Category Archives: counseling science

March 3, 2008 · 11:58 am

Science Monday: The Epidemic of Insomnia


Americans appear to be quite sleep deprived, so says the latest National Sleep Foundation Survey of working adults (2008). Sleep deprivation seems to be linked to obesity as well as driving and work accidents. We’re insomniacs for many reasons. One key reason is our electronic appetite. With 24/7 electronics we stay up later and then stay up longer when we do get up in the night because of insomnia.

Sadly, once we retire and have the freedom to sleep longer, we can’t. Some 30-60% of older persons have sleep complaints. Does anything help? Commonly, doctors prescribe sleep aids, exercise, Cognitive Behavioral Therapy, and sleep hygiene education. While sleep aids are quite attractive they often have significant side effects and tend to be less effective if used regularly. Susan McCurry and her colleagues at University of Washington reviewed 20 key studies published between 1990 and 2006 to determine if any psychological treatments (they eliminated drugs, massage, etc.) would meet standards for evidenced-based treatment. They determined that two treatments have strong evidence of success among the older population:

1. Sleep Restriction/Sleep Compression. This treatment “is based on the principle that curtailing time spent in bed helps solidify sleep.” (p. 20). So, if you are in bed for 8 hours but only sleep 5, then restrict your time in bed to only 5 hours. The idea is that if you do so, you will sleep more soundly for those 5 hours and likely begin to sleep longer until you read your optimal (not necessarily desired) sleep time.

2. Mulitcomponent CBT. This interventions combines sleep hygiene education (information about how to schedule sleep, dietary matters, activity recommendations, etc.), stimulus control(strengthening the association that bed is for sleep and avoiding napping and lying down awake), sleep restriction, and relaxation training (relaxation to induce drowsiness).

Stimulus control may in fact be beneficial by itself but more study is necessary.

It has been generally accepted that most individuals with secondary sleep problems need sleep hygiene education. In other words, they make matters worse by how they deal with their insomnia (staying in bed awake too long, napping, drinking alcohol, not enough exercise or too late in the evening, etc.). As of yet, we do not have actual research (meeting evidenced-based criteria) to prove that education helps in the elderly population–though some exists for the 40-50s crowd. There also may be some benefit to bright light exposure, exercise, and massage but these authors didn’t explore these nonpsychological interventions.

Bibliography: McCurry, Logsdon, Teri, & Vitiello (2007). Evidence-Based Psychological Treatments for Insomnia in Older Adults. Psychology and Aging, 22, 18-27.

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February 18, 2008 · 3:45 pm

Suppressed Anger enhances pain perception?


Today in Psychopathology we will be discussing the problem of problem anger. In doing some additional research I found that there has been a fair amount of literature produced on the topic of angry emotions and a good amount in the last year or so.

We know that chronic anger has significant impact on the body and may influence certain disease states such as high blood pressure, atrial fibrillation, etc. But, Quartana & Burns (Rosalind Franklin University of Medicine & Science, Chicago) investigated the relationship between anger suppression and increased pain sensitivity. Here’s how they explore the possible connection:

1. They asked 209 healthy and pain-free college students to perform a mental arithmetic task (serial sevens). While doing the task, some were harassed (made angry) and some were told to express their feelings, to suppress their experience and/or expression of their feelings, etc.

2. After the task, they had to put their non-dominant hand into a bucket of ice until they reached the point where they could not tolerate pain any further.

What did they find? Well, first they found that 32% kept their hand in the water so long as to be not helpful in their research. But, they also found that, “Participants who attempted to suppress either experiential or expressive aspects of emotion during anger provocation reported greater pain in response to subsequent pain induction than did participants who suppressed during anxiety induction and those instructed not to suppress, irrespective of emotion-induction condition.” They also found, “Participants who suppressed anger not only reported the greatest pain severity, but also described the quality of the pain as more physically hurtful (e.g., throbbing) than their counterparts who suppressed anxiety or those who experienced angerbut did not engage in effortful suppression. More important, those who suppressed anger also described their pain as annoying and irritating to a greater extent than those who suppressed anxiety.”

