Category Archives: counseling skills

March 24, 2008 · 11:03 am

Science Monday: Easing the suffering in schizophrenia


While few outpatient, private practice therapists deal much with those diagnosed with schizophrenia, there are things therapists can do to ease the suffering of both client and family. Kim Mueser, a professor at Dartmouth Medical School has published a number of helpful research and popular writings designed to increase social and cognitive functioning and decrease family distress in people with schizophrenia. Click here for an Amazon.com list of his writings. His Complete Family Guide (#1 on the list) is probably the best though several other texts may be just as useful depending on the reader’s focus. And while medications are important in the treatment of schizophrenia, it is quite clear that when families and client learn to minimize family distress and conflict, they also reduce active psychotic episodes

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There are a number of interesting research angles on the pathways of Schizophrenia. One such hypothesis is that the croticostriatal loops do not work correctly in such patients. In lay terms this means that information doesn’t flow normally from the frontal lobe of the brain to some of the mid-brain structures and then back again. This seems to be part of the cause of apathy and lack of volition and/or planning. One wonders whether the longer time it takes for information to flow properly in order to make a decision or interpretation increases the likelihood of making random assumptions about the world. I know that when my children get stuck in a math problem, they are more likely to begin wild guessing to complete the task.  

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March 19, 2008 · 10:01 am

Integrative Psychotherapy X: Schema interventions for depression


In the last chapter the authors theorized about our propensity to live out of socially constructed schemas. Now in chapter 9 of Integrative Psychotherapy, McMinn and Campbell apply schema-focused interventions (domain 2–dipping beneath symptoms to core issues) to the problem of depression. But before they get to that task, they make these 2 points:

1. It’s “incorrect and potentially dangerous” (p. 278) to assume one does symptom focused interventions with anxiety problems and deeper level interventions for depression. Instead, the therapist ought to move seamlessly between them as needed. They remind the reader that their chapters are illustrations and not manuals.
2. There are useful symptom based interventions for the problem of depression that should not be overlooked: (a) medications (they explore fallacies that keep people of faith from using them and point out that meds are sometimes better than counseling alone), (b) behavioral techniques (keeping an activity schedule, assertiveness training), and (c) cognitive restructuring (keeping a dysfunctional thought and challenge record).

At this point the authors begin to illustrate their version of schema-based interventions. Unlike classic interventions (diagnosing the underlying schema and then correcting it), they describe recursive schema activation which is designed to “give clients many opportunities, session after session, to decenter [see life from another perspective] from the deep, persistent themes of their lives that can never be fully obliterated” (p. 288-9). The main difference between the IP model and the classic model is their humility in seeing schemas as understood and managed rather than corrected. Also, they desire to activate and experience schemas as much as talk about them.

The goal of this part of IP is to stand apart from one’s schema so as to see it and choose to deactivate it where it is not helpful. In the case of depression, it means standing back from “depressogenic thoughts” using mindfulness and spiritual disciplines. The client doesn’t challenge thoughts so much as he or she activates the schema in counseling over and over in a manner that allows distance and the possible formation of a new schema or identity.

Just how does this work in therapy? McMinn and Campbell suggest these strategies:

1. Taking a life history to identify re-occurring themes that might signify the presence of maladaptive schematics (e.g., long history of feeling rejected by others). In taking the history, the client not only tells but re-experiences the schema with the counselor
2. Schema inventories. They mention one in particular: www.schematherapy.com. These are used to get the client thinking about schemas that contribute to their problems.
3. Discussion of faith. The therapist explores how the client’s view of God fits in their view of self. The assumption is that a maladaptive schema likely contains distortions of the character of God. The goal is to understand at this point, not correct.
4. Moving from specific to general. Clients often describe recent painful events (and thoughts and feelings). The therapist encourages the client to explore how these thoughts and feelings fit their general conclusions in life (e.g., people always leave me).
5. Looking for themes. The counselor looks to articulate and activate themes and creates space for the client to do the same.
6. Evoking emotions. The counselor needs to move from an intellectual discussion to the emotions attache to the schema. Often-times, this means using the here-and-now to explore emotions. Otherwise clients only report on feelings in a disconnected manner. If so, they remain disconnected from the insights they gather.
7. Guided discovery (vs. just telling the client the interpretations). The authors present a good illustration  of the difference between telling and collaboration on p. 298.
8. Imagery and meditation. The goal here is to use these techniques to activate and deactivate schemas. Why? They suggest these techniques support safety (to limit overwhelming oneself). They do note that while prayer may help in schema alteration its primary purpose is to connect with God and shouldn’t be thought of as some technique apart from its main purpose.

