Category Archives: counseling

June 14, 2011 · 2:49 pm

Competing Models of Christian Counseling? Who is Right?


A couple of recent pieces have me thinking about (a) models of Christian counseling and, (b) the intramural conversation amongst Christians on which model is most Christian. One piece is David Powlison’s article in the Summer 2011 issue of the Westminster Today magazine (this link is to the magazine site but the current issue is not yet up). The second is by Ed Welch–a blog on Biblical Counseling Coalition website.

This is not a new topic for me. From my “About Me” page you can see that I have training in biblical counseling and also in clinical psychology. I respect the folks at CCEF who had a huge impact on my life and thought–especially that lovely editor they employ ;). While getting my PsyD I published on the historic divide between biblical counselors and Christian psychologists and the need to build bridges. I’m an associate editor for Edification, a Christian Psychology peer-reviewed journal.

All that to say, I have some thoughts on some ways we might move beyond right/wrong while still being concerned about building a clear, cogent, God-honoring model of Christian counseling.

Drop the labels

Yes, we should drop our labels. What is the difference between a Christian counselor, Christian psychologist, integrationist, or biblical counselor? These differences are as varied as the numbers of people who use them. Yes, there are probably some benefits to communicating a personal stance with one of these terms. But, for every benefit, there are probably any number of negatives, including the use of the label as a curse. “Are you that kind of biblical counselor” (whatever kind you find offensive)? “Are you a Christian who happens to be a psychologist or a Christian psychologist?”

In addition to dropping labels, we should also drop broad brush judgments. Calling Christian psychologists “syncretistic” is offensive and ill-fitting. Calling biblical counselors “psychology bashers” does not accurately portray their nuanced approach. Saying that psychology and biblical counseling is “fundamentally incompatible” (from either side of the debate) ignores the benefits that both sides gather from each other.

No labels? What then?

Facets. I’m sure there going to be problems with this idea too but let us choose to focus on facets of counseling models. For example:

  • How does Scripture shape counseling foundations and goals?
  • How do we learn from, utilize, and critique psychological constructs, data, etc?
  • How does typical human development trajectories influence our understanding of the change process?
  • How do we learn from those who do not share our epistemic foundations?
  • How do we articulate diverse counseling goals (suffering well? symptom reduction? discipleship? skill acquisition? insight?) as all working toward the common goal of glorying God and enjoying him forever.

Listen first, repent first

In Ed’s blog post (linked above on the BCC site), he captures the most essential characteristic needed if we are going to learn from each other. We ought to,

listen and enter into the world of the other person (or in this case the other counseling perspective) in such a way that the person representing the perspective says, “Yes, that’s me. You understand.”

It is a sad thing that we counselor types start with diagnosing other model builders without listening first to both the content of that model and the person behind it. We treat our fellow counselors in ways we would never treat a client. How should we listen to others? Can we see what they see? Can we see what they see that we tend to ignore? Can we see the benefits of what they do and the potential liabilities they see in our model?

Be willing to repent where you have unfairly labeled, categorized, and marginalized one who was working for Christ’s kingdom–even if you think you have been hurt more.

List own weaknesses first

Most debates, whether between thinkers or spouses, rarely succeed in winning over the other person. Why? Because we are too busy defending, explaining away, pointing out the weaknesses of the opponent to actually deal with reality.

Wouldn’t it be refreshing to hear a counseling model builder express his/her models weaknesses or needed growth points first before exploring the deficits of the another? “My model doesn’t yet have a good understanding of ____. Your model does so much better with that and I want to learn from you.”

Build the center

Rather than start with the differences (which do indeed exist), what if we cataloged the similarities and areas of agreement among Christian models of counseling? In addition, what if we recognized those things we might not have noticed with out the help of those outside our own community. For example, Scripture may speak a great deal about loving neighbors but a particular model of psychology may flesh out what loving a very unique population of client ought to look like. Even if Scripture is sufficient, we do not diminish it when we acknowledge we hadn’t made a particular application without our neighbor’s help.

