Category Archives: counseling science

May 9, 2014 · 10:36 am

Should therapists talk about themselves to clients? Surprising information


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

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

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

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

Not so fast!

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

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

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March 19, 2014 · 10:11 am

Mapping urban domestic trauma


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

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

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

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

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

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February 19, 2014 · 12:46 pm

When you imagine something does your brain think you see it?


What is the difference between imagination and reality? Sometimes, not that much.

The February 2014 edition of the Monitor on Psychology (v. 45:2, p. 18) lists a brief note about a study published in Psychological Science that looks at eye pupil constriction when imagining light. Here’s the abstract from the link above (emphasis mine):

If a mental image is a rerepresentation of a perception, then properties such as luminance or brightness should also be conjured up in the image. We monitored pupil diameters with an infrared eye tracker while participants first saw and then generated mental images of shapes that varied in luminance or complexity, while looking at an empty gray background. Participants also imagined familiar scenarios (e.g., a “sunny sky” or a “dark room”) while looking at the same neutral screen. In all experiments, participants’ eye pupils dilated or constricted, respectively, in response to dark and bright imagined objects and scenarios. Shape complexity increased mental effort and pupillary sizes independently of shapes’ luminance. Because the participants were unable to voluntarily constrict their eyes’ pupils, the observed pupillary adjustments to imaginary light present a strong case for accounts of mental imagery as a process based on brain states similar to those that arise during perception.

So it seems that thinking about something causes your brain to respond as if it is really seeing. What might this mean about those who are trying to break free of addictions?

  • Would imagining heroin use create observable changes in they body that would make it harder to maintain abstinence
  • Would recalling sexual images create responses that make sexual addictions harder to break?

So, what is the difference between imagining an affair and actually engaging in one? From a brain perspective, maybe not that much. Certainly Jesus’ expansion of the seventh commandment suggests there isn’t a difference between the two from God’s perspective. And yet, we know that actual adultery creates more damage to more people than merely fantasizing about having an affair.

Rumination: the health killer!

I’m currently teaching students a course on psychopathology. Each week we consider a different family of problems. Thus far we have explored anxiety disorders, mood disorders (depression, mania), anger/explosive disorders and addictions. Soon we’ll look at eating disorders, trauma, and psychosis.

There is one symptom that almost every person fitting one of those above categories experiences–repetitive, negative thought patterns.

Rumination.

The content of the repetitive thoughts may change depending on the type of problem (i.e., anxious fears, depressive negative thoughts, illicit urges, fears of weight gain, fears of being hurt, irritability, etc.) but the heart of the problem is the vicious cycle that negative thought patterns produce.

While there are many very good ancillary mental health treatments (Did you know that daily exercise, getting a good 8 hours of sleep each night, and eating a diet rich in protein supports good mental health and may even prevent re-occurrence of  prior problems?) it is essential for those of us who struggle with imagining negative events to find ways to shut down the production of rumination. Mindfulness techniques, thought-stopping, alternate focus may help to interrupt imaging bad feelings, thoughts, events and thereby interrupt the body reacting as if those bad things are indeed happening.

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February 14, 2014 · 11:34 am

Free Issue of Journal of Traumatic Stress


As a member of International Society of Traumatic Stress Studies (ISTSS), I am able to offer you a link to a free issue of their journal, Journal of Traumatic Stress.

Click this link for the February issue page with links to download individual articles.  Several essays relate to PTSD treatment for veterans, at least one essay re: child maltreatment in Uganda.

 

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December 3, 2013 · 7:15 pm

Is PTSD an internal problem causing social problems? Or the other way around?


I am finally getting around to read Ethan Watters’ polemic Crazy Like Us: The Globalization of American Psyche (Free Press, 2010). In this book he details the way America has exported not only its pharmaceuticals but have redefined mental health and disease. As the promotional material on the front cover says, the book “[uncovers] America’s role in homogenizing how the world defines wellness and healing.”

As I read the book, I find he is overly negative and pessimistic, even as he right points out some major bumbling when bringing Western mental health ideas to the world. And yet, consider this…

In chapter two he examines the way Western mental health providers flooded (bad pun but appropriate picture) Sri Lanka after the Tsunami to treat all the PTSD that would most definitely come to light. They “educated” the country about the symptoms of PTSD and trained caregivers and counselors to provide counseling interventions. When certain symptoms weren’t presenting widely, some helpers assumed victims must be living in denial.

