Category Archives: counseling science

The APA on identity therapy and conversion therapy


[Let me wade into something that tends to fire up lots of feelings and lead to controversy. And let me ask all to be civil. Civility seems to be the first thing that disappears when we discuss matters near and dear to our hearts. But let us be different and listen to each other rather than talk at or past each other. As James tells us, let us be quick to listen and slow to speak.]

In recent days media outlets have picked up the story of the American Psychological Association’s release of a report and declaration of their official stance on reparative or conversion therapies for individuals seeking to change their sexual orientation. You can read their press release and find their 100 page research review here. Being a member of the organization, knowing a few of the players in the research side of things, and knowing how easy it is to get caught up in debate and miss some of the finer points, I thought I might make a few comments that may not make it to the public eye.

1. Researchers are beginning to distinguish between sexual identity and orientation. This is a good thing. I dare say that the public lags far behind on this matter. Separating these two different aspects of sexuality allows for individuals to consider and interpret their sexual feelings in accord with their beliefs and NOT as how either the minority or majority of the world tells them to define themselves. This is akin to biracial people determining how they want to self-identify rather than be forced to say they are black or white.  Consider the following quote by one of the players (whom  I don’t know),

The distinction between orientation and identity (or attraction and identity as we often describe it here) is key, in my view, in order for us to understand the experience of those who say they have changed while at the same time experiencing same-sex attraction….I hope we can agree that sexual attraction patterns may be one thing while meaning making aspects may lead two people with the same attraction pattern to identity in disparate ways. (emphasis mine; from http://www.crosswalk.com/blogs/EWThrockmorton/11607271/)

If I understand the relationship between identity and orientation, it would seem that one forms identity from a variety of “data” which leads to an orientation. This is true outside of sexual identity. A number of factors come together for a person to see themself in a particular way (this may include biology, family, life experiences, key “flashbulb” moments, etc) and in cementing that particular identity they develop an orientation towards the world. SO, this may explain why trying to change orientation has little positive effect. Until the person reviews, explores, and reconsiders their identity (something that happens in nearly every counselee I’ve ever worked with) and begins to practice another way of seeing self, not much is going to change in attraction and orientation. Further, what may change is one’s sense of importance (and therefore meaning) of various parts of themself. When my clients explore their identity, it is rare they come to understand that they were completely mis-perceiving their feelings or experiences. Rather, they begin to see those experiences and feelings from a different vantage point.  

2. Change. What constitutes change is still up in the air. Ask a depressed person if they have changed even if they are only 50% less depressed and they will say likely say yes. Ask someone else and they may say “no,  I’m still depressed.” In the realm of sexual orientation, however, many see orientation as all/nothing. All same sex or all opposite sex orientation. Many will tell you this is just not their particular experience. So, IF someone wanted to change their direction of sexual attraction, what standard would they use to determine if change had taken place? Would 50% change be good? Who would decide this?

There is another analogous scenario in psychology. Should psychologists provide weight loss treatment? Given that an extremely large portion of those who lose weight gain it back and more, many have felt it unethical for a psychologist to offer weight loss therapies when they know that success is extremely low. So, how long do you need to keep the weight off to make a treatment worthwhile? How much do you need to lose? Who decides?

My gut feel is that the APA is not accurate in saying that there isn’t evidence that individuals can change. There is some evidence. Not complete change, but let us not deny what is there. Neither are they accurate about their reporting of harm. Harm reports are difficult to objectify. The best research will show you that some are harmed and some are not. Instead of assuming harm, let us evaluate more closely how some are harmed and how some are helped. Just as one might do with the weight loss scenario.  

3.  APA makes an attempt to make room for the work of helping one to find congruence between faith commitments and sexual feelings. This is also a good thing. Now, just how a psychologist does this matters greatly. Does he or she evangelize here? By that I mean (a) encourage a client to choose a different faith or change it to fit one’s sexual feelings, or (b) encourage a client to deny feelings and deny the suffering one might have by choosing not to act on a desire? My personal opininon is that option c (stay neutral) does not exist and is not possible. So, where does that leave us? Informing clients of our personal positions and yet not attempting to force individuals into our view of the situation. In other words, truthful but humble without being demanding.   