Finally, in the last 13 pages the authors take up how recursive schema activation is a bridge-building exercise. It bridges cognitive processes (logic, analysis) and emotional and relational processes; unconscious and conscious processes; past and present; events and meanings that we give them; schema activation and deactivation. They conclude that not every person has the psychological resources to deactivate schemas once activated and point the reader to the next two chapters where relationship interventions will need to be used.

MY THOUGHTS: This is a good chapter that describes what I think is core to therapy: self-observation in a safe environment that happens as much through experience as it does through logical analysis. The reality is that our schemas shape our sense of self and the world as much as our 5 senses do. We think we merely ascertain what is happening to us but in fact we are prepping our critical thinking with assumptions. Here’s my question. Is the schema something that can be changed. I hear the authors saying that they aren’t all that optimistic about it but just maybe we can control it, decide not to listen to it. In part I agree. And yet I don’t want to underestimate just how much a person can change their outlook on life and self. Where I think the biggest challenge lies is helping clients feel safe enough to accept that they make these assumptions. In couples counseling I find many/most couples unwilling to consider the possibility that their assumptions about their no-good spouse were formed before the ever met their spouse. They come wanting to fix the marriage and part of my job is to help them see that before they can fix the marriage they need to understand how their responses tell a lot about themselves and maybe less about their spouse than they think. This is hard for counselees to accept because it sounds to them that they are responsible for their spouse’s bad behavior. Helping a client not live in all/nothing thinking is my challenge. Further, I must make sure not to fall into “telling” mode when helping someone come to this realization. Sometimes I want to speed up the process and thereby lose the client.

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March 14, 2008 · 12:06 pm

Note-taking in sessions?


Counselors have vastly differing styles of counseling. Some choose to be directive, others are remain passive even when the client wants them to give advice. We are different because of our varying theories and personalities. But I always assumed that most counselors do not take notes during sessions unless needing to record very specific details (say taking a family genogram or collecting details for a psychological report). But after having conversations in several different locations I learn that many write during the session. They write down key client phrases and other things that they wish to come back to and explore at a later date.

I’m curious about your experiences–either as a counselor or counselee. Was there note-taking going on during the session and was it helpful (for both)? Did it cause problems?

I don’t take notes in session so that I can stay engaged in good dialogue with my clientele. I don’t want to miss subtle details and I don’t want to break up the work by taking a note. It seems to me that if I take a note during the session, the client waits for me to do so and then they move out of an experience to only describing an experience–and so distance themselves from their feelings and thus any insight or intervention is also distant.

What do you think?

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February 28, 2008 · 5:23 am

Integrative Psychotherapy VII: Functional Domain Interventions


McMinn and Campbell start out chapter six (a deeper review of the 1st domain of interventions, that of addressing symptoms) with this helpful insight: “Many of our graduate students select psychology as a profession after deciding against one of two alternative career paths.” Some are tempted to pastoral ministry and so see psychology as a way to care for human souls. Others are tempted to medical practice and so see psychology as a way to, “help people find relief from their troubles” (p. 177). This distinction is helpful in explaining why some of us hang out in one type of intervention over another.

But whatever one’s interests, everyone must address presenting problems and not bypass symptoms as these are what bring people in to therapy in the first place. So, the authors use this chapter to outline, in general, symptom-focused interventions, The next chapter will apply these interventions specifically to anxiety.

