Category Archives: counseling skills

February 10, 2010 · 5:38 am

Delusions and hallucinations: What are they?


Most of us trust our thoughts, feelings, and perceptions. If we hear something, we assume it to be real. Imagine someone telling you that what you feel or heard wasn’t real. Would you be inclined to believe them? Probably not. And the more they tried to convince you that you were crazy, the more you might see them as trying to deceive you.

That is a little piece of the world of those who experience psychotic symptoms–where they believe, feel, hear, experience things that others deny are real.

So, what is happening when someone comes to believe they are Jesus Christ in the flesh? What is happening when someone hears a voice telling them that they should die?

Possible explanations:

1. Misinterpretation of feelings and perceptions. I walk into a room and the hair of my neck rises. Does it mean that there is a lot of static electricity in the room? That I’m nervous in crowds? Or that someone is beaming thoughts at me? One explanation is that I’m mis-reading the data.

2. Mis-firing of neurons in the perception areas of the brain. I know that isn’t exactly the scientific language we ought to use but it is true that certain electrical stimulation of the brain leads to perceiving smells and sights that are not real. Elevations of dopamine and other neurotransmitters are possible causes of psychosis.

3. Real supernatural experiences. It is possible that spiritual forces are at play and the person is hearing what is being sent to them. Now, whether those forces are telling the truth or not may be the question the person ought to entertain. Further, labeling these symptoms as supernatural does not necessitate a supernatural response (e.g., casting out demons). Deception may be broken by basic Christian responses (e.g., prayer, submission to the Word) and by medications.

As a Christian psychologist I believe all three are at play in any disease. We are individuals with broken bodies that do not work right. We are mis-perceiving and vulnerable to deception. I cannot say for sure that someone who believes themselves to be a prophet is lying. However, if they are not evidencing the fruit of the Spirit in their lives then I do question the validity of their identity.

Counselees experiencing intruding sensations and perceptions can break their influence when they are able to attend to other “data”. For example, “I feel others are out to get me but I will live as one who trusts in the Lord rather than in my ability to prove to others that I am in danger.” “I will not use violence or rage to be heard.” “I will not isolate in order to be safe.” “I feel like God has me here for a special reason but I will not neglect caring for my children nor abuse those who do not think I have a special calling.”

Counselors will find more success joining counselees, accepting their reality, rather than merely attacking their beliefs. It is possible that my counselee is a prophet but I can still encourage them to faithful work, love, and honor of those around them.

[Note: I’m not covering the issues of medications, hospitalization, and other psychiatric treatments in this post. These are important and not merely ancillary to the care of those struggling against psychotic symptoms. I am only musing on the possible causes of delusions and hallucinations.]

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February 8, 2010 · 8:29 am

Do no harm?


[This is the second guest post I am making over on the www.christianpsych.org. You’ll have to click the link to read the whole post…]

Every counseling ethics code in existence includes this principle: Do no harm. This maxim is drilled into the heads of counseling students (and any other medical professional as well). Our work should help, not hurt. Who could disagree?

But pause for a minute and consider how you might evaluate whether an intervention helps or harms. What criteria will you use? From what vantage point will you evaluate the criteria you choose? If a medical treatment extends life for an ill patient that would seem good—unless it keeps them alive and in a vegetative state with no possibility of recovery. Some would then wonder if the treatment was indeed best. Or, is it harmful if marriage counseling encourages truthfulness between spouses leading to the revelation of a terrible betrayal leading on to divorce and financial ruin? If honesty is your criteria for helpfulness, then the intervention is sad but helpful. If stability is your criteria, then such counseling is harmful. We could go on and on. Do we use client interpretation of whether treatment is helpful or counselor observation? Do we consider the difference between short and long term evaluation? And importantly for Christians, do we consider only statistical analyses or do we also consider biblical categories (e.g., intervention “A” leads to increased positive affect but encourages clients to pray to another deity).

Despite the muddy water I just churned up, I want to argue that Christian psychology is well poised to help Christian counselors provide treatment that does not harm. This society includes some of the best philosophers, theologians, sociologists, clinicians, and researchers of our day. These members are interested in looking at how people grow and change, how the bible connects with everyday life, common human struggles and effective interventions, etc.

How then do we go about refining our practices and avoiding harm? Let me suggest some steps we might take:

[rest of post on www.christianpsych.org.]

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January 4, 2010 · 12:39 pm

Psychopathology Monday


Happy New Year all. Our semester begins today with the first session of Psychopathology for the first year students. Before launching into the various forms of mental illness and emotional maladies, we consider the larger concept of suffering. Without a careful understanding of (a) the nature, causes, and theology of suffering, (b) the meanings of suffering, and (c) our beliefs and responses to suffering, we counselors become a dangerous lot. We fall prey to simplistic understandings and responses–and fall prey to false hope and false despair.

