Category Archives: counseling

5 Approaches to Counseling and Christianity


There was a recent conference in Tennessee where the authors of the recently published, “Five Approaches to Counseling and Christianity” (IVP) presented their approaches, dialogued with each other, and showed brief vignettes of their counseling model in action. You might like to see some of the papers and slide presentations by each of the authors. Do so by following this link. At the bottom of each bio, you can find the link to their presentation. They do not have the video clips of counseling available. I, for one, hope they make them available for sale. Despite the diversity of theories, I suspect their actual counseling activities do not differ all that much.

Phil

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The purpose of retreats in counselor education?


I have another post over at the Biblical Seminary faculty blog describing three reasons why we require our counseling students to attend our program retreat each fall.

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More on “Can Your Body Make You Sin?”


I’ve written about this topic here and here before. In those posts I argue that there is a better question for counselors to consider than the one of culpability. Last night, we started the 2012 edition of Counseling & Physiology with the question of culpability and whether or bodies/brains can cause us to sin outside of our will. We also looked at our tendency to focus on judging whether a person is culpable for their sins (e.g., someone with Tourette’s who swears, someone with a TBI who is easily enraged, someone who is chronically anxious or still another who falls prey to addictive behavior). One of my main goals was to get students thinking about whether they under or overestimate the body’s role in counseling problems.

In the second post listed above I indicate the possibility of a better question than culpability. However, one of my students last night raised a question that went something like this,

Doesn’t the fact that you will choose how to respond to a client indicate that you have to judge the cause of the problem? If you encourage a client to consider psychoactive medications, aren’t you suggesting it is a body problem? If you focus on habits or heart issues, aren’t you assuming the problem is primarily a spiritual, will or behavioral control problem?

This was a great question and my answer was something like the following.

No and yes. Functionally, you will choose an area to work first. This does not mean you think that the type of intervention you choose indicates the main problem. It may only indicate that you think one intervention is an easier entry gate to counseling than another.

Here’s an example. Even if my client is severely depressed and I believe that the primary cause of this depression is their longstanding bitterness and anger towards God, I may encourage a psychiatric evaluation and the consideration of an antidepressant. It may be that once their mood improves, we can make better progress in investigating some spiritual matters in their life.

Human sins and weaknesses have multi-factored sources

Have you ever thought of the various sources of human sin? Here’s a visual of all of the things I think of that are a part of nearly every human sinful behavior. The sizes of the factors surely change depending on the situation. For some, will, high-handed rebellion, may be most of the pie. In other cases, bodily weakness may be the prime source. Also, some of these surely overlap and are not distinct. I may have started out in a rebellious state when I started doing drugs. Now, my body and psychological habits are equal players in why I maintain a drug habit.

What else would you add to this chart? Note that I place “will” in the smallest concentric circle. I imagine that we have far less conscious control over sin than we sometimes ascribe. Habits, unconscious motivations, and foolish (unthinking) choices probably dictate more of our behavior than our direct, willful, planned rebellion. Of course, none of this has ANY influence over culpability or morality as Scripture clearly indicates our guilt even when we are unaware of the Law’s commands. When Jesus says, “Father, forgive them for they know not what they do,” it tells us that consciousness of sin has little to do with our need for forgiveness.

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The biological roots of PTSD…and resilience


Brain structures involved in dealing with fear...

Brain structures involved in dealing with fear and stress. (Photo credit: Wikipedia)

A good friend of mine pointed me to a recent Nature essay that describes the biological markers for PTSD and resilience–and provides some of the answer of why some seem to recover fairly quickly while others continue to struggle. Here’s a couple key quotes:

“Functional magnetic resonance imaging (fMRI), which tracks blood flow in the brain, has revealed that when people who have PTSD are reminded of the trauma, they tend to have an underactive prefrontal cortex and an overactive amygdala, another limbic brain region, which processes fear and emotion…”

“People who experience trauma but do not develop PTSD, on the other hand, show more activity in the prefrontal cortex.”

Of course, we need to understand that we are complex beings with complex histories and current social connections. We don’t only look at neural activity but with increasing understanding, we learn how experiences such as childhood trauma, poor social support influence brain activity.

Some worry that the discussion of biological features of PTSD will lead only to increasing chemical interventions (meds, surgeries, etc.). I do not believe this to be the case given that we are also learning about the ways that current relationships and psychotherapies are altering brain activity.