Right off the bat, the authors bring up emotions. They want to dispel the myth that cognitive therapist care little for feelings. They want to define negative emotions as either a sign of cognitive distortions and/or a warning sign that something is off in one’s life. [Hopefully, they do not fully believe that negative emotions means that something is wrong in one’s life. It may be something is wrong in the world…]. To achieve successful interventions in this domain, one must have good relational skills to listen well to both explicit and implicit feelings.

It comes as no surprise that domain 1 interventions include behavioral skills. The authors summarize classical and operant conditioning in a few short paragraphs and suggest that these techniques may help clients have dominion (through reinforcement strategies?) over their own behaviors and responses to life. Their lack of attention to behavioral mod. sends a message.

The bulk of the chapter then focuses on the basic of cognitive restructuring. They divide this task into two parts: sorting an experience into its component parts AND challenging distorted thinking. The authors describe the technique of the thought record and walk through several vignettes to show how it might be used. The record separates situations, thoughts, and feelings (and rates intensity of feelings/experiences on 1 to 10 scale). As the client gains insight, then the work is to counter the automatic thoughts with a rational response. The authors want to remind the counselor to avoid a disputing mindset when countering a client’s distorted thought patterns. Instead, they suggest a more collaborative approach or “Socratic method” using questions and reflections to lead the client to insight rather than drag them to it. 

Beyond the thought record, they describe other methods of changing one’s thinking: scaling (moving away from all/nothing thinking to put stressors in proper perspective), probability estimates (used when someone is worried about an unlikely event), decatastrophizing (helping to move away from “extremist thinking”), humorous counters (identifying silly thinking without making fun of), role-playing (reversing roles and having the client become the counselor), paradox (overstating the client’s fears to see the logical outcome), and cognitive rehearsal (repeated challenge to automatic thoughts).

Finally, they attempt to provide a Christian appraisal of these interventions. First, they tackle the problem of relativism that may underly CT by the biblical concept of testing and trying every “truth.” Instead of rejecting all client automatic thoughts by some sort of Stuart Smalley self-talk mantra, test their thoughts with Scripture, tradition, experience, and reason—aka Wesleyan quadrilateral. Then they give some examples of how a Christian collaborative response to a client with a difficult marriage might look different from a relativistic (be happy) response. The client and the counselor work together to explore what Scripture, tradition, experience and reason might bring to the table (these are not considered equally weighted of course) in discerning the truth about our selves and our thoughts about ourselves.

My thoughts? This chapter is solidly within the CT frame with the recognition that truth has a capital T. Our job as counselors isn’t to tell the clients the truth but to walk with them in a collaborative manner. It is good to see lots of humility in the chapter. We can abuse Scripture, overplay tradition or reason, become disputational, etc. What is missing from this chapter (maybe in comes later) is that while it is helpful to recognize logical errors, it is also true that logic does not always (often?) lead to better thinking. We have some pretty embedded views of ourselves that continue even in the face of our logic. How will they deal with this issue?

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February 12, 2008 · 5:06 am

Good questions when dealing with counseling crises


I’m doing a training with a local counseling center today about dealing with chronic crises and short-term crises. I have a list of questions I think we outpatient counselors ought to ask ourselves in order to keep from missing key helps for those we serve:

1. What supports (family, professional, church) really exist? Which of these are stressors?
2. Am I the primary or only provider? Why? What do I need to do to eliminate this problem?
3. Have I expressly recommend/required other team members. Have I communicated with those already on the team (assuming releases to do so)
4. Have I sought supervision?
5. What course of treatment might this person receive at another center? What is my rationale for why I am or am not following that course?
6.  What plans have I devised, with the client’s cooperation, to implement during the crises? Am I responding to motivation breaches
7. What impediments exist that block optimal functioning? What impediments hinder counseling?
8. Do my goals reflect the need to address impediments first? Have I triaged goals and objectives?
9. Do my feelings for the client hinder my ability to care for them well? Would I treat a new client differently?

