Category Archives: counseling

June 4, 2010 · 1:47 pm

Being the warden


I was sent a new book to review (which I am not planning to do). Since it has to do with pastoral ministry to couples involved in a particular sexual crisis I thought I’d give it the 5 minute skim. In doing so I got a great image: The warden in the relationship. This is the person who was wronged in some terrible way and is now the warden who determines the accountability of the offending party.

When one has broken trust and is now trying to regain that trust, they must become entirely transparent. Their can be no hint of deceit, no unaccountability in any area of life. Not only must the person allow for accountability but they must show evidence they actually desire it and do not chafe at their limitations in life. But what of the other partner? The author says this:

It is not OK for one, considered to be the initial perpetrator, to live totally accountable in his life of genuine repentance, while the other partner never moves off being the warden of the relationship.

How does one fall into this position? The author says “just going with the flow of feelings about the injustice and harmfulness of things is all that is necessary to become the warden, and to never really forgive.” This, I must say, is in the larger context where he also says forgiveness does not require trusting the other or repatriating the other.

In much of Christian counseling, wardens get a raw deal. It is so obvious that they are demanding of a standard of perfectionism, judgmental, unwilling to be vulnerable, etc. It is easy to see this and to go after the hardness of heart that is evident in the warden while accepting the “repentance” of the offender at face value.

It is true that the warden must relinquish the position of judge if the relationship is going to survive long-term in any healthy manner. This does not mean the person stops taking stock of the offender’s actions and attitudes. Nor does it mean that they can forego self-examination.

Here’s my questions:

  1. How do you know the line between careful evaluation of the fact and warden mentality?
  2. What helps might be most helpful to let go of the warden mentality?
  3. How could the church be more supportive of the warden?

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June 3, 2010 · 5:50 am

A Parent’s Private Pain


Most of my current counseling work is with adults. Didn’t used to be this way. When I started, I worked mostly with kids and then sometimes with their parents.

What do adults deal with? Some are dealing with personal problems, some are dealing with difficult marriages, work, and the like, some are dealing with parenting young children. All of them hope that counseling will be part of the solution: depression will lift; intimacy will increase, children will be more obedient.

But what of the parent of an adult child who seems to be going off course? Their beloved offspring refuses to address an addiction; rejects their faith; rejects values from faith or culture. Where do they find help and solace? Given the little power parents have over adult children no longer under their roof, these parents rarely choose counseling as an option. Seems too expensive for something that can’t change the situation.

Surely these parents hurt. Their assumptions or dreams seem dashed. They question what they did wrong. Others offer unsolicited advice as to what to do or why their child has departed from their family values. Surely these parents face confusing decisions. Do they cut off from the child? Cajole? Pretend nothing is wrong?

Where best might they turn?

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June 2, 2010 · 5:41 am

Criticizing Christian Counseling Models


Critical thinking and evaluation of what goes for “Christian” has always been a part of the Christian faith. This past Sunday my pastor preached on Colossians 2:13-19 and in the midst of the sermon he made this brief remark about Paul’s list of characteristics of those who have “false ideas about ‘righteousness’ and salvation”–in other words, those who use their critical evaluation skills to destroy others (rather than build up) or to build their own kingdoms.

Based on Paul’s list, he said these leaders tend to (a) be quick to pass judgment about the views of others, (b) equally quick to dismiss their opponents, (c) and likely to claim a vision or something special on which to base their own beliefs. He added that these leaders commonly hide their views under a veneer of humility.

In the counseling world, we have had many of these thought “leaders.” These are those who have a grain of truth as they point out the flaws in the views of others, who refuse to accept any critique of their own position and claim to have a purer view of the Bible (though never once really articulating it as a positive position).

But is there a place for critiquing others’ models? If so, how do you tell the difference between a false critique and a necessary critique? Try some of these questions:

  1. Are the critique overly personal? Does the writer give the benefit of the doubt or choose to read the one being critiqued in the worst possible light? If you finish a critique and it seems like the author was making fun of their opponent or making outlandish statements about the intentions or consequences of ideas–then they probably fail the test of constructive criticism and love for all.
  2. Does the one doing the critique identify where the author has spoken truthfully? If not, then the critique is not balanced.
  3. Does the critic offer an alternative after making statements of judgment? If not, then it is likely that the critic isn’t really looking for solutions but merely wants to be destructive.

