Category Archives: counseling skills

April 13, 2011 · 8:24 pm

Webinar on Complex Trauma: April 19, 2011


Diane Langberg and I are scheduled to do a three hour webinar for the American Association of Christian Counselors (AACC) on the topic of complex trauma and sexual abuse. It will run live April 19, 2011 from 6p to 9p. You can learn more about the content of the webinar by visiting this link.

Use the above link to register. Cost is $59 to “attend” via your computer or $69 if you want CEUs. AACC is able to give 3 CEUs for those needing APA and NBCC approved continuing ed.

Our presentation will be broken into 4 segments with Q & A. Topics include: overview, differential diagnoses, 3 phase treatment approach, educating the church about trauma, connecting victims to God, counselor self-care, and next steps for church leaders.

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April 7, 2011 · 5:46 pm

Relationship’s role in therapy?


How important is it to get the right kind of counseling/therapy modality? How important is it to get the right person?

These questions plague both researchers and the people looking to get better. Why do some clients get better and others do not? Why do some therapists have a better success rate and others do not? Does the kind of therapy matter?

Well, as you can imagine, the answer is, “it depends.”

Yes, diagnosis and assessment do matter. If your child begins to struggle with bed-wetting after having been continent, you need to know what the problem is and what to do about it.

But, consider this: various studies make overlapping comments as to what really is going on when people get better

  • One researcher suggests that some 85+% of the reason for change are factors pertaining to the client and what is called “extratherapy” factors (social support, physical health, etc. )
  • Another places the portion the therapist plays in the 13% or so

Confusing? Consider this stark fact presented at a recent conference I attended

Patients receiving placebos from the top (best?) 1/3 psychiatrists fared better than patients who received actual medications from the bottom 1/3 psychiatrists. This was cited from the following study: Kim, D., Wampold, B. E., & Bolt, D. M. (2006). Therapist effects in psychotherapy: A random-effects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data. Psychotherapy Research, 16(2), 161-172.

So, when you are looking for a therapist or psychiatrist, you may want to know if he/she studied at Harvard or a degree mill. But, you may be better served to by one who listens to you, doesn’t fall asleep, and is able to collaborate with you to find a solution that works for you.

The moral of the story? Better to have a good psychiatrist with no meds than a poor one with a gunnysack full of pills.

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March 8, 2011 · 5:58 am

How many patients can you see in a day?


Ask a counselor and you might hear of one who has seen 10 clients in a day…10 hours of therapy. I suppose I”ve done as many as 12 or 13 but that was a rare case and likely some emergency.

What about seeing 40… in one day!?

That is what some psychiatrists do. Of course, to do that many, most patients are seen only for 15 minute med checks rather than the 90 minute first session for first-time patients. Psychiatrists used to be the primary therapists. But with the advent of psychiatric medicines,  many psychiatrists no longer do therapy and only make diagnoses and prescribe/manage medicines. For an interesting view from the psychiatrist’s chair, check out this NY Times article interacting with a local psychiatrist who has worked through the transition from therapist to med manager.  See how he tries to not get too involved with patient problems given that he hasn’t the time to do much on the fixing end.

There are only two reasons why anyone would see so many clients in one day

1. Economics. More volume, more money. Plain and simple.

2. Demand. Good psychiatrists are hard to come by. Even more true if you are talking about child psychiatry! If you find a good one, chances are you have to get in line.

Now, before anyone thinks I’m taking shots at psychiatrists, let me tell you I am not. A good psychiatrist is a very helpful aid to us psychologists. Family Docs and other general practitioners may be able to prescribe but I find psychiatrists (good ones!) really know their compounds and are much better at titrating doses. And not all of them just throw pills at the problem. Even in short interactions, the psychiatrist to whom I refer has been able to help my clients understand themselves just a bit better.

Back to the original question: just how many different people can you meet with in a day and still be attentive? When I started out counseling, I could barely see two people in a row before being overwhelmed. Now, I regularly see 8-10 on a day (okay, I only do this one day per week, but before becoming a prof I did 25-30 per week). I can attest that it is a learned skill and I don’t think the last client gets less of me than the first. That said, there is a limit and a point at which what I do suffers.

What is your patient/client limit?

For me, it is less about the number of sessions and more about whether I eat and have a moment to go to the bathroom. There’s nothing that kills the focus as much as a bursting bladder and 45 minutes to go!