Watters describes how one researcher began looking to see how Sri Lankans described symptoms of poor responses to trauma–instead of using a pre-determined set of symptoms. This researcher concluded that Sri Lankans experience trauma quite differently.

1. Sri Lankan PTSD symptoms were primarily physical in nature.

2. Sri Lankans did not identify anxiety, numbing, fear symptoms but rather identified isolation and loss of social connection as key to PTSD symptoms.

The root problem in PTSD? 

So, is PTSD internal or external? Intrapsychic or social? Most Westerners think of psychopathology in terms of the individual. A sick individual will likely find their social lives eroding and less supportive. It appears Sri Lankans think of pathology in terms of social connection which when broken results in some of the physical symptoms. So, does trauma cause psychological damage which in turn harms social networks…or does trauma harm social networks which in turn causes distress?

Your answer to this question likely reveals whether you see the world as a community or a group of individuals.  Or, your answer reveals whether you focus on universal human experiences or constructed human experiences.

One semi-helpful answer

My answer? Our minds, bodies, spirits and social networks are not disconnected. While distinct entities, we are far more connected than disconnected. To paraphrase the bible, if the eye is sick, the whole body is sick. Psychopathology does not reside only in one location, even if we can see it’s impact in one specific location (e.g., cells not functioning). We would not assume that seeing the destruction after a tornado would be all that is needed to find the cause of that same tornado. Whatever interventions we devise, we will not find a one-size-fits-all solution. For some, we will intervene first in the interior of their lives (medications, private counseling). For others, we will start with social reconnection.

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November 19, 2013 · 1:40 pm

The power and perversity of labels


English: Photo of Paulo Freire

[Previous version published  in 2006]

That was great!

You are a liar!

We humans have powerful tendencies to label and categorize. It may be something that Adam passed on to us. Notice that Adam got to name the animals as he saw fit. I suspect that being made in the image of God provides us an innate drive to name things as they are?

But what happens when things don’t fit our categories? We either have to expand our definitions or shove square pegs into round holes.

  • The color line comes to mind. Those who are biracial face the repeated question, “What are you?” And the “one drop” rule still is holds power: one drop of African heritage blood in your recent ancestry makes you “Black” in this country.
  • How about those who don’t fit gender stereotypes. I’ve heard the pain of many who were accused of being gay because they didn’t fit someone’s image of a man or a woman. These labels were so powerful that they caused confusion. “If being a man means…(fill in the blank), then I must not be one. Maybe I’m gay.”

The Counselor’s Power to Label

Counselors hold tremendous power when as they label, especially those who represent both the counseling and the Christian worlds. We label right and wrong, righteous and unrighteous. We label idols of the heart. We want our counselees to see themselves and God in proper form. We see how distortions in labels (e.g., God doesn’t love me; I’m incapable of changing) harm and we want to provide healthier labels.

But, HOW and WHEN we label may be more important than whether our labels are actually correct. The temptation for counselors is to label too quickly, before the counselee is ready. If that happens, the counselee is passive and the counselor’s label is just one more among a chorus of opinionated acquaintances.  

Take a look at how Jesus interacts with sinners and self-proclaimed holy men. Who is he more likely to label? Who does he engage with deep questions? What are his means for helping others see themselves? Notice how the Pharisees were quick to label what was authentically Jewish and what was not. Notice that the Lord seems less interested in that and more interested connecting to others. He was not neutral about sin. However, he engages others in novel ways to show them the righteous path and their need for a savior.

Who Does the Labeling Matters

I’ve been enamored with the late Paulo Freire, a liberation theologian from Brazil. He describes how unthinking, impoverished, people become empowered when they are given the power to name things (problems, solutions). They do not, he says (in Cultural Action for Freedom), learn by being filled up with words and labels by dominant culture individuals. If this were the case, then counseling would only be a matter of memorizing the right words and phrases. No, counseling is a dialogue where the counselee is an active, creative subject in the process of change. In Learning to Question: A Pedagogy of Liberation, (by Freire and Faundez), they say,

I have the impression…that today teaching, knowledge, consists in giving answers and not asking questions.