Acknowledge differences

We will not see eye to eye. We will disagree. Let us acknowledge these where they arise. Let us make sure the differences are real and categorize them into those that are peripheral and those that are substantial. For example, David Powlison speaks about the need for a counseling/care for the soul model back in the 1950s. Despite quality practical theology and discipleship programs, he asked,

But what was the quality [in the 50s] of corporate wisdom in comprehending the dynamics of the human heart? What sustains sufferers and converts sinners? Westminster Today, 4:1 (2011), p7

Right away I ask myself, are these the only two options (sustaining, converting) for Christian counselors? Is it possible also to have the role of treating symptoms? Teaching skills? Reducing suffering? I’m fairly sure that this initial difference is not really there. I suspect David does not reject mercy ministry to reducing suffering. But in dialog, he and I might end up agreeing that some biblical counseling models fail to focus on skill intervention in their quest to address the human heart. And we would likely agree that some christian psychology models fail to address the spiritual discipline of suffering well and the need for conversion. Might we end up agreeing that we want a full-orbed model that neither diminishes nor over-promises symptom care or sanctification?

Promote each other

Finally, we do well to promote each other at our conferences and learning communities. We encourage wide-ranging reading, critical interactions (note, not criticizing), and sharpening of each other. And we commit to lovingly correcting those of our “friends” who speak ill about our neighbors. We reject the fear of defending an outsider for fear of being rejected ourselves. 

 

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June 9, 2011 · 4:47 pm

EFT Seminar in Philadelphia: 7/29/11


Those interested in learning more about Emotion Focused Couples Therapy might wish to take note of a local seminar being taught by a certified EFT trainer. My colleague, Anna Nicholaides, is helping to sponsor this and is hosting it at her office complex on Arch Street in Philadelphia. Cost is $115 ($150 for CEs) and includes lunch. Seminar runs from 9a to 4p. EFT is a validated couples treatment modality. If you are working with couples and having  a hard time softening them or de-escalating the conflict dance, you are likely to benefit from this seminar. See the HEALINGoneday6082011 flier and the registration Healing Relationships training registration[1] for more details.

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June 1, 2011 · 5:56 am

G.R.A.C.E.: A org you should know about


Yesterday, I accepted an invitation to join the Board of Directors of G.R.A.C.E. (Godly Response to Abuse in the Christian Environment).  I first met Boz Tchividjian, Executive Director of GRACE and a law professor at Liberty University, and other board members some years ago when they held a board meeting in Philadelphia. A very impressive group–prosecutors, former prosecutors, pastors, thinkers, and a lonely psychologist (Diane Langberg). I suspect I can thank her for this invitation.

If you have been following the news about abuse in protestant organizations then you may know that GRACE board members were involved in producing an investigatory review of child abuse at a New Tribes Mission boarding school (commissioned by the executive board of NTM).

Having sat with the GRACE board members last Friday night, I can tell you this is a sharp bunch who love Jesus and have a wealth of information for seminaries, churches, and other Christian organizations on how to prevent and respond to abuse in a Godly fashion.

I’m excited to join them in the work of educating the church (and counselors, lawyers, and anyone else who will listen) about how to handle abuse allegations. I’m hoping to get involved in web and print publications on topics related to the aftermath of pastoral abuse.

If this is a burden on your heart. Feel free to donate using PayPal on the link for GRACE above. It is a non-profit and donations are tax-deductible.

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May 31, 2011 · 5:40 am

Healing, recovery, restoration and other words for “getting better”


Recovered. Healed. Better. Restored. Resolved. Whole. What words do you use when describing positive change regarding traumatic events like abuse, the pain of adultery, or other like experiences? And more importantly, what do those words convey to yourself and others?

Why am I thinking about this? Soon, I will begin teaching an on-line summer class called “Healing Trauma in International Settings.” To be honest, I’m a little uncomfortable with the title I chose. Words matter and “Healing” conveys a message. Imagine replacing “healing trauma” with

Trauma treatment

Trauma recovery

Trauma care

Now, maybe I’m being overly sensitive but consider some of these other kinds of problems we face

  • You break your tibia during an aggressive move on the basketball court. Your leg heals and you go back to your basketball playing. Here we use healing to denote that you regained your former capacity to play sports. You are back to normal or near normal.
  • You cut your finger while slicing vegetables. You go to the hospital to get stitches. While you have a scar, your finger heals and you use it again. In time you have only a slight scar to remind you of that day.
  • Your house sustains a fire. You lose belongings. Your insurance company restores your house and replaces your possessions.
  • Your car is stolen. The police recover it and return it to you (with fuzzy dice attached)
  • You have a protracted conflict with a family member. At some point, you have a heart to heart and resolve your differences.