I’ll leave you with a funny story. At a doctoral practicum I saw clients late into the evening. My last client of the evening (same person each week) had a habit of bringing me Starbucks coffee. I think he was trying to make sure he was going to get his money’s worth out of me!

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February 10, 2011 · 5:26 am

When theory, technique and person combine…


Am trying to write an academic journal article on clinical applications of Christian Psychology. Heady…I know. Too heady for me I think. However, in my study I ran across these quotes from

Leitner, L.M. (2007). Theory, Technique, and Person: Technical Integration in Experiential Constructivist Psychotherapy. Journal of Psychotherapy Integration, 17, 33-49.

From his abstract:

From an experiential constructivist position, the distinction between the therapist as a person, the therapist’s theory of psychotherapy, and techniques used within the therapy room is, in some ways, forced and arbitrary.

He starts out this article, after the abstract with,

“Becoming a psychotherapist is not about assembling a bag of tricks and learning the formula for matching tricks (i.e., techniques) with problems. What you do as a therapist emerges from who you are in the therapy room. And, when an intervention comes from who you are, it is no longer a technique.”

SO, it stands to reason that we ought to view therapists in their sessions in order to see what kind of people they are. We therapists often think in terms of theory to practice. But practice probably reveals a truer picture of our theory.

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February 5, 2011 · 12:12 pm

Single session therapy?


Anybody ever found just one session of counseling productive (meaning you only went once but it was extremely helpful)?

Counseling takes time…usually. You want to get to know your client, hear their history, learn how they think and feel, what they have already tried, and walk with them into some new ways of thinking or responding to their life situations. This kind of work takes time, a lot of time in some cases. And the solutions take even more time.

But I suspect there are some folk who could benefit from just 1 hour of troubleshooting. If you have had one of those experiences, what happened? What was helpful?

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February 2, 2011 · 5:36 pm

Forthcoming:collaborative book addressing sexual abuse


Andrew Schmutzer, an OT professor at Moody, is editing a collaborative approach to the topic of sexual abuse. Chapter writers include psychologists, theologians, and pastoral care providers. The book is due out this coming July/August and is to be published by Wipf & Stock.

Title: The Long Journey Home: Understanding and Ministering to the Sexually Abused

Check out the Long Journey Home TOC for chapter titles and contributors (including your’s truly). My chapter is intitled, “The Nature of Evil in Child Sexual Abuse: Theological Consideration of Oppression and its Consequences”

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February 1, 2011 · 11:27 am

Uncomfortable with a conversation? Change the subject


What is your usual response to someone who brings up your “stuff”? You know, that stuff you’d rather not talk about because it is embarrassing or painful or causes you to have to confront some issue in your life? And yes, I know it matters WHO is doing the bringing up and HOW.

But if we are honest we probably recognize the tendency to blame-shift by bringing up their stuff or change the subject to some intellectual debate in order to get off of the topic of us.

At the end of yesterday’s post I mentioned the passage in John 4 that tells about Jesus’ interaction with the woman at the well. Notice a few of her responses as a result of her discomfort:

1. Jesus asks for something………she’s suspicious and defensive and brings up Jewish arrogance against her kind of people

2. Jesus offers something………she’s wondering how he thinks he’s better than their forefather Jacob

3. Jesus tells her to get her husband (she is living with someone not her husband)……..she tells a partial truth

4. Jesus tells the woman her own private story–5 husbands and the one you are with isn’t your husband (notice he doesn’t call her a liar but actually validates her half-truth)………she brings up a doctrinal debate between Jews and Samaritans.

5. Jesus avoids the debate and gives a bigger picture…….the woman THEN drops her defensiveness and gets her village-mates to come see Jesus

We’re probably a lot like this unnamed woman of ill-repute. We blame-shift, focus on possible problems of the other, tell half-truths when cornered and then finally resort to rabbit trail debates all so we can avoid facing certain things about ourselves.

The good thing is that God rarely lets up in his gentle but persistent pursuit.

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January 5, 2011 · 5:06 am

Additional information on the March 2011 sex trafficking and abuse conference at Biblical Seminary


I’ve mentioned the conference before here on this site. But here is additional information for those considering the conference in order to acquire either graduate academic or continuing education credit.

NOTE:

  • Conference dates: March 17-19
  • The conference is free for all attendees, only those who want CEs or grad credit will have to pay a fee
  • A PDF of the information below is available here: Please pass on to anyone who might be interested.