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June 1, 2010 · 8:40 am

Maintaining progress in counseling with short sessions


Ever felt that a 10 minute session every day might be more beneficial than a 1 hour session once a week? While a short session cannot dig very deep, it can keep a person on track. One of the frustrating things about counseling is the fact that a client may leave with direction and clarity only to return 7 to 21 days later with confusion. What seems clear in the office becomes foggy in real life. It isn’t that much different from learning a language or algebraic formulations. You think you have it then you try to apply it to a novel situation and you realize you don’t have it quite down.

The phone call session should be short, directed at problem-solving, remembering a previously learned solution, or improving hope and motivation to continue some difficult task. Consider this for marital discord. So easily conflicted couples stay cold and distant between episodes of conflict. Short sessions may help them remember to soften each day and be more inviting of non-conflict interactions.

There is some support for this kind of interaction, though not in therapy literature. The support comes from addiction quitlines. Those who call in and gain support are more likely to remain abstinent than those who try to do it on their own. Sadly, insurance companies do not support this kind of interaction (they do not cover phone sessions). They should, it would likely save money in the long run.

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May 28, 2010 · 8:38 am

insomnia and suicidality


Counselors need to keep regular watch over the insomnia of their clients. Untreated or unresolved insomnia predicts poor recovery and lesser benefit from therapy. It ought not be treated as a secondary problem. But a recent abstract sent to me via email suggests that insomnia may also be a significant factor in suicidal ideation and action. Some researchers at Wake Forest followed 60 adults with both insomnia and major depression for 9 weeks. All received antidepressants but some received a sleep aid as well. Both were assessed by using the Hamilton Depression Scale and an insomnia severity scale.

Their findings suggest that insomnia is a factor in suicidal ideation independent of depression or lack of pleasure. Insomnia leads to more intense suicidal thoughts. Thus, counselors ought to redouble their efforts to ask about insomnia, to track it and to especially follow-up with questions about suicidal ideation or plans when complaints of insomnia increase.

Interested readers may find the abstract of the research here.

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May 19, 2010 · 5:51 am

Suicide assessment mistakes


Yesterday’s post was about suicide. Counselors sometimes fail to adequately evaluate suicidal ideation, plan, or intent in their counselees. Some years ago, I ran across a research study looking at the most common mistakes made by 215 masters level counselors when dealing with suicidal clients. I’ve lost the bibliographic data for the article and couldn’t find it easily in Psychlit…

Here are some of the mistakes (in no particular order):

  • Superficial reassurance (“you have so much to live for”
  • Avoidance of strong emotions (not allowing client to express strong despair–usually with first bullet point)
  • Professionalism (cold and distant, possibly seen as uncaring in assessment)
  • Inadequate assessment (failure to explore fully because of nervousness or fear of asking)
  • Failure to identify precipitating causes (most suicides have both current and historical precipitating events. Counselors may identify historic event (e.g., divorce 4 years ago) but miss the current precipitant.)
  • Passivity; failure to be empathic (25% took this stance)
  • Insufficient directness. No contract to not harm, no next steps
  • Overbearing advice. Counselee needs to be involved in the planning for safety
  • Stereotyping response (“She’s just a borderline!”)
  • Defensiveness (usually about whether hospitalization is necessary)

Every counselor worries about how they will perform when addressing the serious problem of suicide risk assessment. We do well to review (a) our natural inclinations when stressed (e.g., do we tighten up, become over-controlling, too professional?), (b) our standard of practice when confronted with despairing or suicidal clients, and (c) our assessment procedures with all clients. While there is no way to prevent the suicides of highly motivated people, we can increase our capacity to respond well to those the Lord sends our way.

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May 18, 2010 · 11:22 am

Helpful read on the warning signs of suicide


Sunday’s lead story in the Philadelphia Inquirer unfolds the tragic story of two high school girls who committed suicide by stepping in front of a speeding train last winter. The death of a child is always a tragedy. But death by suicide exponentially multiplies the pain. Could anyone see it coming? Could they have prevented it?