The same could be said about counseling. It is the asking of questions that encourages us to search for answers. Without questions, we may never redefine the problem. When we counselors label (whether we are talking about DSM labels or right/wrong labels) without engaging  the client in the process, we rob them of their words.

What Can We Do?

Freire suggests a three-step dialogical model that may work also in building an effective counseling relationship: Investigate (ask exploratory questions, examine beliefs, myths, etc.), Name (code and decode, a process of un-naming and naming what is going on), and Problematize (identify problem and solutions).

Avoid the Temptation to Give the Gift of Your Knowledge

Freire says that gifts given by oppressors only perpetuate injustice. If the “gift” of your knowledge perpetuates the divide between the counselor (the healthy/wise one) and the counselee (the sick/naive one), then your gift may only serve to perpetuate their illness. This does not mean you should never speak or offer advice. But ask yourself, “does the way I speak to clients encourage and energize (all the better if in the form of a pushback) or cause passivity?

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September 9, 2013 · 7:08 pm

Classroom advice to grad students: Guest post over at biblical.edu


Our faculty blog at http://www.biblical.edu carries my post today. Check it out to see what 3 recommendations I make to our incoming students as they kick off their MA in Counseling program tonight!

 

 

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July 31, 2013 · 1:06 pm

Treatment of complex trauma: Why mistrust of the counselor is necessary and good!


I am reading Christine Courtois and Julian Ford’s, Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach (Guilford Press, 2013). I won’t be blogging through each chapter but I do recommend it for those working with adult survivors of child sexual abuse, especially those who are new to “complex trauma.”

The first two chapters give an overview of complex trauma reactions and diagnoses. If you want to know more about complex trauma, see this post about another edited book by these two authors. Chapter three, “Preparing for Treatment of Complex Trauma” begins the meat of the book. In this chapter they take up the ever important issue of empathy, safety, and respect as foundation to therapy. They emphasize the need for,

safety within the therapeutic relationship with a therapist who is empathic and respectful yet is emotionally regulated with appropriate and defined boundaries and limitations. (54)

Challenging Counselor Safety Is Common and Good?

This empathy and trust relationship is both foundation and method of treatment (59). But while the therapist is responsible to see that at safe therapeutic relationship has been built, it requires the client to be involved in building such an environment. The truth is that the client’s role in building safety in the counseling office is by passive and active testing of limits. Most counselors tolerate suspicious questions the first or second time. But, it is important for counselors to,

being prepared to patiently and empathically respond to active or passive tests or challenges to trustworthiness as legitimate and meaningful communication that deserves a respectful reply in action as well as in words. (60, emphasis mine)

If the therapist understands and does not take mistrust as a personal affront, the therapeutic relationship can evolve gradually. The client can begin to recognize  that the therapist actually “gets” why he or she is initially skeptical, self-protective, or “realistically paranoid” and does not pressure the client to be a “happy camper” but instead works to earn trust by being honorable, reliable, and consistent. This also implies a view of the client’s initial mistrust as expectable in light of the client’s history–that is, as a strength rather than as a deficiency or pathology. (63)

Sometimes clients can present in an opposite way–to be entirely deferential and affirming the counselor before a track record can be developed. Therapists with these clients need also to be prepared to encourage a healthy level of distrust.

What is not helpful is “artificial neutrality or passive and intellectualized detachment on the part of the therapist…” (64). It is my sense that we usually do this when we are afraid of the client. Not so much afraid of being injured, but afraid of failing or being consumed by the trauma. Or, we get consumed by our own history. A healthy therapist must stay emotionally present yet aware of own internal machinations. A healthy therapist must be able to predict some of the angst that arises in treatment of complex trauma and able to prepare self and client for this inevitable distress.

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July 25, 2013 · 5:59 am

Telling Painful Memories: Recommendations for Counselors


[What is below was shared with Rwandan caregivers and counselors. It is written in simpler English and has no footnotes. Academically oriented readers will recognize the interventions come from narrative exposure therapy models for children].

Counselors invite others to tell their stories of pain, heartache, fears, and traumas so that they can find relief from their troubles. However, not every way of talking about past problems is helpful and some ways of talking can actually harm the person. So, it is important that all caregivers and counselors understand how to help others tell their difficult stories in ways that invite recovery and do not harm.