My examples all convey a resolution of a problem where the problem recedes, maybe even disappears. But what about trauma? Is there a form of resolution and healing of rape or sexual abuse or domestic violence where the memories disappear? Should there be? Wouldn’t forgetting these experiences place the person in danger of living in unreality and, in some cases, at risk of re-injury? Here are some important questions:

  • What does healing from an affair look like? How do you know you have “recovered”? What symptoms or experiences would remain?
  • What does healing from a rape look like? What would be expected if you “pretty well recovered”? What is to be expected to not change?

As a counselor I do not want to under or over-sell the recovery process. Victims do find tremendous healing but to assume all vestiges of a traumatic experience go away would be false. Unfortunately, we who have not been traumatized sometimes expect the kind of recovery where victims go back to a way of life and thinking as if the trauma never happened.

If we are honest, we wish to live in a world without lasting consequences from sin and suffering.

We want people to “get over” their pain and go back to a way of life as if it never happened. It would be like asking a person who lost a leg to hope they will run exactly like they did before losing the leg. Indeed, they may run again. But never as fast and never as easy. There will be a stump to care for, a hip to learn new motion, phantom pains to re-interpret, and limits to accept.

This world of limits is one God wants us to live in and one we detest. Our first parents saw the limits of their wisdom and desired to get wisdom on their own. We too love the happily ever after story where humans obtain health and healing apart from limitations. We tell the stories of miraculous healing as if we no longer live in a broken world.

Let us endeavor to tell true stories of healing that glorify God and remind us that we depend upon him for every breath.

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May 17, 2011 · 5:56 am

What is the difference between a trial and a stressor?


Words matter. The words you use to describe an event really do shape how you will view it and how you will respond to it. For counselors, the words they use to conceptualize a client/case will shape how they see clients and how they will attempt to intervene. This is why I take considerable time in my Practicum class to practice case conceptualization.

Most beginning counselors are good at collecting information. But, for most, that data might well be a hopelessly knotted  ball of twine.  Where to start pulling? How do we make sense of the various pieces of data? And since data never comes to us uninterpreted, which “data” do we tend to gravitate to? Behaviors? Family history? Motivations? Biology? Environment? Client beliefs? But even more confusing are the words we use to describe these sectors of life–and the meaning they convey!

Stressor v. Trial?

Here’s how language influences case conceptualization. Your client experiences long-term family discord due to an adult child with schizophrenia. The family member routinely goes off medications and the police have to be called in order to transport him or her to the hospital after threatening self-harm. Your client comes to counseling to seek support for handling this difficult situation. As you can imagine, the client feels alone, worn down, and wondering how to keep going despite no sense that the situation will get better any time soon.

What do you imagine might be the impact of calling this family situation a trial? And how might you view it differently if you called it a stressor. Notice any differences? Benefits of each? Drawbacks of either? In your mind, are they equivalent? (See Eric Johnson’s brief discussion of these two words and their similarities/differences in regard to Christian psychology in his Foundations for Soul Care, p. 240)

Here is my thinking. Within Christian tradition, a “trial” signifies a difficult time or season but from a spiritual or divine perspective. It conveys a purpose–a testing or proofing of one’s faith. We tend to view trials (or desire to at least) from an eternal point of view, “testing of your faith produces perseverance…”  (Jas 1:3). Notice that while “trial” does signify difficulty, the focus is largely on the purpose it serves.

On the other hand, a “stressor” is something that causes stress or distress in a person’s life. Notice that this word carries no sense of eternity, divine value or purpose. It merely describes a facet of life that is troubling a person’s life.

Imagine with me a counselor who uses “trial” to describe the distress in the life of the client mentioned above. How do you expect that might shape the counselor’s view of the situation and thus response sets to that client? Would our counselor be more likely to view the trial as something to endure, more likely to engage in spiritual conversations so as to find comfort and peace in the middle of the storm? Would their conversations tend toward the hope of heaven? Is it possible that using the language of trials might cause a counselor to ignore the real-time experience of distress?

