Category Archives: counseling science

April 13, 2009 · 11:11 am

Practicum Monday: The secret to a good experience


A new semester begins today and I pick up teaching again after a sabbatical. It feels good to get back in the saddle again. Practicum and Professional Orientation starts today and so my students begin their first fieldwork assignments around the region. If they are at all like I was when I first began counseling work, they will be nervous and worried about doing well and doing the right thing. But I have a secret for them. This nervousness will actually help them do well and, for the most part, mistakes in counseling often turn out to be good for both counselee and client. Counseling is more like art and less like surgery. And since counseling is relational art, the opportunity to “do over” actually provides wonderful realism to the healing.

However, there is another secret to good practicum experiences: good supervision. Good supervision makes or breaks an experience. And good supervision requires the active participation of both supervisor and supervisee.

The Supervisor: Supervisors come with a variety of skills, personality, and style. Some are quite directive and keep a tight rein on your practice attempts. Others are very hands-off, wanting you to try stuff yourself and so they respond to your questions and concerns rather than seek you out. Others are very process oriented and focus on your experience more than what you actually do.

The Supervisee: Some students come with hundreds of questions (some out of curiosity but most out of anxiety). Others want very specific directions and then try to act them out as was given. Others still want to talk about their own experiences and have a harder time recalling client responses.

Practicum students do well to prepare for supervision:

1. Before you begin, have some discussion about how the supervisor likes supervision to go? Do they have an idea about how they want you to function in it? Do they want it to happen just after your counseling experiences for the week so you can debrief? Just before so you can best remember what was decided?

2. When you bring your cases to supervision, come prepared to concisely summarize history, presenting problems, attempts to solve prior to counseling, family systems, current crises if present, work thus far in your counseling. Also, come prepared with a specific objective question you would  like to have answered. The more specific your question, the more likely you will come away with an answer.

3. Be sure to ask the supervisor to help you refine your hypotheses. This is a good opportunity to consider alternative ideas.

4. Schedule time when the supervisor can either watch you live or listen to a taping. There is NO better supervision possible. Scary? Yes. But essential if you do intend to become a good counselor

5. Be willing to ask (nicely) the why question when your supervisor gives you directives that don’t make sense. More than doing the right thing, you want to understand the critical thinking behind the right response.

6. Use your relationship with the supervisor to grow as a professional. This is one of your future colleagues. If there are conflicts between you, practice the good art of resolution. Don’t avoid and don’t attack.

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April 10, 2009 · 5:49 am

Psychiatric vs. Psychological evaluations: What is the difference?


In place of my usual physiology Phriday post, I give you this…

“I think I need a psychiatric evaluation? Can you test me?” These are some of the questions I get from time to time. And they reveal an ongoing confusion about testings, assessment, evaluations, the world of psychiatry, psychology, and neurology. Interestingly, if you type in “psychiatric evaluation” into wikipedia, you actually get redirected to an entry on psychological evaluations and testing. So, let me try to differentiate a bit here:

What is a psychiatric evaluation? It is done by a psychiatrist who is a physician with special psychiatry training (courses and residencies). This evaluation is comprehensive but medical in nature. Expect the person to ask for your physical, behavioral, and cognitive histories, order blood tests or other medical exams, evaluate (by observation and interview) your mood, your reality testing, and mental status etc. Ultimately, after an extensive (and usually expensive) interview, the doctor will arrive at a psychiatric diagnosis (if appropriate) and may also recommend medicines to help with the problem–which they can prescribe. A few also provide ongoing talk therapy but most do not. Rather, they recommend you find a therapist for that part. They will follow up with med checks as needed to titrate or refine your medicines. When a person has a very difficult, complex, or lengthy history of mental health, or, when the person is needing a diagnosis for legal reasons, a psychiatrist is a good choice. They are usually gifted at extracting subtle physical and behavioral matters that may help correctly pinpoint the problem. While a person might well get anti-depressants from their regular doctor, a good psychiatrist is better able to deal with complex matters and follow you more closely to get the right compound and dosage.

Neurological Evaluation. Stating the obvious, a physician with neurological specialties and qualifications does a neurological evaluation. Neurologists specialize in…wait for it…the nervous system (brain, spinal cord, and 12 cranial nerves). A neurological evaluation includes many of the things evaluated by psychiatrists but with special attention to your motor and sensory systems, your reflexes, and similar kinds of things. You might more likely see a neurologist when you obviously have a neurological issue. Neurologists are more likely to specialize in ADHD, brain injuries, and psychiatric problems that result from dementias or other known physical problems. They are often better able to give and interpret MRIs and other imaging that might be appropriate. They will also prescribe and follow medications.