This makes sense. When I’m angry, everything becomes an irritant.

Does this suggest that to be more healthy we should be more free with our anger by giving vent to it? Not necessarily so. It does mean that those who hold it in (become embittered?) may become quite sensitive to perceptions of pain–that is, notice all the other things wrong with the world. But anger expression isn’t necessarily the opposite of suppression. Rather, honest self-evaluation, bringing our anger to the Lord, remembering that He is our vindicator may be more important than outward expressions of our anger.

Biblio: Emotion, 7:2, pp 400-414 (2007).

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February 11, 2008 · 11:52 am

Ancedotal Science Monday: Anxiety–Depression–Anger


Today, my psychopathology class will explore the problem of depression. Last week we looked at anxiety and next week, we take a shot at understanding the roots of anger. Here’s my thought for today: these three emotional states are not different animals but three manifestations of the same problem.

There is some psychological research and writing suggesting that anxiety and depression either highly overlap or are two ends of the continuum. Further, we understand that the same SSRI antidepressants seem to alleviate both anxiety and depressive symptoms. I would like to suggest that we consider that they do exist on a continuum and anger as the center point.

Consider these simple definitions for our Anxiety–Anger–Depression continuum:

Anxiety: Manifestations of mood revealing a deep sense that something is not right in the world and hope in activating in someway to forestall the danger.

Depression: Manifestations of mood revealing a deep sense that something is not right in the world and hopeless to forestall the danger.

Anger: Manifestations of mood revealing a deep sense that something is not right in the world and frustrated that others aren’t doing something to forestall the danger. 

How might this change our approach to these problems? Not sure it would. However, all of us have some experience with at least one of these three manifestations and so therefore we can better relate to those who experience one of the other two manifestations.

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February 4, 2008 · 11:56 am

Science Monday: Therapist characteristics that may lead to greater treatment success


Today in Psychopathology class we will be studying the anxiety disorders. In preparing for the class, I happened on an 2001 article by Huppert, Bufka, Barlow, Gorman, Shear, & Woods in the Journal of Consulting and Clinical Psychology (v. 69, pp747-755). FYI, David Barlow is a well-known anxiety researcher in the Boston area.

These authors researched how various therapist characteristics influence outcome in CBT for anxiety disorders.  While CBT has been found to be effective in treating anxiety, does it matter much what therapist you get?

What therapist characteristics were not found to be all that meaningful to outcome? Gender, age, and theoretical orientation did not seem to make any difference. The fact that theoretical orientation didn’t make much difference is quite interesting. This suggests that expertise in CBT may not matter as much as one might think. Anybody with a manual and a willingness to follow it can do it well enough–maybe.  

So what counselor characteristics do increase successful outcome for anxiety treatment? Experience. The more experienced therapists had clients who had less anxiety after treatment. Experience (number of years as a therapist) matters quite a bit. The authors did not find that experienced therapists were more apt to follow the treatment protocol as there were no differences between experienced and inexperienced therapists as far how they did in following the protocol.

So, what does experience mean? We’re not really sure but it probably has something to do with therapist flexibility while continuing to adhere to the treatment protocol. Those who followed the protocol but were more rigid may have communicated that rigidity to their patients and missed key interpersonal processes. This study didn’t explore this issue but I surmise that is part of the issue.

One funny finding was that more experienced therapists suffered the same drop-out rate as did the more inexperienced therapists. And yet, those who stayed in treatment had much lower anxiety when they were seen by the experienced therapists. So, just because you go to an experienced therapist, don’t assume that everything will go well. No, you have to want to be there and be willing to do the hard work. Also, you just may not click with the counselor.

Most of us counselors want to be skilled and have cool techniques. But once again we find that relationships matter more than technique.