Good Storytelling Practices

Counselors who do the following can encourage healthy and safe storytelling of difficult events:

  1. Allow the client to tell their story at their own pace without pressure
  2. Allow the client not to tell a part of their story
  3. Use silence and body language to show interest
  4. Encourages the use of storytelling without words (art, dance, etc.) or with symbols
  5. Ensures the difficult stories start and end at safe points
  6. Encourages good coping skills before story telling
  7. Points out resiliency and strength in the midst of trauma
  8. Encourages the story to be told from the present rather than reliving the story

Unhelpful Practices

Here are some things that we should avoid doing when helping another tell a difficult story

  1. Frequent interruptions
  2. Forcing the person to tell their story
  3. Asking the person to relive the story
  4. Avoiding painful emotions
  5. Exhorting the person to get over the feelings; telling them how to feel
  6. Only talking about the trauma, ignoring strengths and other history
  7. Ending a session without talking about the present or a safe place

**Trigger Warning: rape, threatened violence

A Case Study With 2 Storytelling Interventions

Patience, a 13 year old girl, suffered a rape on her way to school last month. The rapist’s family paid a visit to the girl’s family and offered money as a token of penance. The girl’s father accepted the money because, “nothing can make the rape go away so we will take the money for now.” Patience was told by some family members to not tell anyone about the rape and to just act as if it never happened. However, Patience is suffering from nightmares, refuses to go to school, and sometimes falls down when she catches a glimpse of the rapist in town. Her father has threatened to beat her if she doesn’t return to school or help out with the chores at home. Her favorite aunt, a counselor/caregiver, learns about the rape and asks her to come for a visit in a nearby city.

[Warning: these two interventions are not designed to rid a person immediately of all trauma symptoms. In addition, these interventions must be used only after a counselor has formed a trusting relationship with the client.]

  1. Symbolic story telling. The aunt tells Patience that keeping a story bottled up inside can cause problems, like shaking a bottle of soda until it bursts out. Using a long piece of rope (representing her entire life) and flowers (representing positive experiences) and rocks (representing difficult experiences), the aunt directs Patience to tell her life story. They start with her first memories of her mother, father and two brothers. She tells of her going to school, the time when her mother got really sick but then got better again, the time when her cousins moved away, and the time when a boy told her he liked her. Patience noticed how she had many flowers along the rope and only a few rocks. Then, they put a large stone down on the rope representing the rape. Patience had difficulty saying much at all. She remembered being afraid, the weight of the man, the pain, and worry that her family would reject her. She remembered getting up and going to school and acting as if nothing happened. Her aunt noted that Patience was a strong girl—she had gone to school for a week before telling her mother. So, Patience placed a tiny flower next to the rock to represent that strength. After stopping for a cup of tea and some bread, the aunt asked Patience to notice how much more rope was left. This represented her future. Patience was surprised to see the rope and said that she didn’t think she would have a future now that she was spoiled. Her aunt encourages her to consider what she would like to be in her future. They continued to discuss this over the next day. By the time Patience returned home, she was able to see that she still had a future. Seeing the rapist still bothered her. However, she was able to go to school with two friends along a new path so that she would feel safe. Patience kept a drawing of the rope with the flowers and rocks and extra rope to remind her that she had a good future.
  2. Accelerated Storytelling. About six months later, Patience visited her aunt again. She was still going to school and able to do more chores (getting firewood and buying food in the market). However, she still suffered from nightmares and sometimes fell down when she heard footsteps behind her. This time, her aunt asked her to help create a “movie” of event. Before Patience was to narrate the rape, they first recounted the safety she felt at home before the rape and the safety she felt when she told her mother about the rape and was comforted. Next, her aunt asked her to identify all of the “actors” in the play: her mother, father, herself, brothers who went to school without her, classmates, teacher, and rapist. Patience then made a figurine out of paper for each actor and drew a small map of her village including the path from home to school. Then, the aunt asked her to tell her story as fast as she could from safe place to safe place and to only look at the figurines (and to move them along the map). Her aunt noted those places where Patience slowed down in the story. When she paused, the aunt asked her to try to keep moving. Once the story was complete (when she told her mother about the rape), she asked Patience to tell the story backwards as quickly as possible. Then, she instructed Patience to tell the story forwards again twice as fast. However, this time, Patience stopped part way through the story. She added one detail she had not disclosed before. She recalled that a young boy of about 5 was peering at them from behind some bushes. Her aunt encouraged her to finish the story and thanked her for her courage. Patience indicated that she was so ashamed of being seen in such a position. Again, her aunt thanked her for working so hard but asked her to tell her story forwards and backwards one more time. Patience noticed that she was less upset by the presence of the 5 year old than she had been the first time through the story.