Psychological Evaluation, AKA testing, psych assessment. These are offered, mostly, by doctoral level psychologists. These evaluations will cover much of the same history, mental status, and provide diagnoses when appropriate. Interviews, just like the previous two options, are essential. However, what sets psychological evaluation apart is its use of standardized tests. These may be paper and pencil or electronic. They may be filled out by the client or by family members. The results provide a snapshot of behavior, or cognitive functioning, or mood by contrasting the individual results against a peer group. For example, a child may complete a computerized test to assess attention span. The results are compared to thousands of children taking this test who either are “non ADHD” and or ADHD. A good psychologist collects data from multiple data points (test data, interviews by client and maybe family, observations, etc.) and uses that data to make interpretations and recommendations for ongoing care. Usually, the best psychological evaluations begin with a very objective, specific question. Just throwing a bunch of tests at a person to “see what comes up” isn’t all that helpful. Just because something pops up doesn’t mean it is meaningful.

It is true that masters level therapists (licensed or not) give and interpret some tests. But most of the best tests can only be given and interpreted by doctoral level, licensed psychologists.

There are other types of evaluations. Neuropsychologists are doctoral psychologists with specialized training and help pinpoint brain injury, unravel more complex learning disabilities, etc. Neuropsychiatric evaluations are done by another similar but slightly different professional. You can check out their interesting history on this wikipedia page.

So, how do you choose what is best for you? Answer a few questions.

1. What do I really want to know when it is all said and done? What might help me decide how to proceed? The more specific you are, the more likely you can get the answer you want.

2. Do I think I need to focus more on physical options or behavioral options?

3. Do I think I’m likely to need medications? The physician types are better. Psychologists cannot prescribe meds (unless you live in Hawaii or are in the military).

4. If I am given a diagnosis, what do I need it for? Both doctoral level psychologists and psychiatrists are capable of giving you diagnoses. However, some people or systems value one opinion over another. Figure out if it matters for your purposes.

5. Am I looking for specific behavioral/relational suggestions? Then psychological evaluations are more appropriate.

6. Am I looking to form an ongoing therapeutic talk based relationship? See the psychologist.

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April 8, 2009 · 5:16 am

Ramp up your helping skills!


Biblical Seminary is offering community education (non-degree) for those not able or not eligible for graduate education. It is a way to get a taste of what we do here. Starting next Monday night, Jenn Zuck (one of our counseling adjuncts) will be teaching an introductory counseling skills class for 6 weeks. If you’ve wanted to ramp up your listening and helping skills, wanted to see what we teach counseling students, or just wanted to improve your family relationships, you should enroll in this course.

By the way, the course isn’t just for your head. You will practice some new skills and you will find that your spiritual life will also be enriched.

Here’s the link for more info (flyer and syllabus): http://www.biblical.edu/pages/embark/about-us-upcoming-eventstest.htm

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April 3, 2009 · 5:53 am

Physiology Phriday: Your brain and your food


We all love certain kinds of foods and when we eat them, our pleasure quotients increase dramatically. Some recent work in brain imaging suggests that women with propensity for bulimia show “greater activation of key reward regions of the brain” after tasting a chocolate milkshake. These same individuals may also experience decreased activity in parts of the brain that control self-regulation and impulse control (as reported in the April 2009 Monitor on Psychology, pp. 48-49).

This area of research is new and so the results need replication plus interpretation. Does the brain function this way after years of bulimic behavior. Or, does the brain instigate or tempt such behavior (strong reward response plus increased impulsivity) with it’s prior functioning?

Of course, the individual struggling with bulimia cares only a little about the why. They really concern themselves with the what. How do I eat with moderation? How do I not eat for emotional reasons? Unlike alcoholics who can always avoid alcohol, everyone has to eat, and eat everyday.  So, what to do when your brain responds the way it does to food? Here’s a couple of practical ideas to start you down the right path:

1. Get a “coach” or counselor who you will be completely honest with. This coach will help you construct an eating schedule and an array of responses to eating or purging temptations.

2. Construct a realistic eating schedule that avoids avoiding food. Keep a food journal. Be honest. Keep troubleshooting with your coach until you find something that works best for you. Remember to check out your schedule (times and foods allowed) with a nutritionist.

3. Construct and use an array of behavioral responses to eating temptations. These include distractions, connections with others, ways to make the moment better, crisis call opportunities.

4. Develop mindful techniques to focus on eating, on stopping eating, on other forms of pleasure God has given you–even on the difficult emotions that you feel.

5. Identify controlling automatic thoughts and lies in your “script” that drive you in particular emotional and behavioral directions. These can be about your body image, about your relationships, etc. Begin responding to them with truth from God’s point of view. Make sure your coach and others know what truthes you are trying hard to believe.