Continuing Education at Biblical Seminary

March 17-19, 2011

The Biblical Call: A Christian Response to Human Trafficking and Sexual Abuse[i]

Mental health professionals and clergy interested in attending this seminar may be able to acquire 10 contact hours of continuing education by attending this conference. Biblical Seminary is an accredited graduate institution and thus is qualified as a pre-approved provider of continuing education in the form of graduate coursework by Pennsylvania’s State Board of Social Workers, Marriage and Family Therapists, and Professional Counselors (§47-49.36) and Pennsylvania’s State Board Of Psychology (§41.59). (Attendees who wish to receive academic credit should follow directions in the footnote below.)

While Biblical Seminary provides verification of attendance and a transcript showing completion of the CE course, attendees are responsible to verify acceptance of these hours by their particular licensing boards prior to registering and paying for CEU credits.

The following information may be used to apply for approval to your licensing body.

Speakers:

Diane Langberg, PhD; Bethany Hoang, MDiv; Pearl Kim, JD; Robert Morrison, MBA; Philip G. Monroe, PsyD

Seminar Overview:

This conference continues the “Conversations on Christianity and Culture” series focusing on sexual violence and injustices in a variety of contexts: domestic and international settings and sexual abuse in Christian communities. Attendees will explore these issues from biblical, psychological, legal, and sociological perspectives. The conference will conclude with a focus on practical intervention and prevention strategies.

COST:

The conference is free for all attendees. Register here. Those who wish to receive CE credits will be charged $20.00 per CE unit (0-9 credits) or $180.00 for all 10 CE units. Attendees will be billed following the conference and certificate of attendance will be held until payment is received.

Educational Objectives:

  1. Become familiar with the psychological and sociological data regarding domestic and international trafficking phenomena and also sexual violence within Christian settings
  2. Describe common community and individual consequences resulting from these sexual traumas
  3. Consider biblical and theological factors relating to sexual violence
  4. Identify effective and practical interventions as well as preventative actions to treat and stop sexual slavery and sexual violence

Tentative Schedule:

Thursday, March 17

Speaker Title Time length
B. Hoang Biblical Call: Response to Violence (obj. 3) 1:15
D. Langberg Biblical Call: Global Violence against Women and Children (obj. 1-3) 1:15

Friday, March 18

Speaker Title Time length
B. Hoang International Human Trafficking (obj. 1) 1:15
D. Langberg Domestic Human Trafficking (obj. 1) 1:15
Breakout Sessions (choose two as each session is repeated; total length: 2:30)
B. Hoang Follow up from morning session (obj. 3) 1:15
D. Langberg Follow up from morning session (obj. 1-3) 1:15
P. Kim Spiritual Warfare and Criminal Prosecution (obj. 3) 1:15
R. Morrison Mobilizing all Christians in Effective Action Against Human Trafficking (obj. 4) 1:15

Saturday March 19

Speaker Title Time length
D. Langberg Sexual Abuse in Christian Organizations (obj. 1-4) 1:00
Panel (all speakers) Panel Discussion (obj. 1-4) 1:30

[i] This course is also available for one (1) academic credit. Credit students will be required to complete additional readings and coursework after the seminar. Those interested should view the course syllabus on our school’s website and complete a brief, online non-degree application. Cost for a one credit course is $447.

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December 21, 2010 · 4:02 pm

Christian anxieties?


In light of the holiday stresses and anxieties, I bring you a couple of thoughts regarding “Christian” anxiety.

Everyone faces anxiety at times in their life (unless you lost your amygdala) But some anxieties are unique to evangelical Christians:

1. What if I am out of God’s will? What if I make the wrong choice?

2. What if I committed the sin of blaspheming the Holy Spirit?

3. What if I am missing out on the blessing of God? What does it mean if I don’t feel thankful?

4. What if God wants me to stay in this awful situation? What if my situation is God’s punishment for previous sins?

5. What if I’m not sure I believe? Am saved? Have faith?

6. Is God holding out on me because I have weak faith?

I’m sure there are more you could list (feel free to add to this!) that are unique to Christians.