This is a divisive topic. Do individuals seeking to change their sexual orientation have the right to try to do so with the help of psychologists? Is change possible? Desirable? Damaging? And of course in trying to answer these questions you have a number of players on each side–each reading the “evidence” the way they would like to see it. You have those who have personal experiences in one direction or another. You have those with political or philosophical agendas. And, on top of that, you have media players interested in creating controversy where they can. I observed this last one myself where a local talk show host did his level best to create differences between two parties that weren’t disagreeing with each other as much he wanted them to.

So, what do you make of the difference between identity and orientation? Is it meaningful? How do we speak of change? Can we admit that it happens for some and not for others no matter our personal opinion whether change is good or not? And finally, can we avoid the “what if…” tendency in our conversations so that we deal with what is happening and not what we fear might happen?

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Filed under APA, Christianity, counseling science, ethics, homosexuality, Psychology, sexual identity, sexuality, Uncategorized

What should Christian counseling look like?


 I posted this little item for my last guest blog at www.christianpsych.orgfor the month of July. In it I mention “Christian Counseling: An Introduction” by Malony and Augsburger (2007).

And no, I don’t say what it should look like–merely a comment that we still need to figure out how we handle the faith/science dichotomy that we’ve been handed all these years.

Those who have been around wisecounsel for a while will remember I blogged through each chapter. If you are interested in seeing those posts, just use the search engine on this page to find posts mentioning Malony.

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Rwanda Day 8 (and 9)


Our final day in Rwanda! We fly out at 7:45 pm. This was a day packed right up to the last minute to get to the airport. Just like the Bishop to make sure we use every second! We had lunch with the Commission to prevent Genocide and the rector of KHI to present the beginnings of our proposal to them. We proposed a 3 pronged response to the needs we observed:

1. Information dispersal: (a) 1 page informational statements to educate adults and children about the symptoms of trauma, simple things to do if one witnesses another having a trauma reaction (grounding), and ways to remember the genocide without creating more trauma. This would be sponsored by the Commission; (b) basic workshops for psychiatric nurses, doctors, HIV workers, and pastors), (c) helping community care givers, and (d) developing better ways to run the memorial 100 days using their own new theme of Hope.
2. Support the sending of key Rwandans to the US to complete MA/PhD in Counseling so they can return as teachers
3. Developing a Masters degree counseling programfor KHI to run that is Christian based (at least a track of it would be.

Our proposal was met with enthusiasm!

We thought we were going to end the day with a bit of shopping. I got a bit of coffee and a few trinkets. However, on our way to the airport, we detoured to see the  Minister of Education. He had been unavailable earlier in the week and now wanted to meet us before we left. Though we should have been at the airport, we flew across the city to meet with him for 15 minutes. As an MD, he was able to give us some good guidance.

Got to the airport and through security (much laxer than the US). A large number came to see us off. Sadly, the Bishop was not allowed to get on the plane. Something wrong with his visa (he got back to the States where his family is staying til December two days later). Our plane left one hour late and very full of children (expats on the way to holiday in Europe). Going up the stairs to the plane I got what I hope not to be my last sniff of the cooking fires. After the doors closed the attendants went through the cabin spraying something to kill mosquitoes (repeated after our brief stop at Entebbe, Uganda). They said it wasn’t dangerous to us but I wonder just the same.

After a full day in Rwanda, we travelled to Belgium (10 hours), had a lay over of several hours (where I purchased some Belgian chocolate), and then another 8 hours to Newark. Sadly, I cannot sleep on planes so I enjoyed several “Bourne” movies. Our team was not able to sit together on the flight to the US and this was sad. As we got off the very full flight, we lost track of Leah. We went in the wrong customs line and she must have gotten through before us.

So, we end our trip with much to process, little time to do it, and no time to do it together. I have grown fond of my new acquaintances in Rwanda and teammates Leah and Josh. But, now it is time to sleep as 40 plus hours of being awake is taking its toll!