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February 1, 2008 · 9:58 am

When groups go bad


In preparation for some training I’m doing today, I came across an article published by Karen Chicca Enyedy and her colleagues regarding the types of phenomena that hinder effective group supervision for counselors. In analyzing the data, they suggest that group supervision may fail as a result of 5 separate clusters of problems. You will note that these problems exist in any group, whether bible study, therapy group or group supervision.

1. Between-member problems. (e.g., conflict, griping, competition attitudes, story-telling that hinders supervision)
2. Problems with the supervisor. (e.g., lack of focus, being overly critical of others, dominating conversation, lateness, going on tangents, rigidity, not allowing other theoretical perspectives, using supervision for personal issues)
3. Supervisee anxiety (e.g., feeling unsafe, unsure, inability to be transparent)
4. Logistical problems (e.g., room size, supervisor illness)
5. Poor time management (e.g., not being able to bring up cases).

While these problems are not surprising, they provide a good reminder of the ways we can care for each other by all observing the group dynamic and being willing to address personal and interpersonal matters as they come up. Too often we are hesitant and then the dynamics become cemented and difficult to change. While we supervisors must take stock of what we do, acknowledge weaknesses, and avoid defensiveness, students also must take responsibility for communicating their concerns in a timely fashion.

Biblio: Hindering Phenomena in Group Supervision: Implications for Practice. Professional Psychology: Research & Practice, 34, 312-317. 

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January 30, 2008 · 11:09 am

Integrative Psychotherapy III


In chapter two of Integrative Psychotherapy, McMinn and Campbell attempt to set our their foundation for psychotherapy. You’ll remember that in the last chapter they articulated their theological foundation. This chapter nicely divides into two parts: (a) A defense of the science of psychotherapy, and (b) a summary of what is “known” about the what works, when, and why.

They begin the chapter by admitting that there are many competing and dispirit theories/models of psychotherapy–many which have never been tested through empirical means despite lofty claims. They also acknowledge that many Conservative Christians have cherry picked certain studies that show that psychotherapy is ineffective and ignored many others that say the opposite. In other words, anyone can find a stat to prove whatever they want.

McMinn and Campbell remind their readers that they intend to build a Christian Psychotherapy model built on a robust Christian worldview and fleshed out with scientific methods to tell us, “what works, whey, and why” (p. 56). They lament that since both scientists and theologians aren’t known for their humility, a robust Christian psychotherapy model has not really been built. Collective wisdom is needed to accomplish the goal.

Then the authors turn to some of the details about the science of psychotherapy? Is it really effective? They summarize some of the effectiveness and efficacy studies (these are different: effectiveness: client survey; efficacy: lab studies of very specific interventions on one particular problem). Back in the 1950s Hans Eysenck published a number of studies reporting, “there was no research evidence to support the effectiveness of psychotherapy compared to no-treatment control groups” (p. 57). By 1980, however, there was ample evidence to the contrary. In fact, McMinn and Campbell report, “that the average effect size for psychotherapy is .82 indicating that the average treated is less symptomatic than 80% of untreated persons” (p. 58). They then compare that number with the effect size of certain medications on psychiatric problems (stimulants for ADHD: .91, SSRIs for Depression: .50, Atypical Antipsychotics for Schizophrenia: .25).    

Does any one model work better than another? The authors report the oft-heard conclusion: no one model seems more effective than another. And yet, at the end of this chapter they state their preference for Cognitive theory models (due to the research published about cognitive techniques) joined to aspects of client-centered models and other aspects of psychotherapy research. In olden days, we called this eclectic. They do not call it that, most likely due to the negative connotations associated with the word (it has often been used to cover up the lack of theoretical awareness of the clinician using the term).

Before they end the chapter, they consider whether length of treatment matters. They do not really do much with this question other than to point out that most therapeutic courses are much shorter these days. They also consider the question whether therapy benefits last. Again, they don’t cite the literature but state the that certain factors will make it more or less likely for the benefits to last.