When working with someone struggling with these kinds of intrusive spiritual fears (aren’t all fears intrusive?), I have noted that they often

  • struggle with frequent guilt
  • are comforted by voices around them telling them that they are okay…but the comfort doesn’t last very long as cognitive efforts to convince them they are wrong fail
  • work very hard to do Christian service–sometimes to the point of compulsion

If you or someone you love struggles with these fears consider the following recommendations

1. Listen for the deepest concern. What if’s are almost always present in anxiety. What if I’m not saved? What if God isn’t going to give me my desires? Instead of responding to the surface fear, listen between the lines for deeper concerns (without debating them). For example, fears about not being sure about faith may really be a deep sensation of guilt and or failure to be perfect.

2. Validate AND encourage re-evaluation of the meaning of the fears. Always begin with validation—communicating that (a) it is clear the counselee has a real problem that needs attention, (b) such concerns are painful, BUT—and this is important—, (c) it might be possible that they have mis-identified their spiritual problem. Fear tends to deceive the mind and misdirect attention away from more important matters (e.g., a worry about germs focuses attention on cleanliness but away from underlying fears of being out of control).

3. Counter fear with STOP and MEDITATE techniques. Most people have their self-soothing techniques. Unfortunately, some of these can add to the anxiety. For example, repetitive “Lord save me” prayers will only lead to more belief that you may not be saved. Look for these repeated responses to fear and try to stop them–even if they seem rather religious in nature. Instead, look to meditate on some other part of the bible or of the character of God–something completely out of the orbit of the fear.

4. Develop alternate goals. Most anxious people would like not to be so. Who can blame them? But eliminating anxious spiritual thoughts may not be a good goal. And, the efforts to do so may only increase the spiritual angst. Yes, medication and preceding efforts may reduce anxiety, often the fears remain active in the background. An alternate goal might include (a) resisting the old dialog that engages the fear as important, (b) choosing to use the stimulus of the fear to focus on a specific person in need (a shut-in who needs a call, praying for someone else, etc.). These alternate tasks will reduce the anxious person’s thoughts about self…and thus reduce their anxiety.

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November 15, 2010 · 9:53 am

Can you change your nightmares?


Blogging has been much harder this fall with a busy teaching and traveling schedule. I’ve been doing a lot of reading and thinking about best practices to deal with trauma in international settings–specifically in the Great Lakes region of Africa. Diane Langberg and I have been consulting with a Christian organization to help develop those practices with a local, sustainable mindset.

One of the recent items I read had to do with attempts to address repetitive “posttraumatic nightmares.” Bret Moore and Barry Krakow published, “Imagery Rehearsal Therapy: An Emerging Treatment for Posttraumatic Nightmares in Veterans” in the September 2010 issue of Psychological Trauma: Theory, Research, Practice, and Policy (v. 2, 232-238).

Imagery Rehearsal Therapy (IRT) attempts to alter nightmares by changing the storyline of the nightmare. The authors view nightmares as learned behavior such as insomnia. The CBT style treatment entails

  1. education about the relationship between nightmares and insomnia.
  2. education about cognitive restructuring via imagery
  3. client selects a particularly disturbing nightmare (maybe not the most disturbing one first)
  4. Client then instructed to “change the nightmare anyway you wish” (notice they are not asked to make it positive or even less distressing)
  5. Client then rehearses (over sessions) the new dream through imagery techniques

Previous controlled studies indicate a reduction in nightmare frequency and intensity. This particular summary article reports that the evidence is there that veterans find it helpful even at 12 months post treatment with 4 sessions.

A couple of things to note. There may be some effect of desensitization from rehearsal of the initial dream (exposure therapy) though the exposure is brief. Also, the client does not spend time rehearsing the actual traumatic events in this therapy–only the nightmares.

Some thoughts:

  1. This treatment makes sense. Ever have a dream that seems to go on and on, or one that you go back to upon waking up in the middle of the night. Often we may find ourselves trying to make the dream turn out okay. This treatment uses our fully awake brains to rehearse something we want to think about.
  2. If nightmares are the result of a collection of anxieties then it stands to reason that repeating new thoughts and images will begin to make associations in the brain that might compete with the anxieties.
  3. Christian living emphasizes re-telling the truth to ourselves. Consider how OT authors remind readers of the Exodus or Paul reminds the Ephesian readers of their prior state (chapters 1-3). What we rehearse does have an impact on our brains.
  4. Finally, some of our nightmares seem written in indelible ink. Do you still have test anxiety nightmares 20 years after your last class? I do. But I feel differently about them now than I might have back when I was still worried about school. It may be that we begin to feel differently about the nightmares. The less we are bothered by them the more infrequent they will be.

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