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Rwanda Day 7


Started the day as usual with some quiet meditative reading on the porch overlooking the lake and the distant sound of many children getting water on the other side (yelling Muzungu (white person) to get my attention). Diane read us this quote from John Fawcett’s “Christ’s Precious” (published by W. Milner in 1839, p. 82)

I am but a stranger in this world, wherever I may be situated, or however I may happen to be distinguished. And such, it is my privilege that I am so. [However] when I look not upon myself as a stranger and a pilgrim, when I am captivated with anything in this place of my exile, I forget myself, and act far beneath my character, as a candidate for an immortal crown.

Fitting. It is easy in the US to forget our “exile” status. We focus, instead, on our own status. But here in Africa, there is little to do but remember how fragile life is and how we must depend on God for our daily existence.

Today we met with Justin Remera, a psychiatric nurse at Gahini hospital. The hospital was built in 1920s. He is the head of mental health. He sees some 30 patients per day and has a caseload of 500 with PTSD. He sees lots of “epilepsy” and has documented some 350 new cases in the past 2 years. But they have normal EEGs, thus it is trauma related not brain injury. Justin told us that there is an openness to therapy here because they see the benefits.

Problems noted by him? no medications other than Haldol. Infrastructure needs. His office is the size of a small closet and he has had violent patients and no escape (his desk and chair are away from the door). Also, next to his office are rooms where patients were screaming (while we were there). Seems they may have been doing some minor surgery without anesthetic. He also mentioned problems with demobilizing military and their own trauma as well as his own burnout.

Next we went to Kigali and met with the the permanent secretary of Defense. One of the persons there talked about having 520 peer counselors in the military to deal with the problem of HIV. Nothing dealing with PTSD. They have NO chaplains in their military.

Next, we visited the National Council of Protestant Churches of Rwanda. Specioise told us that 52% of the country are protestant. They have a program to deal with gender based violence, to educate the the church about laws designed to protect women. Their booklet combines Rwandan laws and biblical passages.

For our final meeting, we visited with Jean Baptiste at World Vision. He is new to WV in Rwanda but not new to WV (previously in Mali). He is a tall man with much presence. He spoke very openly and honestly about the issues of NGOs in the country and the problem of lukewarm Christians. He suggested they were much more problematic than rank atheists or Muslims. He gave us some advice as how to work with both churches and government officials. Josephine, a woman Diane had worked in Rwanda on previous trips, was there and spoke of the continued need to train and care for Rwandan caregivers.

Our day ended in Gahini with a farewell dinner. Members of the church and community (the local mayor) attended a dinner at the Seeds of Peace retreat houses. The dinner was outside under a canopy. During dinner we watched the local youth perform traditional dances with drums, singing and costumes. The young women danced with wooden milk bottles on their heads. We learned their trick. A heavy stone in the bottom of the bottle helps it stay on their head. Ouch! The night ended with gifts from our hosts to us and a few words of thanks from us.

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Practicum Monday: Learning counseling skills from videos


Counseling education includes the usual academic exercises as well as hands-on practice. There is no substitute for the practice piece. But, videos can provide students with good illustrations of various counseling activities, styles, processes, etc.

But which videos to watch? The classics (masters in unstaged vignettes)? Training videos (usually staged with actors)? One of the first videos I ever saw was of Salvador Minuchin at the Child Guidance Clinic. There he was in a room, unashamedly smoking a cigarette, and manipulating (in the best sense of the word!) a family with an eating disordered girl. I was taken with his larger-than-life presence in the room and his ability to be irreverent. Needless to say, I could never emulate him. In fact this video that I loved made me wonder if I had what it took to be a therapist.

Last week and this week the practicum class has been viewing Mark McMinn’s christian counseling video produced by APA. One ought not expect the APA to be up on Christian counseling (and its many varieties) but this video is useful for many reasons. First, Mark illustrates a relational style of cognitive therapy and so what he does in this first session is usable in almost any method of counseling. Second, the counselee is not an actress. She is a real person with real concerns (which students relate well to!). Third, Mark doesn’t merely focus on her problems but does a great job highlighting her strengths and resources. Finally, Mark isn’t a big personality–meaning we can all see ourselves doing what he does.