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July 24, 2013 · 3:45 pm

Tuza 2.0: Day Six and Seven


[June 28-29, 2013, Kibuye to Kigali, Rwanda]

Since my little fire mishap in the middle of the night, this conference has gone ever so smoothly. Our only difficulty has been figuring out what to cut since our talks now take twice the time due to translation time. The cuts have been to case studies in order to protect the cherished small group times. I opened our morning session with a devotional on “the cup of sweet water” and our need to address the bitter water that flows out of us. In a conference like this where we talk about domestic violence and sexual abuse, it is easy to think about evil “out there” in its most grotesque images. However, we all have the roots of this evil even if it only show up as pride and arrogance. I ended our devotional reminding us of the grace and hope given us in 1 John 1:9.

Our morning session consisted of Dr. Beverly Ingelse giving a talk about caring and counseling children who have suffered abuse. After a break and a group picture, we returned to our small groups to respond to some of Bev’s questions and to discuss cases. In my group we went fairly off topic to hear how two of our group members survived the genocide and how they are now dealing with children who did not go through the genocide but have symptoms of traumatic reactions (depression over lost Aunts and Uncles, dissociation during memorial periods, chronic fear). Just in these two stories, they counted 115 murdered extended family members! It boggles the mind of those of us who have only read about such experiences.

Just before lunch I gave a brief talk about how to facilitate storytelling in ways that does not further traumatize the teller. We looked at common behaviors of counselors that support recovery and common behaviors that may hinder recovery. Look for those in an upcoming post!

We concluded our conference a few hours earlier than expected so that attendees could return home to manage household duties prior to Saturday’s Umuganda, or monthly required civil service. We concluded with a short “What’s next?” session led by Baraka. A couple of key ideas were proposed and repeated:

  • One day set aside for hearing and responding to case studies
  • Seminars about integrity for pastors and lawyers (apparently, some very public abuse cases (by pastors) have rocked the counseling community in recent months
  • Network building: the attendees discussed formal or informal counselor network (to promote learning, peer supervision, and support. They requested technical assistance from AACC.

After our last lunch overlooking beautiful Lake Kivu, we boarded a bus and returned to Kigali. I sat next to Worship and her mother (a most precious toddler who batted her eyes at me and played peekaboo with me for 3 hours). Arriving in Kigali at dusk, we ended our day with a meal and good conversations.

Day Seven (the last)

The day started quiet and lazy with a savoring of my favorite breakfast: tropical fruit salad, coffee, and a croissant. It is good that it started this way because last night, neighbors of the retreat house decided that midnight to 5 am would be a good time to remove a sheet metal roof. The workers worked diligently and loudly, singing and laughing right outside my window. Around 5 I fell asleep for about 2 hours. These would be the only 2 hours for the next 40 or so.

As this was our last day in Rwanda, some wanted to get a bit of shopping done. I wanted to be sure to get some Rwanda tea and coffee. We hung around until about noon, when the required civil service was completed. Then, we struck out for good places to buy a few items. Though this is my third trip to Rwanda, it is my first to a shopping district. Some of our team looked for dresses, others for artistic work. I bought a few things but mostly enjoyed the people watching (and being people watched). Back at our Solace Ministries, we got our bags ready and watched a Rwandan wedding get underway. We were told after 3 hours that the bride had yet to make an appearance and that this is quite common–a good reminder of the differences in time culture!

By 9 pm we were boarding our plane to return home. I found it interesting that much of this flight (including the stop in Uganda) is filled with young (mostly female) adults looking to be college age. Some we spoke with had just spent 6 weeks with a professor and seeing various NGOs at work.

This has been a short but fulfilling trip. I look forward to returning in 1 year with our first round of Global Trauma Recovery students.

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