6. As you recognize triggers, temptations, etc., also identify “ways of escape” offered you by God.

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March 31, 2009 · 5:42 am

The Value of Psychological Testing


My friend, former teacher, mentor, Ed Welch, has posted a blog on the CCEF website on the topic of psychological testing and how biblical counselors might view it. You can see his blog here as well as my comment on their site: http://www.ccef.org/psychological-tests-are-you-or-against#comment-28

Ed, as you will see, isn’t really against testing, recognizes value in it, but doesn’t really think they are all that special–no more so than a really good interview. And, in part, he is right. A really good counselor/interviewer and learn a lot. In my mind, though, testing provides confirmation of what you are learning about the counselee PLUS uncovers subtle data that you might not get quickly or at all (especially through the more objective forms of testing).

It seems people think about testing in one of two ways: either they think testing uncovers secrets that couldn’t be gotten without a test or they dismiss it as pure theory. It is neither. Good testing provides a response profile that one can look at and compare to either the general population or a specific population. That, in itself, isn’t all that helpful but when combined with a specific assessment question, the examiner can interpret the data and build good hypotheses to direct future counseling and intervention.

I love to do psych testing. I find that interacting with test results and counselees provides dialog points that wouldn’t have been as easily discovered or talked about without the data in front of us. For example, if someone takes a personality test and one of the scales suggests that they are approaching the test in a manner consistent with those who are trying to look better than they really are, that provides an opportunity to discuss an pattern in their life that we might not have had the chance to do so easily.

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March 27, 2009 · 10:03 am

Physiology Phriday: Hormones and Behavior


Sex hormones influence our mood and memory as well as a things like sexual desire. It is fairly clear that women with decreasing levels of estrogen (during their cycle or in perimenopause) have a higher propensity for depressed affect. It seems estrogen has an impact on the serotonergic receptors in the brain. Further, menopausal women suffering from low sexual desire report increased desire when given testosterone patches.

Clearly, our bodies are designed to function at their best with the right mix of hormones. But, given our fallen, less than perfect, bodies, men and women have to deal with mood, memory, and behavior challenges when hormones are “off.” This does not mean we are controlled by hormones and unable to function well if they are suboptimal. But, it does mean thinking and responding well may be more difficult.

Consider this hypothetical. A 15 year old challenges a 43 year old, out of shape, man to a game of one-on-one basketball. At that moment, testosterone fires through his body. He is more likely to accept that challenge and play beyond his conditioning so as to crush that 15 year old (to prove his male superiority to the 15 year old and to prove to himself he’s still got it, whatever it is.) in a best of 3 series. He gloats in victory only to cross the street and be unable to move for some time because he overextended himself and is experiencing severe ozygen deprivation.

How did testosterone work here? I don’t know but I’m looking for something to help me look less stupid 🙂

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March 20, 2009 · 5:43 am

Physiology Phriday: Repetitive thoughts?


Have you ever been tortured by a repetitive word, sound, phrase, song, or the like run through your head? Does it happen only during the day? At night when you wake up?

In psychological studies, there are a number of ways people talk about these experiences. Sometimes folks talk about intrusive thoughts/imagery, but this is usually in the context of PTSD or OCD studies. Others talk about rumination or repetitive thoughts, usually in the context of worry, depression, or anger. Finally, another batch talk about hallucinations in regards to psychotic disorders.

But what is going on in the more mundane repetitive thoughts? Diagnostically, they probably fit a bit more in the OCD genre than anything else (like counting, ordering, etc.).

1. Stress is usually a factor. They happen more frequently the more distressed a person is. It means the person is on higher alert than normal. The repetitions may be directly related to the stressor or may not. What is not know is whether the repetitions are a consequence of stress or a mediator of stress. What is known is that when a person, under stress, experiences repetitive thoughts salient to the stress, feels responsible to fix the problem, and attempts to suppress repetitive thoughts, their ruminations are MORE likely to increase.

2. Neuroticism is probably a factor as well. Sorry folks: those with anxious and depressive tendencies have more repetitive thoughts than others.

3. Emotional intensity as a native trait of the person may also be a factor. There is some evidence that individuals with strong emotions have a greater predisposition to PTSD (and therefore intrusive thoughts) if exposed to traumatic events.

But what to do about repetitive thoughts? Have you found anything helpful? There are certain things that are NOT helpful

1. Ruminating over the thoughts (Ugh, I can’t believe I’m still having that thought)

2. Trying to solve the problem they may be attached to

3. Trying not to think about pink elephants

Okay, so maybe those things don’t work. What does? Sad answer? We don’t know. Distractions do for a short time. Some actually give in to them and repeat them outloud to try to quell them. The more it is possible to pay them little notice, the easier it is to let them slide on out of the mind.

Maybe try to consider them an interesting mental quirk–like the lovable Monk (TV detective) 🙂

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March 13, 2009 · 3:38 am

Physiology Phriday: Anticipation and Anxiety


Anticipation and its relationship to anxiety.