Now imagine the counselor who uses “stressor” to describe the same distress. Would this counselor be more likely to discuss in detail the physical, psychological impact of living with a mentally ill and unstable family member? Would this counselor then be more focused on finding ways to decrease the moment-by-moment stress levels? Is it possible that using the language of stressor might cause a counselor to ignore an eternal perspective?

Hopefully, you can see the value of both word meanings and the interventions described. It is possible to use the language of trials and focus in on the details of how that trial impacts the client. And it is possible to use the language of stressors and keep in mind an eternal perspective. Whatever language, the interventions off stress education and reduction and hope building are necessary interventions.

If you are a counselor or counseling student, observe the language you use to describe your clients and their lives. How does that language influence your view of them and the interventions you might use with them?

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May 11, 2011 · 12:32 pm

Thinking about Licensure in PA?


If so, come to Biblical to meet with other interested parties on June 11, 2011. If you are working on your masters degree or already have one and want to talk through the process for becoming a LPC in PA you might benefit from talking with those who have recently gone through the process. The following link will give you more information on the lunchtime seminar and contact information to RSVP should be interested in attending.

bib-0511-F2

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April 7, 2011 · 5:46 pm

Relationship’s role in therapy?


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

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

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

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

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

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

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

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

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

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

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March 8, 2011 · 5:58 am

How many patients can you see in a day?


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

What about seeing 40… in one day!?

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

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

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

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

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

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

What is your patient/client limit?

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

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

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February 25, 2011 · 11:09 am

Strengths profile


I’m advising one of our DMin students on his dissertation. He is researching how the use of Gallup’s Strengthfinders assessments and some training materials from World Harvest Mission might help build better functioning ministry teams.

This is my first time getting to see how the Strengthfinders works. So, Drew, the student, gave me the assessment. This tool returns the top five strengths themes (out of 34) based on my answers to the questions on the test. Here is my Gallup profile (in order of strength) with a few descriptive sentences:

Relator

Relator describes your attitude toward your relationships. In simple terms, the Relator theme pulls you toward people you already know. You do not necessarily shy away from meeting new people—in fact, you may have other themes that cause you to enjoy the thrill of turning strangers into friends—but you do derive a great deal of pleasure and strength from being around your close friends. You are comfortable with intimacy. Once the initial connection has been made, you deliberately encourage a deepening of the relationship. You want to understand their feelings, their goals, their fears, and their dreams; and you want them to understand yours. For you a relationship has value only if it is genuine.

Individualization

Your Individualization theme leads you to be intrigued by the unique qualities of each person. You are impatient with generalizations or “types” because you don’t want to obscure what is special and distinct about each person. Instead, you focus on the differences between individuals. You instinctively observe each person’s style, each person’s motivation, how each thinks, and how each builds relationships. You hear the one-of-a-kind stories in each person’s life. Because you are such a keen observer of other people’s strengths, you can draw out the best in each person. This Individualization theme also helps you build productive teams. While some search around for the perfect team “structure” or “process,” you know instinctively that the secret to great teams is casting by individual strengths so that everyone can do a lot of what they do well.

Strategic

The Strategic theme enables you to sort through the clutter and find the best route. It is not a skill that can be taught. It is a distinct way of thinking, a special perspective on the world at large. This perspective allows you to see patterns where others simply see complexity. Mindful of these patterns, you play out alternative scenarios, always asking, “What if this happened? Okay, well what if this happened?” This recurring question helps you see around the next corner. There you can evaluate accurately the potential obstacles. Guided by where you see each path leading, you start to make selections. You discard the paths that lead nowhere. You discard the paths that lead straight into resistance. You discard the paths that lead into a fog of confusion. You cull and make selections until you arrive at the chosen path—your strategy. Armed with your strategy, you strike forward. This is your Strategic theme at work: “What if?” Select. Strike.

