalysis (and later versions of object relations), humanist/client-centered, behaviorism, cognitive (and later combinations of the two), and various forms of family systems models. Students in advanced courses may learn a bit about various combinations of these models but usually such classes leave learners picking and choosing a theoretical home–or becoming eclectic by trying to take parts of each model.

But nowadays, models are built not to explain the meaning of life but to show “what works” in therapy. Sometimes model builders stumble onto a technique and then attempt to provide evidence how and why such interventions work. For example, I would classify Les Greenberg’s EFT, Francine Shapiro’s EMDR and Marsha Linehan’s DBT (though DBT has much more robust evidence supporting and has validity whereas Shapiro’s techniques have reliability but lack validity in my mind) as these kinds of models.

Now comes another model to try to capitalize on a number of proven techniques: Integrative Cognitive Affective Therapy. Right now, it seems to be used and studied for the treatment of Bulimia. But, I expect to see it grow over the years to any number of problems (just as DBT is not just used for Borderline Personality Disorder anymore).

What is ICAT? It is an attempt to improve upon the weaknesses of Cognitive-Behavioral Therapy (CBT) while maintaining the robust empirical power of the model. What are CBT’s weaknesses? Stephen Wonderlich says they are “1) a limited view of emotional responding; 2) inadequate consideration of interpersonal factors; 3) insufficient attention to therapist-client relationship; and 4) overemphasis on conscious-controlled cognitive processing.”*

ICAT attempts to improve on CBT by paying very careful attention to emotion, mindfulness, and other aspects of a person’s experience of self and world. Again, Wonderlich describes ICAT as “a collection of interventions drawn from an array of cognitive behavioral and emotion-focused therapies and based on a testable theoretical model…”

ICAT for Bulimia exists in a 21 session form as of now. It focuses on experiencing and identifying key emotions involved in the Bulimic process, making initial changes to eating habits, developing alternative coping mechanisms to deal with distressing emotions, dealing properly with desires, practicing self-regulation and challenging discrepancies between ideal and actual self. What makes it different from CBT is its focus on emotion and collaborative work between patient and counselor.

In many ways, it seems to adapt other model’s focus on validation, affect, mindfulness, and distress tolerance. Over and over it appears that understanding and addressing subtle emotional interpretations of life are the building blocks to changing pathological behaviors.This is not the first attempt to build an affective version of CBT. Some attempted to talk about constructivist CBT but that did not take hold. I suspect this model has a better chance at catching on.

*Wonderlich, Stephen (Summer, 2009). “An introduction to Integrative Cognitive Affective Therapy for Bulimia Nervosa” Perspectives: A Professional Journal of the Renfrew Center Foundation, pp 1-5.

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August 31, 2009 · 5:44 am

Disorders of Extreme Stress Not Otherwise Specified (DESNOS)


I recently scanned a book, Healing Trauma(published by Norton in 2003), and ran across a new name (for me) for the problem of complex PTSD–Disorders of Extreme Stress NOS or DESNOS.  Because many christian counselors are only marginally aware of the research on complex PTSD I’ve decided to give a brief summary here.

The following symptom presentation may be found in those with prolonged and severe personal abuse (and often starting at an early age): 

  1. alterations in the regulation of affective impulses, including difficulty with modulation of anger and being self-destructive,
  2. alterations in attention and consciousness, leading to amnesias and dissociative and depersonalization episodes,
  3. alterations in self perception, such as a chronic sense of guilt and responsibility, and chronically feeling ashamed,
  4. alterations in relationships with others, such as not being able to trust and not being able to feel intimate with people,
  5. somatizating the problem: feeling symptoms on a somatic level when medical explanations can’t be found, and
  6. alterations in systems of meaning (loss of meaning or distorted beliefs)

Some folks include a 7th characteristic: (alterations of perceptions of perpetrator(s).

Check out the this paper(44 pages long) written on the assessment and treatment of DESNOS.  Though written for psychiatrists, I found the language easy to understand. The authors do a nice job of helping counselors differentiate between Borderline Personality Disorder and DESNOS. While they recognize significant overlap between the two constellation of symptoms, DESNOS folks tend to experience less relational push/pull (less manipulative behavior) and more push behaviors coupled with more intense sadness and grief.

Counseling work falls (per this paper) into 3 categories: stabilization, trauma processing, and re-integration into their world.

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