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Filed under counseling, counseling science, Post-Traumatic Stress Disorder, Psychiatric Medications, Psychology

Booknote: Broken Memory


Just posted a short book review over at Global Trauma Recovery Institute. It is a novella about a child survivor of the 1994 genocide in Rwanda. If you are interested in getting an inside look at life after a trauma, dealing with memories and spaces in memories, and a common recovery process, I commend the book to you.  Quite moving, easy to read (not triggering for most), and gives some good illustrations of actions of the survivor and other caring individuals that help the young woman regain control over her internal world.

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What good is a diagnosis?


At the recent AACC conference Dr. Michael Lyles, a board member of AACC and practicing psychiatrist, stated the following,

A diagnosis is only a word on a page if it doesn’t serve a function.

What kind of function was he thinking about?

  1. Does it explain a set of symptoms?
  2. Does it point to a treatment plan?
  3. Does is help differentiate between overlapping symptoms?

I’m a firm believer that our current DSM diagnostic system is at once both flawed and useful. It is flawed in that DSM diagnoses don’t address causes or do much to point to treatment. It is useful when used carefully to help differentiate between overlapping sets of symptoms–even as it needs considerable overhaul to do a better job. Take differentiating between Major Depression and hypothyroidism instigated depression. The two look identical. But using a multiaxial diagnosis, a person could rule out Major Depression if they were able to make a positive diagnosis of low/inactive thyroid function.

So, until we have a better nosological system (i.e., a replacement for the DSM), I will continue to use it. In years to come we will, however, recognize it for the blunt instrument that it is.

Right Diagnosis…Wrong Focus?

Consider the following case study (not a real person, devised from several stories) as an illustration for the problems we have moving from current diagnostic categories to proper treatment.

Tom is 27, married, father to one young daughter, working part-time as a youth pastor and going to seminary full-time. He comes to counseling on the encouragement of his primary care doctor. One month ago during final exams and an overly busy ministry schedule, Tom began experiencing rapid heartbeat, shortness of breath, feelings that he was losing his mind, and chronic fear of dying. After experiencing 4 panic attacks in rapid succession, he began worrying that something was terribly wrong and that he was about to die. His doctor first ruled out a physical origin for these symptoms, taught him breathing and distraction exercises to interrupt the buildup of panic, prescribed an anti-anxiety medication, and recommended he make an appointment with a therapist. During the first session, Tom details his history of stress, reports he has been able to forestall 2 more panic attacks but admits he still struggles with fears of dying, lacks assurance of salvation, and feels flooded with guilt that he worries so much. Upon further exploration, Tom believes the bible teaches him that he should not fear if he has “perfect love”. He has read all of the verses about anxiety and feels condemned for his struggle.

Tom meets criteria for Panic Disorder, without Agoraphobia. This is a highly treatable problem and within a few short sessions, Tom is likely to gain mastery over his body in that he will no longer evidence panic attacks. This, of course, is not the same as saying he will stop experiencing worry, guilt over his chronic worry, or start having assurance of his salvation. Logic, disputing worries, distractions, exploring and altering core beliefs may help reduce the symptoms that brought Tom to his doctor and counselor. A good Christian counselor may also be able to reconnect Tom to Scripture in ways that help him experience God’s care for him in spite of his fears (e.g., hearing the gentle voice of Luke 12 vs. a harsh rebuke).

But has the diagnosis been properly made? Yes. Tom met the criteria for an anxiety disorder. No. Tom’s counselor also helped him discover a deep layer of shame that may have been the source of his anxiety. Without the latter, the former is not altogether helpful.

So, should the diagnosis be an anxiety disorder or shame? Until we have shame as some form of a diagnosis, I’m okay with maintaining the anxiety disorder as a good description of external symptoms. But, Tom and others like him will need wise counselors who can dig a bit to discover diverse multiple shaping factors (e.g., biopsychosociospirtual) that lead to a common expression of symptoms.

What good is a diagnosis? I concur with Dr. Lyles: not much.

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The Five Minute Antidote for Anxiety


I’m an anxious person by trait. It is a common trait, especially in graduate school (in combination with narcissism. I say this also in self-disclosure; both features support successful completion of doctoral studies). Anxious people tend to spend considerable time ruminating through “What if…” questions along with should, coulda, woulda thinking. We worry about our past failures coming to light and whether we’ll be up to the challenge the future presents.

Sound pretty negative way to live? It is. The only way we differ from depressed people is that we still have some thought that our worry might save us from disaster. As you can imagine, such worry robs us of joy. It keeps us from enjoying the present or seeing God’s gracious hand on our lives. And we compound our problems by then shaming ourselves for failing to follow God’s command, “Do not be afraid.”