Sound like a great way to start of the New Year? It does to me because we now have an opportunity to look at ourselves and our world with more realistic eyes than we may have during the stress of the holidays.

Coincidentally, we had a Sunday School class yesterday on the topic of suffering. Our church has buried 10 people who died before their time (so it seems to us!) in the past 5 years. Not only have we had these tragedies, we’ve also splanted a church and been in a transitional malaise for maybe 7 years? The class allowed individuals to talk about suffering and heartache. Good class. We heard those who felt that what was going on was a message from the Lord, from those who just felt confused and in pain, from those who felt the nearness of the Lord during these normal ups and downs of life in a fallen world.

What was said in multiple ways was that one’s perspective or expectations about suffering really impact how one feels about the struggle of life. If you expect life to always be healthy then repeated sicknesses and death will set you back. Someone said there that if you lived in a dirt hut that moving into a trailer would seem wonderful but if you lived in a palace, the trailer would seem a terrible thing.

So, what should we think about suffering and the seeming explosion of death and heartache?

  1. God is saying something AND yet He may not be sending some special message to us
  2. Our actions may cause some of our own suffering but living more righteous lives does not prevent suffering
  3. Suffering is to be expected in this world AND yet it is NOT THE WAY IT IS SUPPOSED TO BE
  4. Isolation and failure to connect to others in suffering ALWAYS makes that suffering worse
  5. Even those who only observe those in suffering suffer as well and need to connect with others in order to avoid despair
  6. Good may come out of suffering, but suffering itself is not good
  7. God, through the cross, bears our suffering and yet it still hurts
  8. It will not last forever

Finally, how do you respond to suffering? Turn away? Become numb? Angry? Probably all the above, right? Take a moment to consider how you respond to suffering right in front of you and watch yourself for those trite statements that can hurt those who are already in pain.

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December 8, 2009 · 1:54 pm

End of semester thoughts


Looking at a stack of papers I need to grade and yet not feeling the energy to do so. Late night classes take more out of me than I care to admit. My physiology class ended with student presentations and a look at bipolar disorder. As we concluded the class, I asked them to remember that,

  1. Even with all the advances in neuroscience, we must humbly admit we still know little how we are fearfully and wonderfully made.
  2. It is good for counselors to keep learning about the body and at the same time hold what they know lightly. Tomorrow may bring evidence to the contrary
  3. Yet, what we know about the body can be helpful. We ought not to look down upon our ignorance but remember that doctors do not always explain or walk with patients
  4. There are great medical interventions available, but (and that but shouldn’t diminish what I said before it),
  5. Over and over we saw that the basics (maintaining balance in life, self-care, mindfulness) are so important to health, perspective, etc. No, they aren’t magic interventions. Yes, they pay-off over time rather than immediately.

On this last point I am pondering a bit and so let me be hyperbolic. Most people who come to see me for paid counseling come because they think (naively) I have some expertise that will shed light on their situation and a solution to their problems. They want me to do something. Why else pay that kind of money? And yet much of what I have to offer isn’t rocket science. Beyond a few fun techniques, what I have to offer is a listening ear, a willingness to walk with the other person in their travail, and encouragement to keep going back to the basics. Most people like the first two but balk at the last one. Why do we balk at going back to the basics? Two reasons: (1) we want something that will fix the problem NOW, and (2) we’ve tried the basics and they didn’t seem to work (see reason 1).

Examples of what I mean.

  • If you are a parent and you go to a counselor to deal with your young child’s behavior problem. More than likely, you will get some counselor telling you to use some reinforcement strategies. And what do many parents say? “I tried that and it didn’t work.” Chances are they did try it and either they didn’t keep at it or they didn’t realize they were doing something that reinforced the wrong thing, or they had a misguided view of what success should look like
  • A couple is struggling with fighting. They go to the counselor who encourages them to return to the basics of respectful talk. Usually, they will feel like they have already tried it–and it didn’t work. Chances are… You get the picture.

In physiology, we see that care for the body includes mindful meditation (My friend and former professor says a substitute word would be “watchfulness”) on the world as God sees it, developing and maintaining good circadian rhythms, watching food intake, exercise, maintaining healthy relationships and social supports. In every mental illness, these things are shown to decrease the severity of symptoms and delay relapse.

Here’s the problem: we forget the basics and because they don’t give immediate results, we go searching for other fast-acting mechanisms. For example, I want to feel safe. Instead of engaging in centering prayer over the long haul, I fall prey to the temptation to act in such a way to avoid all possible danger–thereby increasing my fears of danger.