The story in the paper details the texts and social networking trail of tears leading up to their final actions. If this event happened when I was a child, the parents might have been left with a note or a journal to pour over looking for clues. But, in this case, there are texts and posts over a long span of time. Even worse, the girls made a number of final texts just before their deaths. It appears that loved ones searched frantically for them while “watching” cyberspace during their final act. I can only imagine that this “real time” aspect multiplies the trauma for the family.

Can we learn anything from this? Yes, I think so.

  1. Pay attention to your child’s (or friend’s) social networking and texts. Clues to their state of mind may well be evident.
  2. Act on concerns; take stock of their actions and attitudes. Per this case, it appears there were efforts to help them. Probably not enough. But let us not judge the family here. It is far too easy to become complacent. A child has strong feelings that they express over a period of time, thus making suicidal expressions normal. After the fact the signs seem so obvious. During the stress, it is hard to discern how bad it really is.
  3. Compounding suffering requires additional interventions, whether the child wants it or not. One girl’s father committed suicide, parents’ divorced requiring a move and change of school, a boyfriend was killed by a car. The more these kinds of experiences happen, the more attention the child needs by mentor or mental health workers.
  4. Even good schools won’t likely pick up on problems. Don’t assume school counselors have enough time to respond. It is not that they are incapable but the sheer number of students to follow makes their capacities limited.

Know that some people commit suicide and no one could have predicted it. Be wary of judging family members. They will live with enough guilt on their own. And yet, look for this recipe of pain and perceptions (summary of Jeff Black’s booklet):

  1. Strong powerful experiences of pain
  2. Perception that the they cannot tolerate the pain
  3. Hopelessness and inability to see alternatives other than relief via suicide
  4. Isolation

Other risk factors to consider: previous attempt? Suicidal ideation/plan? Hospitalization (even for non-psychiatric reasons)? Access to lethal means? Depressive anger coupled with impulsive history. These factors aren’t that helpful by themselves but looking over the total may provide *some* clues.

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May 12, 2010 · 12:24 pm

Professional communications by counselors: What do they reveal?


What we say and how we say it can tell someone quite a bit about our character. We counselors earn our keep with words. And yet, it is our words that may do the most harm to others. As a result, I encourage us to take stock of our words. What do they reveal about us? Oh, and don’t just consider the words you use in a session. How you talk to a colleague, about a colleague, to another professional may reveal your character more than you think. Consider the following communication issues:

1. Client put-downs. In agencies where counselors share clients with other professionals (e.g., psychiatrists, social workers, community workers, etc.), it is common for conversation to descend into put-downs. No doubt these professionals care about their clients. But if they are frustrated with the client, does it result in blaming the client? Making fun of their idiosyncracies? “He’s such a narcissist; She’s so Borderline”. These kind of comments reveal more about the speaker than the one spoken about.

2. Professional Lingo. Every guild has its lingo. Read a psychiatric or psychological evaluation and you will likely come across a number of words that only make sense if you are on the inside. The client probably wouldn’t really know what is being said about them with translation help. What do your progress notes communicate? Who are you writing for? How might our lingo hinder our work. I highly suggest that use the client as a standard to evaluate all our written communications. If the client couldn’t understand or could possibly be harmed by what we write, the think better of it.

3. Professional Territorialness. We communicate with other professionals about our clients. Does our communication reveal any condescending attitudes? Any unnecessary hierarchy? How do you talk about another professional to clients? To other colleagues? Do we withhold data for power reasons? For fear of mis-use by the other. If so, we have serious issues to address. Leaving them unaddressed will only injure the client.

4. Unprepared staffings. Staff communications regarding shared clients often include off-the-cuff comments about clients. These kind of statements can sound as if they are well supported by data. Sadly, we can offer up anecdotes about a client and they are weighted as heavily as objective test data. Can we support our comments and insights with data? Are there other data that might challenge our offered hypotheses?

5. General coarseness. I once had a supervisor who used the “F” word in every sentence (and in every form of speech possible). He relished the power he got from using that word. I’m not opposed to ever using curse words but they usually reveal more about the user than the situation. More recently, I’ve noticed how frequently we use genital imagery to talk about important character traits. “Do you have the stones to do that?” I heard this question asked in prime-time television. Why couldn’t they just talk about the trait of courage? I do think that language has a way of devolving in the heat of battle. Counselors work in the trenches and so it stands to reason that they might slip here some.

