Category Archives: counseling

June 5, 2012 · 8:07 pm

Word choice matters!


Counselors often use what they call “additive” words to help flesh out the thoughts, feelings, and experiences of their clients. For example,

CLIENT: I feel so frustrated about how long it is taking for me to hear about the job I applied for.

COUNSELOR: You’re feeling anxious?

Certainly, my example is superficial and simple but you get the point. Frustrated doesn’t really adequately describe the true feelings of the client. We sometimes need help with defining what we really feel, think, or believe. This word addition happened to me today in a powerful way.

Today I was telling someone about a repeated discouragement I have experienced in recent months. In describing my experience I used the word “rumination” to describe the re-occurring thought pattern. She deftly said just one word.

“Grumbling?” [well, in fairness, that is what I remember]

That one word changes everything. When I choose to describe myself as having a repeating thought–a rumination–I am accurate if I am speaking only about the repeating part of the thought pattern. But notice that “rumination” doesn’t evaluate attitude or belief. What my trusted friend was trying to tell me was that I was allowing myself to have a pity party. I was accepting the disappointment feelings without any evaluation of what it was that I believed about the situation at hand. Truthfully, she was right. I was accepting the thoughts and feelings as accurate rather than interpretative of my situation.

Now, I am not arguing that those who have actual ruminations (a part of OCD) are all grumbling. But, it is a good reminder that the words we use do shape our perceptions of our life! We do not just respond to disappointments, we interpret them.

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May 21, 2012 · 5:31 am

Why we react and then think


Human brain parts during a fear amygdala hijac...

Human brain parts during a fear amygdala hijack from optical stimulus. (Photo credit: Wikipedia)

Ever wonder why? Check out this quote by Richard McNally¹ about the role of the amygdala,

LeDoux discovered two pathways for activating the amygdala, a subcortical structure integral to the experiences and expression of conditioned fear. One pathway rapidly transmits sensory input about fear stimuli to the amygdala via a subcortical route, whereas the second pathway passes through the cortex, taking twice as long to reach the amygdala. Subcortical activation of the amygdala makes it possible for a fight-or-flight reaction to begin even before information about fear-evoking stimulus has reached conscious awareness via the cortical route.” (p. 178, emphases mine)

If this is true, then in anxiety and intense emotion-producing events our brains begin the reaction phase prior to any thought processes. If true, then we might consider

  1. The goal of trauma treatment or anger management is NOT to avoid having reactions but to more quickly reach cognitions and alternative emotions that help moderate a negative reaction
  2. the empirical evidence for the clinical process whereby a client adopts a neutral reaction as opposed to a negative reaction is quite lacking. There are a number of models that process to “cool down” the amygdala, but these treatments often lack serious empirical support.

So, the next time you instantly react in a way that bothers you, don’t be so hard on yourself. Instead stop yourself, take a deep breath, work to analyze the situation and to lean into a post hoc truth. We have our hands full enough with what we know we need to do, we don’t need to worry so much about our first reaction.

¹McNally, R.J. (2003). Remembering Trauma. Cambridge, MA: Harvard University Press.

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May 15, 2012 · 2:46 pm

2 reasons why finding the root problem may not be a good goal for counselors


How important is it for a counselor to diagnose the client’s root problem? Consider these analogies:

Imagine being diagnosed with cancer in one part of your body but having your doctor tell you that it isn’t important to discover whether the source of that cancer lies elsewhere. You wouldn’t be happy and you would likely seek another opinion. Or, consider this analogy: you keep cutting off the tops of dandelions only to find that they keep coming back. Not a very wise decision. Instead, you find the tap-root and remove it if you really want to stop the weed from growing.

In the last week I have had three conversations about identifying the source or primary cause of someone’s emotional struggle. In each case I was asked questions about the source of the problem.

Is it a chemical imbalance? Is it the result of childhood trauma? Is the primary problem his sin?

I understand these questions. They are reasonable and important to ask. As a counselor, I am trying to assess how a particular psychological problem develops in an individual. But, maybe these questions aren’t as helpful as they first appear. Here are two reasons why we ought not put too much stock into seeking out the root problem and a suggestion for a different approach than the “why” question.