We use mock vignettes as well. I participated in making some mock counseling videos at Regent in Virginia Beach. Mock sessions tend to focus on discrete skills and are better in 2-3 minute vignettes rather than full sessions, and for beginning students rather than those about to graduate.

If you ever took a counseling class that used videos, what counseling videos did you watch and were they helpful?

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Physiology Phriday: Abuse alters genes?


Check out the following link for some very interesting research on how abuse alters the NR3C1 gene in the hippocampus which functions to limit our stress responses. It appears that when the gene is altered, it inhibits natural control of stress responses thereby leaving the abuse victim on high levels of alert.

This may give new meaning to “the sins of the fathers passed on to the third generation” comment in Scripture.

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Rwanda!


My on again off again trip is now on. I have tickets and yesterday I got my shots! Our small group of psychologists (4) will be leaving on June 22 and returning July 1. We will be going as the guests of the Right Rev. Alexis Bilindabagbo, Anglican Bishop of the Gahini diocese. You can learn a bit about him here.

We will be meeting with pastors, government officials, victims, and perpetrators of the 1994 genocide. Our goal is to immerse ourselves into the culture to learn how best to provide trauma training and counseling education at the graduate level for pastors and key leaders of the church right in Rwanda. While we know quite a bit about trauma and counseling training, we wish to avoid the mistakes of assuming we know best what this particular people need and what works within their cultural milieu.

I hope to be able to give you more details as the time approaches and to blog from Rwanda when I have Internet access.

FYI, each of us are paying our own way. Some donors at Biblical Seminary gave generously to underwrite a small portion of the trip. Further, the American Association of Christian Counselors is helping to sponsor this trip. So, if someone wants to give to the trip, I’m sure we can find a way to provide you a receipt for tax purposes :). Email me at pmonroe[at] biblical [dot]com and we’ll figure it out.

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Filed under biblical counseling, christian counseling, christian psychology, counseling science, counseling skills, Post-Traumatic Stress Disorder, Rwanda, teaching counseling, Uncategorized

Practicum Monday: counseling mistakes?


I’d like to compile a list of mistakes mostly likely to be made by novicecounselors. In the past I’ve written on some of the mistakes or foolish behavior of counselors and some of you have helped contribute stories like the counselor who fell asleep during the session, the counselor who ate a meal, who tried to set the counselee up with a son or daughter, the counselor who took phone calls, etc. Most of these mistakes wouldn’t be made by the typical counselor, even one who had never counseled before.

So, what are the most common mistakes of the novice counselor? Not sure, here are some I’ve observed:

1. Failing to collect enough data during the first sessionto assess matters of suicidality or mental status. Novice counselors tend to either drill too deep on one topic (and so miss other important matters) or stay on the surface and fail to ask questions they think might embarrass the client

2. Promising too much. We want the client to have hope and we hope they don’t see us as novice, so we promise the world. Such temptations lead sometimes to offering our phone number to call at all hours, to agreeing to meet outside of sessions, too allowing sessions to go beyond the planned limit.

3. Encouraging. Beginning Christian counselors sometimes fail to let the counselee sit with their pain. Instead, they trot out verses to comfort and encourage. Often, these passages fall flat without their intended result.  

4. Writing too much. Progress notes may look like novellas. When you don’t know what is important, everything is documented.

5. Going along with the parents. Novice counselors often seen kids and their parents. It is easy to become railroaded into allowing the parents to use the session to gang up on the kids. Novice counselors have a hard time managing the parents and the kids in the same session.

What mistakes did you make? Did you experience at the hands of a novice?

When I started, I hated the question about my age (I was 24 but looked younger). I tried all sorts of creative ways to illustrate my experience and to be vague about my actual age. I’m sure I never convinced anyone. They stayed because they didn’t want to start over. I should have just said (nicely), “your right, I’m young. We can either find you another client now or we can try the following intervention and if you don’t like what I’m doing, we can find you someone else then. What would you like to do?”

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Physiology Phriday: Dieting starves your brain?