The Five Minute Antidote

Part of the problem with anxiety is that we are trying to control/manage every possible outcome in order to avoid future disaster(s). Fearful people know that the answer to their anxiety will not include,

  • Just not caring anymore. We’ve tried that…it doesn’t work.
  • Making sure we get it RIGHT. Tried that too. Didn’t work.

So, what might work? Try this on for size,

What is God’s plan for me for the next five minutes?

Most of us have no clue what God is planning for us next year or even next week. But, I suspect most of us can discern what we need to do right now…for the next five minutes,

  • I need to make dinner
  • I need to read this assignment for school
  • I need to attend to my child’s homework
  • I can call a friend who is grieving

We usually know the one thing we can do for the next five minutes. Do that with as much focus as you can. Here’s what you are likely to discover: your anxiety decreases, or at least does not increase. When we stop the ruminations or internal conversations, our anxieties decrease and our ability to be present increases. So, when you find yourself in an anxious stew, try to ask yourself, What is one thing I can do for the next five minutes or What does God want me to do for the next five minutes? Consider this your method of living out Psalm 131, where you are are stilled and quieted like a weaned child, content with what He has for you for the next five minutes.

Oh, did you think this will solve all your anxiety problems? No, of course not. But where God does give you something to focus your attention, call that a success. Part of the Christian life is repetition–repeated worship, repeated repentance, repeated obedience, repeated trust. So, do pray for God to remove your “thorn” but look for five minute relief. Notice when it works and then ask God for another five minute focus on the thing he has for you RIGHT NOW.

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Dissociation (amnesia) and remembering abuse anew?


How is it that someone could forget a horrific event or experience? What is happening when something new is remembered about a very old event? Is it possible to forget (lose the capacity to recall) for long periods of time but then later remember?

Continuing my series on memory, abuse, and the controversies of recovered memories [you can read my previous posts: here, here, and here], I now want to address the issue of dissociation, amnesia, and remembering abuse. In those previous posts we have looked at how memory can be degraded by intent (conscious denial or unconscious rejection), by other overwhelming stimuli, or by failure to encode. But, since I have not spent much time on the topic of dissociation and repression, I want to say just a few words about these two ideas–in part because they are frequently used but poorly defined.

What is Dissociation? Is Amnesia a better term?

People define dissociation in a variety of ways but most definitions include some disconnection from present reality–sensations of disconnection from self, others, or time–and exists on a continuum. The most mundane forms happen everyday. You are driving from point A to point B but realize you cannot remember what you saw along the way. While we could describe this as a failure to encode data into memory, we could also describe the process, a disconnecting from what is happening in the present. Some dissociation is even beneficial. If you have ever been in pain but then got a distracting phone call, your pain perceptions probably decreased. You were, in effect, dissociating from the present experience of pain.

Now, when we talk about dissociation from a counseling perspective, we are talking about a more significant disconnection from present experiences, one that often seems to happen outside the conscious control of the person (but may be a practiced habit that happens without mindful decision). Dissociative experiences include feeling unreal, disconnected from the body, unable to engage the present, unable to remember salient portions of pesonal identity, or even, rarely, the presentation of alternate personality states that appear to fight for control of the individual.

You can imagine that if you are in the position of a repeated trauma (such as child sexual abuse by a parent figure) and unable to escape it, you might develop ways of dealing with the pain by disconnecting from the present. As a result, you might find that any time you begin to feel unsafe, you naturally disappear in some minor or major way. What happens during that “disappearance” depends on the individual. For some, they are reliving some other experience (I’m no longer present but reliving a painful event in my life). For others, they report being blank–thinking and feeling absolutely nothing. The most telling sign to a therapist is that the client no longer seems to be present in the room (nonreactive or reacting clearly to something other than is going on in the present). Whatever the form of disconnection, most then experience some level of inability to remember portions of the trauma.

Interestingly, there is some evidence that those who dissociate have greater capacity to self-hypnotize. In addition, McNally describes a study (in Remembering Trauma) that followed a person with psychogenic amnesia who had altered brain function when in amnestic states.

Does dissociation lead to forgetting traumatic data?

Can a person dissociate enough to create a persistent amnesia for a traumatic event? There is evidence that those who experience frequent disconnected states have greater difficulty remembering important details of traumatic events. However, many would say that repression is a better conceptual tool to explain such forgetting. But then, repression is not well-defined either (even Freud himself interchanged repression and suppression when talking about decisional vs. unconscious forms of forgetting). Despite the frequent use of repression in common parlance (and without the Freudian baggage) I would suggest that amnesia or motivated forgetting may be better terms, a bit more descriptive and less connected to psychoanalytic theory.