  1. “Why” questions almost always lead to a simplistic/categorical answer. Most psychological (or spiritual) problems have multi-factored roots. There are biological predispositions, experiences, behavioral choices/habits, perceptions, beliefs, etc. all working together to “allow” the problem to develop. Usually, we do not find this kind of complexity very helpful. We like to narrow things down to single or primary problems. Narrowing down to either/or categories helps us “understand” the problem and exert energy towards a single solution. However, when we demand a primary cause, we will almost always misrepresent the problem and may communicate to others a distorted image of what is taking place. Saying that a psychological problem is the result of sin or neurochemicals or family upbringing ALWAYS flattens the problem and as a result puts too much hope in any intervention.
  2. “Why” rarely leads to the most important question, “so, now what?” Let’s say that we can figure out why you struggle with Obsessive-Compulsive Disorder (OCD). Your mother contracted a virus during the 7th month of her pregnancy and that virus altered your prenatal brain and caused your OCD. Okay…so now what? Notice how the why question provides interesting information and possibly helpful in eliminating the problem in future expecting mothers…but as enticing as it is, the diagnosis doesn’t help much with the, “so now what do I do about it.” In fact the desire to figure out the “why” never is as clear and easy as I have just made it in the virus example and so the search for “why” doesn’t lead to the “so now what” question at all. Now, I don’t want you to think that I care little for historical data gathering. The multifactorial etiology of our problems are worth exploring. We ought to take a look at how early childhood experiences shape our current behavior. We ought to explore the possibility of a biological predisposition to our anxiety. We ought to examine how our beliefs about self, other, and God influence our current problems. However, we explore these historical facets not because they answer the “why” question but because they help us understand “how” we function and whether we want to alter some of these shaping influences.

An Alternative Approach?

I’ve just tipped my hand in the last point. How is a better question. Finding out how a particular feature (belief, habit, experience, perception, biological process, etc.) influences current life and how a person might respond to or engage differently over a problematic emotional expression is more likely to bear good fruit. Consider these examples:

  1. How does your history with pornography and secret shame influence your seeking accountability from your other men in the church?
  2. How do you react to trauma triggers and what different responses to triggers might you want to practice?
  3. How do you want to think about or assess your unwanted sexual desires and feelings?

So, asking why we do what we do or why we are the way we are is interesting but not always the most helpful question from a counselor. Instead, explore your perceptions, reactions, thoughts about what is happening and explore how you might come to feel, think, or engage the problem from a different perspective or with a different goal in mind.

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May 5, 2012 · 8:15 am

Do your labels help or hurt?


I have a post over at the Seminary’s faculty blog today. You can find it here.

Counselors label all the time. Even when we don’t offer official DSM diagnoses, we label things as good, bad, healthy, unhealthy, dysfunctional, sinful, etc. The key question counselors face is WHEN and HOW to share their views on a subject. Just because we can see something is wrong doesn’t mean we ought to share it yet. While you may wish your family doctor to share suspicions of Lyme’s disease with you on the first visit, your counselor may need to earn the right to say, “I think you have become embittered over your husband’s insensitivity.”

If you are in a position of authority (parent, teacher, boss, counselor, leader, etc.) consider how quickly you use labels and whether or not they invite dialogue and action. If the result of our labeling is increased passivity in the one being labeled, then maybe we need to consider that our labeling is part of the problem.

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May 3, 2012 · 1:59 pm

eye contact and amygdala stimulation?


I’m in the midst of a CE training by Janina Fisher–Traumatic Attachment & Affect Dysregulation–and here is something she just said (not quote…my recollection),

When you make eye contact with another, you stimulate the amgydala. The arousal of this part of the brain arouses emotions, especially those connected with desire for or fear of intimacy. The point is that eye contact stimulates the attachment system which in turn plays on our feelings about being in relationship with others.

Later, she quoted someone (named Benjamin), “To be known or recognized is immediately to experience the other’s power. The other becomes the one who can give or withhold recognition: who can see what is hidden; who can reach, conceivably even violate, the core self.”

Thus, some clients (those who are ambivalent) find our “seeing them” (via empathy) as anxiety provoking. Counselors do well to help the client notice these reactions without over-stimulating reactions (which likely would trigger fight/flight reaction).

How you feel about making eye-contact with another depends largely on (a) how you feel about that person, or (b) how you feel about yourself. Both feelings depend on prior experiences and perceptions of self and other.

Try out a few moments of eye contact, either with someone you have authority over (supervisee, child, student) or someone who has power in your life (spouse, boss, teacher). What reactions did you have? Reactions in your body, thoughts, feelings? What impulses did you have? What does this tell you about how your brain works in regard to knowing and being known?

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April 24, 2012 · 10:32 pm

Why is some trauma complex? A helpful distinction from Judith Herman


Counselors talk about trauma as if all traumas lead to traumatic reactions. They do not. Some people have significant distress from what might be considered slight traumatic experiences (surely an oxymoron!) while others appear not have any negative or ongoing reactions to very large distressing events.

There’s another problem. We sometimes talk as if all traumatic reactions are the same. This is also not the case. While the symptoms of posttraumatic stress disorder (PTSD) are well-known to many (i.e., intrusive re-experiencing of trauma experiences, emotional numbing and other attempts of avoiding memories or triggers, and hypervigilance), you can find counseling students and practitioners who are less aware of a cousin of PTSD: Complex Trauma.