I heard a psychiatrist recently tell her depressed client that she should not go on a diet to lose weight. The client was confused. She thought that losing weight would help her with her self-esteem. She had not been exercising and had put on 15 pounds over the past 3 years. So, she asked her doctor why not. This was the explanation (paraphrased):

Exercise does provide a natural antidepressant and so I heartily encourage you to start an exercise program. However, many diets consist of decreasing foods rich in carbohydrates. Getting more protein is good but your brain needs glucose to produce neurotransmitters (e.g., serotonin) and foods rich in carbs are more easily turned into glucose. When you starve your body of glucose, your brain is the first place that starves.

Maybe this explains a bit of yo-yo dieting. The person is feeling poorly about weight, reduces foods that provide simple sugars in order to lose weight, starves their brain of serotonin (thereby creating a greater feeling of depression), and then caves to a binge in order to feel better. 

Don’t know if this supposition is true, but it might be important for those on antidepressants to make sure that they are keeping a balanced diet and exercising frequently.

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Practicum Monday: The green counselor


No one wants to be a green counselor. “Hi, I’m an intern and you are my first counselee.” Who wants to say that? Also, no one wants to entrust their most significant problems to a green counselor. “I see you haven’t any experience, so let me expose my most tender parts to you and see what you can do.”

Houston, we have a problem.

Every counselor has to get their start somewhere just as every surgeon cuts a live human being for the first time. Young single folk counsel conflict-riddled married individuals or offer parenting advice while not yet a parent. Individuals with no history of addictions sit with folks in their 10th inpatient stay in a treatment center.

Is there any way this goes well? YES! Let me tell you why going to an intern with a good supervisor is good, even sometimes better than getting a seasoned counselor by them self.

1. You get two heads instead of one. Even if the supervisor is not in the room, you get a young, determined-to-do-it-right counselor and a supervisor on his or her toes (who loves to teach and wants nothing bad to happen) thinking about you and planning carefully. They talk about the intricacies of your situation at great depth, they consider the options, and carefully review the outcome. If you only have a seasoned counselor, they may perform better (relationship wise) in sessions, but they probably aren’t thinking as critically as they could. I can attest that I am thinking much more carefully about clients during supervision (as supervisee or supervisor) than when I am not there.

2. Book knowledge actually does help. The further a person gets away from textbooks, articles, etc. the more they rely on old knowledge. Teaching counselors and green counselors are fresh from their reading and thinking about key problems. For example, the student having just completed an ethics course will be more sensitive to boundary violations than the one who has grown accustomed to thinking they will always do the right thing. Sometimes resident doctors are more aware of subtle health issues because they are running down every article to learn and running down every symptom.  

Now surely a seasoned counselor provides many good benefits. Working with an intern or medical resident often takes longer to get to a good outcome. They just aren’t as fluid. They are still learning–learning on you. A seasoned counselor will make fewer mistakes. But if they are a humble learner, the green counselor will catch on quickly and repair any damage. Whether green or seasoned, the most dangerous character problem in counselors is arrogance and listening only to him or herself.

But the intern can manage some of this by dealing with his or her own anxiety. Confidence does actually help. It enables you to think clearly, consider options, be honest about your own weaknesses, offer the client help in finding someone else if you aren’t the right fit. It is like baseball. If you are afraid of getting hit, you’ll likely not catch or hit the ball. If you have confidence, you’ve got a better shot of catching it and/or at least making contact when hitting.

 

All that said, I have to tell you a story about my “first time.” I had just completed a 13 week internship where I counseled 2 separate clients with my supervisor in session and by myself. I could be given good grades for trying hard, but probably was too impatient to get to the good stuff of people’s problems–the stuff of repentance. In a moment of insanity my supervisor set me up as a staff counselor in a satellite center. On my first night I saw a person who said the Lord had told her I was the counselor for her but now was rethinking she had misheard. How could an 18 year old be right for her (ahem, I was all of 24!)? After trying to find out the issues, she said if I couldn’t figure it out, she definitely had misheard God. The next client was a couple. In the course of the session, the husband actually stood up and started choking his wife. I stood up–not knowing what else to do–and he fled the building.

There’s nothing like baptism by fire 🙂

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