These are not all of the questions I think we should ask, but these may help us focus our attention on important matters that have escaped our notice.

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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 19, 2007 · 5:48 am

Should you listen to your clients?


In chapter one of Workmen of God, Oswald Chambers has this to say about the work of curing souls (bold emphases mine):

Keep these three things in mind—reliance on the Holy Spirit of God, keeping in contact with people, and above all, keeping in contact with the revelation facts in God’s Book; live amongst them, and ask God how to apply them.

Another thing I want to mention—never believe what people tell you about themselves. There is only one person in a thousand who can actually tell you his or her symptoms; and beware of the people who can tell you where they are spiritually. I mean by that, never be guided by what people tell you; rely on the Spirit of God all the time you are probing them.

Let me read you this in regard to medical treatment—

Recent evidence in the law courts has pointed to a fact which the medical profession holds of great value—the necessity, not only of personal and private interview with a patient, but of the penetrative ability to get at the real facts and symptoms. In other words, successful diagnosis depends on the doctor’s acumen in cross-examination. “Cross-examination of a patient is almost always necessary,” says an eminent medical man. “They will give me causes, or rather what they think are causes, instead of symptoms. The rich patient is more troublesome in this respect than the poor, for he has had leisure in which to evolve a sort of scheme of his illness, based on ‘popular’ medical knowledge.

“Patients always colour facts, speaking absolutely instead of relatively. They never tell the truth about the amount of sleep they have had or as to appetite. They frequently say they have had nothing to eat. Casually you find there were two eggs at least for breakfast. A minute or two later they remember stewed steak for dinner. Perhaps the greatest need for cross-examination is that it gives an extended opportunity to the medical man to examine the patient objectively. The most important symptoms are generally those the patient never notices.”

If that is true in the medical profession which deals with men’s bodies, it is a thousandfold more true about spiritual symptoms when it comes to dealing with a man’s soul. Do beware, then, of paying too much attention to the talk of the one that is in trouble, keep your own heart and mind alert on what God is saying to you; get to the place where you will know when the Holy Spirit brings the word of God to your remembrance for that one.

If you are unacquainted with Chambers, you might think him rather harsh and condescending to those he ministers. To the contrary, he very much cares for the souls he serves. In fact, his next lines are some of my favorite. He confronts those who love to hurl bible texts at others without listening to the Spirit.

So, how might these thoughts from Chambers inform the counselor?

Listen to what is being said, even if not the actual words. It is not hard to hear the heart cry despite being dressed up in words that accuse the self or other for causing the misery presently experienced. Then, consider what the Spirit and the Word have to say to that heart cry (Chambers alludes here to John 14:25).  It is a delicate balancing act to listen to our clients describe their dream of a solution to their problems, validate that dream, and yet bring reality into that dream. Sometimes, we are called to help them see how their dream leaves themselves out of the solution? Sometimes, we are called to help them work where they have the power to make changes and let go of those areas where they do not.

So, listen, validate, and yet point to those areas where God is leading the client. Of course, this assumes that the counselor is in touch with the Spirit and not just in touch with their own mind.  

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November 28, 2007 · 4:57 pm

Watching student videos


Am grading student videos of their first counseling experience in their very first class. Here are two reflections

1. I’m amazed at the depth of problems their counselees choose to bring up right away. These are people who know they are being videotaped for a class project and though only the grader and the student watch it, it is still taped. And yet, they tell about very personal matters. I’m blessed to be able to hear their life struggle and the student is blessed to hear it as well. I can’t say that I would talk about such deep matters if I were asked to be a counselee for a beginning student.

2. First year counselors do pretty well when it comes to gently attending to their clients and exuding kindness, empathy, and compassion. What is harder is for them to identify and discuss subtle and/or painful emotions expressed by the client. Instead they go for more data from the client. Get more history, more details and maybe it will be better. I think we do this when we listen to our friends. We provide pithy advice, we want to know more details, or worse–we talk about ourselves. My students know not to talk about themselves but yet they struggle to identify and repeat painful emotions.