If I don’t exercise (and I don’t much) I rarely get immediate feedback that my body is falling apart. If I don’t eat right, I don’t immediately gain 10 pounds. If I don’t pray, I don’t immediately get embittered. So, I assume that these basics aren’t all that important. Or, I know they are important but since they don’t pay off now, I don’t do them. I only do what demands I do it to avoid a crisis.

How do we stay on track with the basics? We need another person(s) willing to keep us on a short leash. As a kid I ran because I had a friend who was going to wonder where I was. As a doctoral student, I played basketball at 6 am because my peers would  ask me where I was. I lost some weight a couple of years ago because my wife and I worked together. Notice that the social accountability is a key facet to help us build the disciplines long enough to see that the pay off is more than can be delivered by an exciting new technique.

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November 20, 2009 · 1:40 pm

Edwin Friedman on the search for solutions…


Consider Edwin Friedman’s counsel to leaders in book, A Failure of Nerve (Seabury Books, 2007)

In the search for the solution to any problem, questions are always more important than answers because the way one frames the question, or the problem,  already predetermines the range of answers one can conceive in response. (p. 37)

Seems true for counselors as well. How a counselor begins the exploration of a client’s problem narrows the field of answers as to the problem and solutions. Now, assumptions are always present–especially in questions. So, asking questions doesn’t keep the field of view open unless one is willing to ask questions not normally conceived. It is difficult to remember to ask questions that run counter to our initial hypotheses. And yet such questions are necessary if we are going to counsel actual individuals and not mere figments of our imaginations.

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November 13, 2009 · 4:00 am

When Sex in Marriage Doesn’t Work


Today is the first full day of the CCEF annual conference in Valley Forge, PA. The conference is entitled, “Sex Matters” and so all plenary and breakouts are on said theme. It is not too late to drop by if live in the area and want to register. I believe they will still take walk-ups.

Besides the faculty-led plenary sessions, Lauren Winner (Girl Meets God; Mudhouse Sabbath, & Real Sex) will speak on Saturday. For those of you who can’t come, CCEF sells mp3 downloads on their website.

I will be providing an hour long seminar entitled, “When Sex in Marriage Doesn’t Work” at 4 pm today. We will focus on desire, arousal, technique, and relationship problems (whether perceived, physical or emotional) couples sometimes encounter. Slides and an additional home-grown sex therapy questionnaire is available here (#16 on the list, scroll to the bottom).

The best part is that after I’m done, Biblical Seminary is hosting a pizza party for current students and alums (5:30p) at our information table.

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November 12, 2009 · 3:33 am

On-line counseling courses through Biblical Seminary


Those interested in taking an on-line, graduate-level counseling course might wish to consider this new joint offering from my school, Biblical Seminary, and the Christian Counseling & Educational Foundation (CCEF).

Counseling in the Local Church (2 credits)

The course is taught by Dr. Tim Lane, Director of CCEF and runs from 1/18/2010 to 3/19/2010. It is completely on-line with mp3 lectures, assignments, and threaded discussions with others in the class. You can register here for this class. If you have Internet access and an undergraduate degree, you can take this class.

Later in Spring 2010 we will offer David Powlison’s Dynamics of Biblical Change.

CCEF started Biblical’s counseling program back in the mid 80s and has continued to lend their faculty to courses here and there at Biblical. They have been offering on-line and residential courses (non-accredited credits) for 25 years. In my personal opinion, our joint venture brings together quality biblical counseling and theological expertise with practical and professional counseling expertise!

Now, we have a chance to work together to provide on-line students with quality teaching from CCEF but now for academic credit. (You must have an undergraduate degree already)

What can you do with these credits? Well, for one, you could apply them to a number of Master’s degrees at Biblical. They could count as elective credits in our MA Ministry, MDiv, or MA Counseling program. Second, you might seek to have them transferred to your own local graduate school program. Biblical Seminary is ATS and Middle-States accredited and so will be considered a legitimate institution. However, you should know that every school sets its own polices regarding transfer of credits. Usually they look to see if the course fulfills a course they would have required in their own program. Remember that it is up to you to find out if they will transfer.

Or, you can just take them because you want to be enriched! We’d love to have you as a student!

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November 9, 2009 · 5:44 am

Thinking about moral responsibility and agency in TBI


Tonight I will assigned my Counseling & Physiology students a response paper to the following case study. As you read this fictional case, consider how you might answer these two questions:

  1. What are the spiritual issues in this case and how do you consider Tim’s limitations in considering these spiritual issues? What is his personal accountability in light of his functional limitations and injury?
  2. How might you advise Tim’s wife and pastor as they struggle to understand and respond to Tim’s inappropriate behavior?