Intellection

You like to think. You like mental activity. You like exercising the “muscles” of your brain, stretching them in multiple directions. This need for mental activity may be focused; for example, you may be trying to solve a problem or develop an idea or understand another person’s feelings. The exact focus will depend on your other strengths. On the other hand, this mental activity may very well lack focus. The theme of Intellection does not dictate what you are thinking about; it simply describes that you like to think. You are the kind of person who enjoys your time alone because it is your time for musing and reflection. You are introspective. In a sense you are your own best companion, as you pose yourself questions and try out answers on yourself to see how they sound. This introspection may lead you to a slight sense of discontent as you compare what you are actually doing with all the thoughts and ideas that your mind conceives. Or this introspection may tend toward more pragmatic matters such as the events of the day or a conversation that you plan to have later. Wherever it leads you, this mental hum is one of the constants of your life.

Learner

You love to learn. The subject matter that interests you most will be determined by your other themes and experiences, but whatever the subject, you will always be drawn to the process of learning. The process, more than the content or the result, is especially exciting for you. You are energized by the steady and deliberate journey from ignorance to competence. The thrill of the first few facts, the early efforts to recite or practice what you have learned, the growing confidence of a skill mastered—this is the process that entices you. Your excitement leads you to engage in adult learning experiences—yoga or piano lessons or graduate classes. It enables you to thrive in dynamic work environments where you are asked to take on short project assignments and are expected to learn a lot about the new subject matter in a short period of time and then move on to the next one. This Learner theme does not necessarily mean that you seek to become the subject matter expert, or that you are striving for the respect that accompanies a professional or academic credential. The outcome of the learning is less significant than the “getting there.”

Pretty good description I think…I like to relate to a small group of people. I like getting deep with a few. I enjoy the work of seeing the individual differences of friends, staff, clients, etc. I’m pretty good at getting a plan of action going right away. I’m not so good at carrying it out because I love to think and learn and so new information is always available and since I like to think about a wide diversity of things, it can be hard to stay focused on any one thing for too long. 

What I like about this particular tool is that it looks at a variety of strengths rather than personality traits.

Anybody have experience with this tool?

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February 22, 2011 · 11:47 am

One treatment protocol for many DSM diagnoses?


Could we devise one mental health treatment for many counseling problems? Given that so many problems have similar symptoms (anxiety, mood dysregulation, vigilance, intrusive and unwanted thoughts, etc.) and appear to involve common neurobiological processes (limbic systems), might we be able to find a single treatment for multiple expressions of problems?

David Barlow and others say yes.

The Renfrew Center (an eating disorder clinic) publishes Perspectives: A Professional Journal of the Renfrew Center Foundation, a free journal. In their Winter 2011 issue they have a brief article by David Barlow and Christina Boisseau about a new “transdiagnostic unified treatment protocol” (UP) that can be applied to all anxiety and depressive (and eating) disorders. Let me summarize a few points from the article:

  • 70 to 80% of clients with eating disorders also have anxiety disorders, 50% meet criteria for depression
  • A number of anxiety and depressive disorders have emotional dysregulation as a central theme
  • Etiology of these diagnoses may be best accounted for by “triple vulnerability theory”: biological vulnerability to negative mood…early negative childhood experiences due to attachment issues or unpredictable environment leading to an elevated sympathetic nervous system…and psychological learning from an event focusing on a particular issue (anxiety, panic, observation of parent’s panic, etc.)
  • The Unified Protocol (UP) focuses on “the way that individuals with emotional disorders experience and respond to their emotions” (p. 3). UP consists of 5 core modules
    • emotional awareness training (focus on “nonjudgmental present-focused awareness”)
    • cognitive reappraisal (“identifying and subsequently challenging core cognitive themes”)
    • emotion driven behaviors (EDB) and emotional avoidance (identifying maladaptive EDBs, learn new responses and avoid avoiding emotions)
    • awareness and tolerance of physical sensations (self-explanatory…as they relate to emotions)
    • emotion exposure (“…goal is to help patients experience emotions fully and reduce the avoidance that has served to maintain their disorders(s)”)
  • These modules are flexible and shaped to the individual needs of the client

Obviously, there is much work to be done to validate this protocol but it makes sense. You can see the CBT foundation but also a greater focus on emotion rather than cognition.

Those interested in the full text and references can find it here!

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