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September 25, 2007 · 9:51 am

Your negative mood and how you view your loved ones


When you experience negative emotion in your most intimate relationships, what do you do? A recent study published in the Journal of Counseling Psychology (54:4, 2007) suggests that we are inclined to place much of the blame on our loved ones. Instead of attributing the problems to external factors (as we tend to do when feeling good), many tend to attribute the cause of their unhappiness to their spouse’s character or behavior. The researchers suggest that when we feel happy we broaden our cognitive focus and when we feel unhappy, we narrow it down to the most salient (convenient?) factors–our spouse’s behavior.

A couple of other interesting factoids that came out of this study. When either partner is unsatisfied in the relationship, the woman engaged in more demanding behaviors (blaming, discussing, putting pressure on the other) as opposed to withdrawing behaviors. When couples improved their relational mood by attributing the positive change to either individual, they were less satisfied than when couples improved their relational mood by attributing the positive change to environmental factors.

Does this make sense to you? Why would couples have more satisfaction if they think external factors account for their positive mood than if they attribute positive change to one or the other? Are we suspicious of our spouse’s motives? Don’t really believe their good behavior will continue?

Here’s why this matters for therapists. As the authors say, we are generally trained to explore a couple’s presenting problem, investigate the history of the problem, and then intervene. They suggest that this will INCREASE the couple’s negative emotions and tempt them to choose a bad solution such as blaming the other or withdrawing. This may suggest that therapists begin couples counseling by increasing positive mood before jumping right into the problem. The authors also remind us of some of Gottman’s research that how a conversation begins has a huge impact on the rest of the conversation and influences the particular problem-solving skills a couple uses.

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June 6, 2007 · 5:30 am

What is the method of Christian counseling?


In chapter 4 of Christian Counseling, Malony and Augsburger attempt to prescribe what should happen in counseling, “after you say ‘hello?’ In other words, What do you do when the door is shut and there is nothing but space between you and another person?” (p. 26). Note that they do not intend to survey what Christians do, but what they should do.

So, what should they do? The authors suggest that like all counselors, Christians should listen first; advise second. The first part is universal to all counselors, the advising will need to be uniquely Christian. So far, so good. At this point, the authors detour into what behavioral essentials mark the Christian life: prayer, worship, bible study, acts of service to others. The question they undertake is to discern whether these activities are to be part of the counselor’s work with the client. The authors answer both yes and no.

Yes, these behaviors are important in reaching the “master motive” of Christian counseling: increasing and maintaining a sense of God (p. 28). To do so counselors help people encounter (not study) God AND to interpret that experience (just as Moses encounters God at the burning bush, so he also needs God’s words to understand. So, there are explicit uses of prayer, scriptures (not worship as they deem that a church role), and service.

No, the counselor does not always explicitly use these activities. They may incarnate Christ through modeling and not words.

So, how do the authors suggest that be worked out? Intentionality in the following way:
Action 1: Pray for the session prior to meeting with the client
Action 2: Invite the client to pray silently and end with a liturgical phrase such as, “The Lord be with you…”
Action 3: Proclamation: The risen Christ is with us (naming that Christ is present in the session)
Action 4: Creative middle: the heart of the counseling that may be following a particular counseling model. Mostly, there will be searching for insight and moving towards practicing new habits.
Action 5: Committing clients to God

Commentary: If I were more liturgical, I might like this. But I’m not. I’ve never done exactly what they say. However, I think it is helpful to remember why we are counseling (the superordinate goals). And so, I do pray for clients and for wisdom, we do have a middle part, and then we ask for God’s help at the end. My beef with this chapter is that the creative middle is massively important. How does one use the Word there, if at all. How does one listen and advise. Too little is given to that area. I understand that there will be differing opinions but a methodology chapter that focuses on starting and stopping sessions misses much.

What do you think about the essential behaviors of the Christian life? Somehow they cover most of it and yet of course it feels rather thin since lists never convey the rich vitality of living in community.

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