This week we have been thinking about how we evaluate our world. Evaluations or judgements come from a variety of locations. Our expectations and desires prep us to look for certain kinds of “data.” Our histories and past perceptions prep us as well. Finally, what is actually happening is part of the data we use to evaluate ourselves and our world. Notice that we aren’t as logical and objective as we’d like to think. Instead, we ANTICIPATE life and then respond to data that fits into that anticipation.

The primary feature of chronic anxiety is that anticipation of negative, dangerous outcomes. The anxious person views ambiguous data (e.g., a boss who is grumpy, a funny feeling in the chest, etc.) and reads that data in the worst possible light (I’m going to get fired, I’m having a heart attack).

If the problem is bad habits in thought patterns, it would make sense that the treatment ought to be to challenge these logical fallacies with the truth. And while cognitive counseling does indeed work (clear data that one can challenge and reject anxious, ruminative thinking) most find that counseling stops anxiety from growing but doesn’t often stop it from starting in the first place. This struggle to fight anxiety leaves many Christians feeling quite guilty for not trusting God more. 

But what about the amygdala? There is significant research that anxious people have very activated flight/fight activity in the amygdala. In fact, brain scans of this area show greater activity in anxious people than non-anxious people even when they are responding to neutral events. Thus, the anxious person’s brain is in a chronic state of hypervigilance even when nothing is going on. Hypervigilance maintains higher levels of norepinephrine the body, which in turn keeps the adrenal system in high alert. Medications (of the SSRI and NSRI type) have the capacity to positively impact serotonin and Norepinephrine and thereby allow individuals to decrease the negative hormonal activity in the brain.

Which comes first?

So, does biological hyperactivity in the amygdala result from either bad experiences or bad thinking? Or does a predisposition towards overactivity of this part of the brain encourage negative and anxious thinking, forming a vicious cycle? 

Seems to me good treatment needn’t answer this question. Good treatment would include (a) medications that might make it easier to slow down the anxiety processes (biology and behavior), (b) recognition that vigilance can be directed via counseling work away from the feared object and to a better understanding of the brain, and finally (c) that one changes the goal from cessation from fear to a more godly and humble response to Jesus in their fear.

What I mean by (b) is that the anxious person see themselves as like unto a person with colorblindness or dyslexia. In each case, the brain functions in a way to send the wrong messages. The dyslexic person learns to recognize the problem and designs a means to compensate in order to truly see the right order of letters/words. The anxious person accepts that their brain sends certain messages but that their job is to stay remember that while something real is happening it is not necessarily the way their brain is putting the “facts” together. Thus, the work is not to remove the fear but to practice a better response to it.

Ironically, when the person reinterprets the stimulus differently, they do see a marked reduction in fear triggers.

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March 6, 2009 · 5:30 am

Physiology Phridays: Deep Brain Stimulation


Next fall I will teach “Counseling & Physiology” for the first time so I am beginning now to plan through such a course. It’s my intention to use Fridays to blog on counseling stuff related to the brain and biology. Here’s my first post:

The March issue of the APA Monitor on Psychology magazine has an article on the use of deep brain stimulation for chronic and untreatable depression (after failures with medicine and ECT). DBS is a surgical procedure, first pioneered to stop Parkinsonian tremors, where electrodes are placed in the subgenual cingulate region and a “pacemaker” produces electrical current to the electrodes on a continuous basis. You can read about DBS here on wikipedia. The studies are small as of yet but the FDA has already approved this procedure for OCD patients.

This surgical procedure seems to produce positive feelings and relief from the depression. So, does this mean that depression is merely a biological problem? No. This is why medicines are quite helpful but it is counseling that maintains the relief from depressive symptoms.

Bottom line: Depression is a multi-faceted disorder–both from an etiological standpoint and from a treatment standpoint. One must consider biology, spirituality, cognition, and behavior. These areas are not mutually exclusive as work in one area has impact on the others. Efficacious treatment not only seeks to resolve the depression but also to consider how to live well–whether in a depressive state or not.

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February 4, 2009 · 5:37 am

Try your hand at diagnosing clients…


Ever wondered if your counselor really knows what is in the Diagnostic & Statistical Manual (DSM, ver. 4TR)? Or do they just do the flip and dip method (let the large book open to any page and blindly point to a spot on the page)? Let’s hope not. Well, some professors are trying to increase the accuracy of their students via video vignettes.

One such person, Dr. Aaron Rochlen of U. Texas, has a website with 5 video vignettes available on his website (http://www.edb.utexas.edu/psychopathologypractice/index2.html) for students to watch and then try their hand at giving a DSM diagnosis.

Warning. Site is free. There are no answers given so don’t bother submitting your diagnostic considerations as they won’t go anywhere unless you send them to someone. Second warning: At least one of the “clients” uses some curse words.

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