They speak briefly about two more important matters in the consideration of the effectiveness of psychotherapy: (a) recognizing that common threads of the change process (insight, affective experience, stages of change, behavioral change, etc.) and point to the works of Prochaska and DiClemente, and (b) common factors in all models of therapy that seem to account for success. They cite date regarding these factors (and the percentages the factor accounts for for therapy outcome) as

  1. Client and extratherapeutic factors (40%). Such as intelligence, motivation for change, persistence, social support, resiliency, etc.
  2. Relationship between client and therapist (30%). This is why program emphasize relational skills over techniques or models
  3. Hope/expectancy (15%). How much hope does the client have in the possibility of change?
  4. Model/Technique (15%). Notice that the learning of special therapeutic techniques only account for a small portion of the outcomes in psychotherapy.

My thoughts on this chapter. Nothing out of the ordinary here. The chapter follows conventional wisdom about the science of therapy. The reader who wants to go deeper can look look at their bibliography and dig pretty deep. The reality is that though we think we know a number of things, the research on psychotherapy is complex and sometimes controversial. This is not to say that we know nothing. But we do have a long way to go. I might have liked to see some more discussion on what we as yet do not know but really want to. Further, I would have also liked a short discussion of philosophy of science. Why? Just as we need to be tentative about some of our theological underpinnings, so we ought to be a bit tentative about the modernist underpinnings of psychological research. I don’t think they are overstating their case yet, but the reader may view these two disciplines (theology and psychology) as one having only theory and the other only fact.

I do hope that they will take a look at the presuppositions of cognitive theory in the next chapter. How does that model influence what they see? 

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January 28, 2008 · 10:53 am

Science Monday: New Treatment for Mania?


The Harvard Mental Health Letter (v. 24:8, Feb. 2008) has a short blurb about a new medication being researched for the treatment of active mania.

Tamoxifen. Yes, the drug best known for treating and inhibiting the growth of estrogen sensitive breast cancers. Apparently it also inhibits an enzyme (protein kinase C or PKC) which may contribute to mania. The study lasted only 3 weeks and on a tiny sample of people (both males and females). But, there are positive signs that it stops active bipolar symptoms. 63% of those taking the drug improved, many within five days. Only 13% of those taking a placebo improved.

Side effects include hot flashes, increased risks for stroke and blood clots (known from its study in breast cancer patients). We will have to wait to see if it is useful just in bringing mania under control or also in long-term maintenance. Actually, we’ll have to wait a long time to see if it is ever used at all with manic individuals.

I do wonder about the back-story. How did this drug get targeted as a possibility. Was it in the lab or did doctors report that their actively manic breast cancer patients seemed to get better. That is how many of these discoveries get made. Viagra, for example, was first used to reduce hypertension. Turns out it was not particularly good at doing that. But, the men in the studies reported some other surprising and very desirable side effects.  Oh, if you can believe wikipedia, it also helps reduce plant wilting in cut flowers. Sorry, couldn’t help but add that little factoid.  

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January 21, 2008 · 12:41 pm

Science Monday: Suicidality in Teens across Cultures


This week we spend time in our psychopathology class considering the biblical literature regarding causes and effects of suffering. We do this because any course on problems in living must help students first understand the depths and complexities of suffering. Otherwise our study of problems will be rather sterile if we can’t deeply feel the pain. Some painful suffering leads to suicidal thoughts and that is where I want us to go today…

The January 2008 issue of American Psychologist (63:1) considers “Cultural Considerations in Adolescent Suicide: Prevention and Psychosocial Treatment.” Suicide is most likely to be considered by those who feel intolerable emotional pain and perceive no way out of that pain–other than death.

Not surprisingly, there are significant racial and cultural differences in rates of suicide across ethnicities (Native Americans have the highest, African Americans have the lowest in both genders). Culture plays a big role in each ethnicity’s perception of suicide behaviors, choice of help-seeking behaviors, and what might help prevent suicidality. A couple of examples from the article:

  1. African American male emphasis on coolness may protect them from giving into suicide at first but may increase the likelihood of individuals trying “to provoke others into killing them as an indirect method of suicide” (p. 19).
  2. High rates of suicide among Native American youth, “occur in the context of high rates of other risk-taking and potentially life-endangering behaviors” (p. 21).