Defining Complex Trauma

I’m reading Treating complex Traumatic Stress Disorders: An Evidence-Based Guide, edited by Christine Courtois and Julian Ford (Guilford Press, 2009). This is an excellent text if you are interested in exploring the symptoms, neurobiology, and treatment protocols for complex trauma. In the foreword, Judith Herman helps the reader clarify the main difference between regular and complex trauma

These days, when I teach about complex PTSD, I always begin with the social ecology of prolonged and repeated interpersonal trauma. There are two main points to grasp here. The first is that such trauma is always embedded in a social structure that permits the abuse and exploitation of a subordinate group… The second point is that such trauma is always relational. It takes place when the victim is in a state of captivity, under the control and domination of the perpetrator. (xiv, emphases mine).

For trauma to become complex one needs to experience the trauma at the hands of those who are most perceived to control a social unit (family, community, etc.). It needs to be repeated and woven into the fabric of distorted relationships. You can see that prolonged abuses experienced as a child prior to development of an understanding of the world and of the self would have more devastating impact than an unfortunate and distressing event that happens as an adult. If I experience a horrific accident and an unexpected attack by a stranger, I would not, usually, begin to feel unsafe amongst friends and family. I would likely continue to trust them even as I might not trust the larger community. However, if I experience repeated abuse by a teacher, a parent, a relative, a church leader as a young child, I do not have the prior experiences of safety to rely on and thus, I am likely to experience all of the symptoms of PTSD and then some more.

What More Symptoms?

Courtois and Ford give a cursory description of complex trauma on the first page of the book,

…involving traumatic stressors that (1) are repetitive or prolonged; (2) involve direct harm and/or neglect and abandonment by caregivers or ostensibly responsible adults; (3) occur at developmentally vulnerable times in the victim’s life, such as early childhood; and (4) have great potential to compromise severely a child’s development.

Adding to the typical symptoms of PTSD, complex trauma victims also struggle to regulate emotions, impulses, somatic experiences, consciousness, and evidence significant distortions in views of the self and others leading to difficulty forming trust relationships and finding meaning in life and faith.

Those interested in learning more about the current thinking on complex trauma conceptualization and treatment may find this book useful. Others may wish to check out the latest articles at www.traumacenter.org, one of the leading centers in the country focused on the problem of trauma.

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April 17, 2012 · 10:11 am

3 important goals for trauma recovery


In the last week we have been discussing the best words used to describe the process of trauma recovery (see related post below). While words are important and carry much meaning, it may be more helpful to consider what recovery goals are in order for trauma victims. While we know recovery road can be long and arduous, it helps to know when we make progress and a general sense of the direction we are headed. In the days before GPS, if you went on a long car trip you probably consulted a map on several occasions in order to make sure you were headed in the right direction. So also, when you are working to get better after a traumatic experience, you want some sense you are still working on good goals. This need is especially great if the traumatic symptoms are complex and the treatment not brief (think war, genocide, child sexual abuse, etc.)

What three goals?

Esad Boskailo, as noted on p. 94 in his memoir (written and reported by Julie Lieblich) works toward these three goals that in turn support the ultimate goal: thriving (notice that the goal is not being free of symptoms, free of triggers, or back to life as if the trauma did not happen).

  • Acknowledge losses
  • Foster resiliency (i.e., build the capacity to use current coping resources)
  • Find meaning in life again

I think these do function well as helpful signposts or intermediate goals in the process of recovery from traumatic experiences. Now, I don’t believe these goals are necessarily in sequence. For some clients, they stumble on something that gives new meaning to life and thus are better able to acknowledge losses. Others get to work on building better coping mechanisms (e.g., a vet puts away items that cause him or her to dissociate, an adult victim of CSA stops cutting and develops acceptance strategies, etc.) and then can acknowledge losses.

So, in the murky water of therapy (and it surely is murky!), the trauma victim can find some comfort in activities pointing to these intermediate goals. Each day they reject self-condemnation for not being who they used to be before the trauma, they are moving toward thriving. Each day they embrace available coping resources (e.g., a friend who will call or pray), they are moving toward thriving. Each day they find one meaningful experience, they are moving toward thriving.

the how we meet these goals is, of course, the 64,000 dollar question…and not something we can set in stone. I will write on some general activities that are common in most treatment modalities in the coming days.

Related articles

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April 16, 2012 · 10:48 am

In Counseling, Who is the Teacher?


Most counselors and therapists get into the field of counseling because they want to help people. This is a good thing! Imagine if they only wanted to make money or to be the center of attention. But, underneath the goal of wanting to help people lurks an insidious goal:

being seen as wise.