Tim is a 34-year-old, married man and deacon in his church. Prior to a serious car accident 2 years ago, Tim was a successful general contractor generating income over $200,000 a year. 2 years ago, Tim suffered a traumatic brain injury when a drunk driver, traveling at a very high rate of speed, slammed into his vehicle. Damage to his brain was located in the frontal and temporal lobes. Tim spent a total of six months in the hospital and in rehab. Initially, He was in a coma for 3 weeks and not expected to recover. However, he did emerge from unconsciousness and with rehab regained his capacities to walk and talk. His memory is mostly intact, missing only the week prior to the accident and the five weeks post accident. He seems to be able to form new memories but complains that he has to write everything down or he will forget tasks. He also complains that it is hard for him to find words. His friends notice that his speech is slower now. He is oriented to person, place, and time.

Tim’s wife and pastor ask you to meet with him. Tim complies. In session he is affable, talkative, but unsure why others think he needs counseling. He notes that he works hard every day, uses his daily contacts in business to talk about God’s miraculous work in his life. He admits that he smokes now and should quit but that shouldn’t be reason enough to warrant counseling. He signs a release to talk to his wife and pastor.

You learn from his wife that Tim has numerous problems that did not exist prior to the accident. Most notably: he doesn’t complete work; fails to bill clients properly; seems to over-estimate what he can complete; work done does not meet his pre-accident quality; he is easily angered and even aggressive; he curses and smokes 2-3 packs per day (none prior to accident); he drinks; he spends beyond his means; he has periods of deep depression; he engages in foul language about sex; is demanding of sexual activity with his wife (but cannot perform since the accident); he flirts with other women.

Tim refuses to return for further appointments. His wife and pastor come to you to discuss options and how to think about Tim’s behavior. The church board has removed Tim from his diaconal position this week and is likely to initiate church discipline after it was discovered that he made a sexual comment to an 18-year-old girl (he commented (spoke admiringly) about her breast size).

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November 2, 2009 · 11:40 am

Technoethics?


At September’s AACC conference I attended a presentation entitled, “Technoethics” by Jana Vanderslice, a psychologist from Texas. She got me thinking about the use of e-mail and other Internet-based technologies with counselees. Here are some of the issues:

1. E-mail. Do you have a policy about your use of e-mail with counselees? Do you inform them about the limits or possible problems that might be encountered? Problems such as security and confidentiality, whether or not you will read them “in time”, what becomes of them (printed out and kept in a file?), whether or not you provide brief counseling through e-mail and possible charges, etc. Dr. Vanderslice suggests having a start to the email that says, “Confidential! This is not meant to take the place of in person consultation…”

2. If you do e-mail counseling, do you (a) know who you are emailing? What data do you collect from the person you provide email counseling to? And (b), do you think about how your email may sound if it is printed off and/or forwarded to others. You should assume that your electronic communications may be passed on. Further, if you have regular e-mail contact, how will you deal with the nature of always being at the beck and call of clientele?

3. Your Social networking accts. Do you use twitter? Do you have a Facebook or MySpace account or the like? Do you “friend” your clients? Do you have anything personal on the web you’d rather your clients didn’t see? This becomes a form of self-disclosure. There may be things revealed about yourself on-line that you would never reveal to a client. Remember, if the client is in the same Facebook network, they can likely see more of you than you might realize.

4. Google searches. Similarly, it might be worth your while to search yourself and see what is out there. Did you know that there are “rate my counselor” type sites out there? Many of these exist to help you find healthcare providers in your area, but include ratings by current or former clients. Do you know what others are saying about you?

5. IT and other providers. Who has access to your accounts and computer? Does your IT dept (if you are in a larger organization) know to honor HIPAA regulations? If you use a vendor (e.g., Geek Squad), they need to sign an agreement to maintain the privacy of the clientele data on your email or database. Can you encrypt email and/or WORD documents?

Can you think of other technoethics issues?

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October 29, 2009 · 8:40 am

Your opportunity to help asylum seekers


For my licensed mental health readers, you might be interested in checking out Physicians For Human Rights (PHR) an organization that helps asylum seekers get proper evaluation as part of determining their application for asylum. PHR has an “Asylum Network” that you can join for free and be contacted if there is a case in your area. These are usually pro bono cases. PHR also provides an extensive guide for those doing psychological evaluations of torture and/or persecution on the website. If you are looking for something exciting to do, I would think this would be a good choice–an opportunity to immerse yourself in another’s world and to care for the “alien” among us in obedience to God. My friend who does this says that you are not required to take cases offered to you and that you determine how many cases you might want to do in a year’s time.

Check them out! I plan to join.

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