The authors look at issues including acculturative stress, enculturation, different manifestations of distress, and cultural distrust in trying to treat and prevent suicide across various cultures. They contend that few culturally sensitive prevention and treatment models exist at this point. In other words, we cannot assume that generic methods of encouraging youth to seek help when distressed will be helpful. In other words, if given the chance, we must make sure we try to understand their (not our) perception of their situation, their pain, their family/community, and possible avenues of hope. Further, we must try to understand how they may perceive us (the counselor) due to our own ethnicity and position of power. We must counter our tendency to allow fear to draw us into a position where we start exhorting our teen clients–thereby shutting them down.

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December 7, 2007 · 5:16 am

The science of happiness and why we are not


My latest Monitor on Psychologyfrom the APA (December, 07) has a couple of short articles on happiness. One mentions that 1998 study that found Midwesterners predicting Californians would be happier because of their climate. Apparently not true. The author suggests that we’re not that good at predicting what makes us happy and are likely to focus on one positive or negative and neglect other factors that might be important. This sound quite true to me. We tend to point to particular anecdotes from our day/life and use those to confirm our set opinion about whether we are happy or not.

One other little tidbit on p. 38. “White Americans expect to be happy, so day-t0-day positive events have less effect on their overall mood than such events have on Asians and Asian Americans… Negative events, however, are a different story.”

It appears that it takes two positive events to offset a negative experience for White Americans. For Asian Americans, it takes only one.

Interesting. The researching author is quoted as saying, “the happier you get, the more powerful negative events become.” I suspect the truth is more like this. The happier you think you should and can be, the more powerful negative events become. I’m not sure we are more happy. But, I am sure we think we should be.   

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December 6, 2007 · 1:32 pm

How do you evaluate the “next best thing” in Christian Counseling?


Last Monday we discussed this topic in my social and cultural foundations of counseling. There are always new ideas and books trumpeting something exciting that surpasses other counseling techniques with successes never seen before. Just read this book and your life will change forever!

Do you hear my voice dripping with suspicion? You should. While there are advances in counseling, popular books are often just that because they package a good idea or two into something that people want to buy (which means they also package it with fluff). What do we want to buy? Freedom from suffering; the end of our sorrows and struggles; we want complete removal of mental pain. This isn’t a bad desire, but it does set us up to buy the “next best thing” without proper critical evaluation.

And yet, we need to be open to the possibility that there is something new on the horizon. And so, I propose we do the following:

  1. Read with an open mind. Ask these questions: What does this author observe about their world, about people, about change? What are the problems they see? What are the solutions they envision? Can we see what they see? Can we consider the importance of what their observations?
  2. What techniques and interventions do they use to solve the problems they see? We may disagree with authors at numerous points but we can still evaluate the techniques they use. Do they work? How do we know?
  3. What assumptions, worldviews, presuppositions, etc. bleed through on their pages? I used to always go here first. The problem was it made me unwilling to consider their observations if they were wrong in their assumptions. But everyone sees—even if poorly. And observations can be very helpful—even if fixated on one small aspect of life.
  4. How might their observations and assumptions challenge mine? Where are my assumptions and worldviews uncritically formed; based on faulty logic or distorted beliefs?
  5. What techniques or interventions might find a home in my repertoire and what impact would they have on my work?
  6. What promises do they offer that must be critiqued? What misrepresentations must be exposed? What admissions must be made about our own models as a result of their work?

Now, these are good questions to use to evaluate the “next best thing” that actually has substance and as several commenters observed, creation therapy probably doesn’t merit this level of work until it moves into the realm of transparency and shows that it is available for observation and critique. With research on 5,000 individuals, where is the evidence? The real challenge is evaluating those models that run too far with a few facts and ideas and sell it as a type of cure-all. Much of the “change your brain, change your behavior” popular literature out there does just this. Some significant piece of data is then used to promote an idea that one can change everything.

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