Being seen as wise (notice the difference between being wise and being seen as wise) tempts us to become the teacher, the teller, the obnoxious sage.  Teaching, telling, training are all activities that may happen in counseling, but only when necessary. Truth be told, we counselors resort to teaching and telling because it gives us a job to do and makes us feel good. This is especially true when we work with the most severely traumatized people. Here someone is hurting in front of us. We can see that they are stuck. Who wouldn’t want to pull them out of the mud? Now, there may well be important teaching moments–gently instructing someone on the symptoms of trauma and/or the physiology of trauma. This might be important for the client who believes that the symptoms are really signs they are sinning and that they can just choose to stop being triggered.

In Counseling, Who is the Teacher?

“The patient is the ultimate teacher about trauma, and a good therapist is a good listener.” (Boskailo, p. 81)

While the counselor has much to offer in regard to teaching, training, and goal setting, we must remember that the client is the one teaching us about their trauma experiences and how much they can deal with at a given time. For example, Boskailo reminds us (see above link for book) that while telling the trauma story is an important part of the healing process, the “how” of telling (and the “how much”) is something each client will need to teach us. One client may need to tell and re-tell the same story each week. Another may be better helped by drawing. Still another may tell once and never again.

We counselors are the student in these kinds of matters. It is our job to listen well and learn well!

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April 12, 2012 · 5:47 am

Trauma recovery? Healing? Integration? Which words communicate a good outcome to you?


Recovery. Healing? Restoration? These words contain both information, movement, and emotion. What words do you like to use when describing the process of getting better after a traumatic experience? How do you communicate that you are better but not so much better that you have no more bad memories; that you have no more nightmares; that you are not triggered into panic when you see someone who abused you?

What words do you shy away from?

Let’s consider healing first.

I was and am being healed?

Some hear healing language as a completed task. “I have been healed.” Past tense. If I was in a wheelchair but now I walk…would I say I have been healed if I walk with a limp or need a walker to get around? Do you ever hear someone say, “I was healed, in part.” Would it be better to say I am being healed or I am recovering. Compared to Greek verb tenses, our English language doesn’t communicate well the ongoing state of something. In Greek, we can communicate a present perfect tense such as, “I was and am currently being healed” all in one verb form. But in English, we cannot communicate such an ongoing process without more words. Thus, when we use the shortcut, “I am healed,” it sounds like a finished job.

Recovery?

What about recovery? Restoration? Renewal? Recovery words are popular amongst former addicts. For them it connotes that they are no longer using but making the daily choice for sobriety. However, they recognize the danger exists of falling back into drunkenness and so they communicate that they are in a lifelong process. For some, however, recovery sounds like a failure–failure to find victory and failure to accept a new identity.  The truth is, few people outside of AA use the word recovery in every day speech. The other “r” words are more likely used in Christian circles but not so much in discussion of life after trauma.

Can you integrate trauma?

I have just finished reading Wounded I am More Awake: Finding Meaning after Terror by Julia Lieblich and Esad Boskailo (2012, Vanderbilt University Press). Julia helps tell Esad’s (a Bosnian doctor) experience of being held in 6 different concentration camps. He is now a psychiatrist in the US and works with trauma victims. However, he faced much brutality in being treated worse than one would treat an animal and so was not in good physical or psychological shape when he came to the U.S. I commend the book to those who want a basic understanding of trauma and of this thing we are trying to call healing and recovery. Listen to these quotes from Boskailo the psychiatrist,

 I can’t take away what happened” [said to another survivor]. But [I] can help [you] imagine a better future.

“You are fifty, not twenty-five. You will never be the person you were twenty-five years ago. Even if you didn’t have trauma, you would not be the same.”

What Boskailo is arguing for is integrating trauma into one’s present life. One cannot go back and recover what was lost. A trauma survivor is never going to be free from losses suffered. To do so would be to deny truth. Integration means allowing the reality of trauma and its losses while finding meaning and value to live in the present with hope and even joy. Integration requires acceptance and willingness to look for meaning and purpose.

I like the connotations of integration. But, I am not sure I like the word integration since it also doesn’t connote some level of arrival at a good enough place. What word would you use?

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April 10, 2012 · 12:21 pm

Invite your pastor (or key leader) to attend our “abuse in the church” conference, July 20-21 2012


church should be the safest place in the world! Unfortunately, it isn’t always. Even worse, when abuse does happen, the church may not always protect the victims. While this shouldn’t surprise us since the church is full of sinners, we ought always to be working to make it a place free from abuse. Is your church working to protect the congregants from abuse? Is it ready to respond to an abuse allegation?

This summer I will be co-teaching with Boz Tchividjian (Liberty Law School prof and former prosecutor) a weekend course/conference on preventing and responding to abuse in the church. We are inviting church leaders to join our MDiv and counseling students at Branch Creek Church, Harleysville, PA. The class will run Friday night, July 20 and all day Saturday, July 21, 2012. All the details you need can be found on this Abuse Course Flyer.

Would you consider personally inviting your pastor or church leader by passing on this brochure?

For non-student registrations, click here. If you want to see a syllabus, click here.

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