Whatever you call it, some level of forgetting can happen to those experiencing relentless traumas.

  • a young Jewish woman forced into an internment camp has her infant child ripped from her and killed. After the war, a relative asks the woman about the child and the woman responds, “what baby?” Only much later does she remember having a child or how this child died.
  • A young male cannot remember much about his childhood. When asked about his Uncle (only 5 years older than he), he can only remember a vague uncomfortable feeling. His younger brother recounts this uncle would routinely enter their bedroom at night to sodomize both boys. Only after numerous conversations does the older brother begin to remember abuse details, even beyond those supplied to him by his younger brother.

Forgetting then Remembering anew?

In my 23 years of counseling I have never encountered someone who recovered memories of a trauma after completely blocking all memory (I believe it is theoretically possible but extremely rare). I have, however, had a number of clients recall previously long forgotten or vaguely remembered traumas. Often when they recall events with VASTLY new interpretations, so new that it feels like an entirely new memory even as they admit the memory isn’t new to them. Here’s a real example (with details changed to disguise identity),

Alice, a 52-year-old elementary school principal, enters individual therapy at her husband’s insistence to deal with her irritability at home. She admits she has developed a fantasy of leaving her husband for the new (and younger) president of the school board. She discloses that this fantasy began not long after her husband suffered a work-related accident rendering him partially disabled. During the initial intake Alice denied any history of trauma or abuse. As the therapy progressed, it became evident that Alice connected her personal identity to that of being pursued–something that her husband no longer attempted. In addition, her attempts to flirt with the school board president had been ignored. In a moment of frustration, Alice exclaimed, “I’ve always known that men found me very enticing, ever since I developed [breasts] at an early age. I’ve always had to be so careful around men, especially married men. I knew they wanted me and that made me feel dangerous but desirable. Now, who am I if no one wants me?” Alice’s therapist asked her to recount a bit of her early sexual history and without much delay Alice reported her first sexual experience at age 12 with her 35-year-old, married Sunday School teacher. She recalled her teacher hugging and fondling her breasts while telling her about his failing marriage and the need for the two of them to avoid further sexual temptation. At age 16, she reported that she and a 4o-something father of a child she babysat engaged in a 6 month sexual relationship.  Alice’s counselor indicated some surprise at how Alice described both experiences. She asked Alice how she would describe the same interactions between one of her current 6th grade students and a school teacher. Alice immediately flushed with horror. “Why, it would be child abuse!” Once Alice regained her composure, she explored how she had always remembered herself as the protagonist in both experiences. In that session and over the next several weeks, Alice reported a flood of new memories, mostly about things done or said by the two sexually abusing men and now interpreted to be predatory behavior. On several occasions she reported that it felt like she had never had these memories before even though she recounted that she never forgot the sexual encounters. The new interpretations and labels created the experience of recovering long-lost memories–ones that seemed blocked as long as she was responsible for the trysts but freed in light of her victim interpretation.

In this little vignette I want to illustrate that memories of abuse can be forgotten, whether only small portions or large, and remembered anew. Recalled or recovered memories are frequent as individuals gain the freedom to explore events from different vantage points. A therapist does not need to go on an abuse hunt or attempt to conjure up forgotten memories for this to happen. Merely exploring the narrative of a prior difficult experience can be all the priming a client needs to begin to experience “new” remembering.

But here’s where good therapy differs from unethical therapy: how the therapist responds to or pursues memories may be the determining factor when it comes to the development of false memories of past abuse. In the next post we will take up the ethics of memory work and explore therapist habits that may produce false memories of abuse.

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Guest post over at Christianpost.com


The website, www.christianpost.com has picked up one of my recent blog posts about whether our bodies can cause us to sin. Never heard of the site before but nice to be noticed. You can see the post here if you missed it on my site: http://blogs.christianpost.com/guest-views/can-your-body-cause-you-to-sin-11696/

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Of Babies and Bath Water: Navigating the Controversies of Repressed and Recovered Memory


Recently I ran a conference about abuse within the church. In these kinds of venues (this blog and conferences) I am asked about a couple of related problems—the problem of false memories of abuse and the reliability of recovered memories of abuse.

While I intend to address these matters here (and in future blogs), I want to reiterate something that I think gets lost in most conversations about recovered and/or false memories.

Sexual abuse is real. The vast majority of adult reporters of abuse during childhood never forgot the details.

Why say this first? Discussions of rare and extreme cases (i.e., repressed memories, recovered memories, and false memories) tends to create undue suspicion for all adults who choose to reveal their child abuse later in life. It is my experiences that conversations about false memories or recovered memories lead many to assume that a report of extensive or horrific abuse is probably false. So, let us remember that as we take up the matter of fully repressed memories of abuse, we are talking about a very small percentage of people.

But, the issue of repressed and/or recovered memories and the construction of false memories is indeed worthy of a careful review given the strong feelings on both sides of the recovered memory debate. In order to be as careful as possible, I want to consider a few topics that may help us understand the issue. First, I will explore foundational topics (memory, forgetting, repression, and dissociation). Then,  I’ll explore the how trauma is known to create confusion, self-doubt, and “motivated” forgetting. Finally, we’ll take up the practice of counseling victims of sexual abuse and the particular matter of dealing with memory retrieval in counseling. Strap in!

Just in case you NEED to know my opinion at the outset…

I find Partlett and Nurcombe’s 1998 summary of an APA report on the topic to be fairly comprehensive,

The plain point here is the consensus set forth by the Working Group:
1. Controversies regarding adult recollections should not be allowed to obscure the fact that child sexual abuse is a complex and pervasive problem in America that has historically gone unacknowledged.
2. Most people who were sexually abused as children remember all or part of what happened to them.
3. It is possible for memories of abuse that have been forgotten for a long time to be remembered.
4. It is also possible to construct convincing pseudomemories for events that never occurred.
5. There are gaps in our knowledge about the processes that lead to accurate and inaccurate recollections of childhood abuse.[1]

I would add one more point: most people (myself included) in this debate are motivated by strong feelings as well as “facts.” These feelings may be the result of experiences with those who appear to be abused or appear to be falsely accused.

Issue one: Memory and Memory Retrieval

Let me start by stating the obvious: this isn’t a neuropsychology primer on memory and I am not an expert in memory. However, there are a few things on which I think we can agree:

  1. memory is a whole brain biochemical process. While structures like the hippocampus are clearly involved in memory storage, no one structure handles all aspects of memory storage or recall.
  2. memory is multi-faceted. Researchers differentiate between recognition and recall memory, explicit and implicit memory, short-term, long-term, and working memories…and much more.
  3. memory-making is a process.  The formation of memory requires attention, perception, encoding, storage, and retrieval. Thomas Insel calls it a 5 act play. A person moves from perception to long-term encoding to retrieval and finally, expression of memory.
  4. relational and affective context influences memory formation and memory retrieval
  5. the act of recall may change memory,

The concept is simple: memories are not fixed; they are periodically retrieved, and modified each time they are retrieved. This process of strengthening a memory by retrieval is called reconsolidation. One profound implication of this concept is that what you recall is not only a reflection of what you first learned, but also a product of each time you have recalled the original information.

How does this relate to our issue of recall of abuse?

  • memories are both fragile and yet not so. You recall what the house you grew up in looks like, even if you haven’t seen it in 30 years. And yet, your recall may or may not be particularly accurate. You may remember a large house even when it is much smaller to your adult eyes.
  • repetitive recall along with high levels of emotion may solidify memory. Most of us know exactly where we were on the morning of September 11, 2001.  You remember this because you talked about it, played it over in your mind, and because of the powerful biochemical process kicked off when you heard of the first plane crashing into the twin towers.
  • Most child sexual abuse has little corroborating evidence, especially when revealed decades later. This leaves victims by themselves to sort through the narratives they and others tell about their history.  The result? Ample opportunities for both denials of actual abuse as well as false memory.

Return with me to my first point. Most child sexual abuse is never fully forgotten. Some memories may be lost, others distorted, still others intentionally forgotten. Memory, as we have seen here is not a structure but a narrative.[2] In most cases, the story being told has much merit, even if some important details are perceived rightly. Thus memory retrieval during therapy (something that WILL happen whether therapist or client wants it) plays a powerful role in the re-storying work of therapy.

In my next post on this topic, I will make some comments about forgetting, motivated forgetting, dissociation, and repression.


[1] Partlett, DF & Nurcombe, B (1998). Recovered memories of child sexual abuse and liability: Society, science, and the law in comparative study. Psychology, Public Policy, and Law, 4, p. 1273

[2] “Rememberings—whether valid or invalid—are communicated by means of narratives.” Sarbin, TR (1998). The social construction of truth. Journal of Theoretical and Philosophical Psychology, 18, p. 145.

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Filed under Abuse, christian counseling, christian psychology, counseling, counseling science, counseling skills, Post-Traumatic Stress Disorder, Psychology, ptsd