6. General grumbling. It is easy to slip into the habit of grumbling. I am tempted to revel (yes revel since I think I enjoy it some) in pointing out the failures of other people. I feel better when I can see their mistakes that I would never commit. We grumble against people, against institutions, against policies; against pretty much anything that irritates us.

Let us be diligent to explore what our communication reveals about our hearts and character and let us resolve, with God’s help, to love others even when they are not watching–and to model that love in our speech.

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May 11, 2010 · 10:12 am

Changing Your Narrative in Counseling?


If you have gone to counseling, then you probably wanted something to change in you or something connected to your life. If you have counseled someone or been their wise friend, you also wanted something to change. There are a variety of ways to try to calculate or observe change. Is there a reduction of unwanted behavior or an increase of hoped for behavior? Is there a change in affective or perceptual change (i.e., do I feel better or have more hope?)? Is there more insight? More acceptance of what cannot be changed? Greater responsibility taking for what can be changed? Is there greater congruence between faith and practice, head and heart?

While everyone (counselor, counselee, insurance company) wants objective evidence of positive change to prove that counseling was worth the cost and effort, the most powerful and most valuable change gets little attention. What is that change? Script or narrative change. We all live by a storyline. We use that story line to make sense of our world and of ourselves. However realistic we think we are, we never really use all the data to determine our reality. Rather, we use scripts to fill in blanks and supply us with the “truth.” Don’t think this is true? Just examine the common fights of a couple. Most likely you can remove the content of the fight and you will find an enduring pattern of feelings and perceptions about self and other in each spouse.

How did we get these scripts? We have experiences of self in the world? We make interpretations of what we experience. Others communicate interpretations for us. But we are not blank slates, we come to these experiences with a distorted imago dei–a God-given image and agency that is both active and yet distorted due to Sin.

So, how does counseling change a script or life narrative? There are a couple of options. You can begin with behavior change. Changes in behavior may cause someone to re-evaluate view of self and other. For example, a person may move from “I can’t” to “I can” based on the evidence in behavior change. You can begin with insight. What is my dominant life narrative and is that really accurate or is there a better one to live by? You can begin with relationship. This form of intervention is less clear but probably more powerful than the first two. By focusing on the “here and now” you are having an impact on narrative as it plays out in the moment. In opposition to insight which pulls narratives apart, this form of intervention is predominantly an experience that shapes the narrative in a more implicit fashion. In other words, we realize the change sometime after the fact.

What you cannot do is exhort someone into a new script. When we try (and we do sure try: “Don’t be afraid of ____ …It isn’t that bad…”), we fail. Even if the counselee “buys” the new script, they have only listened to you say it. They have not yet written it on their heart. Passive acceptance ought not be mistaken for real change. In fact, sometimes hearing the needed change over and over only makes the person more resistant to it. A change in script must be practiced and owned for it to become real. That is why an addict may well become sober by accepting the limits imposed by others and still yet remain an addict at heart.

Narrative changes usually take time. It is possible for powerful experiences to create instant change in our view of self and other. Certainly conversion experiences are evidence of massive script changes. Many of us have had powerful “a-ha” moments that also change our perception of self and the world. But most of our script changes happen via the drip method–water dripping on rock does indeed make changes when viewed over the long haul. When we look back on our lives, we often note places where we have indeed changed–sometimes for the better, sometimes not.

———

For more on intervention points in counseling, check out this post I wrote 2 years ago. I tried my hand at illustrating both the script and the intervention points.

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May 6, 2010 · 11:28 am

What to say to suffering people: When truth isn’t helpful


Is the truth always helpful? Always the best option?

I think it is. But when we humans seek to convey truth, we never capture it all. As a result, what truth we do share may not be the truth that is most helpful. There are two things that have me thinking about this today:

1. On Monday night I shared with a class some of our experience with infertility. Some things said to us were downright stupid and wrong. Other things were true. In fact, God does have a wonderful plan for us. But it wasn’t helpful to tell us that when we were hurting. Scripture teaches us that when we sing songs of joy to the downcast it is like drinking vinegar or adding baking soda to it. Kaboom!

2. In recent weeks, CCEF has posted a couple of things on their website that need to be read together. This week they posted David Powlison and John Piper’s “Don’t Waste Your Cancer” to their homepage. This was written by both men when they were in the throes of Prostate cancer. I encourage you to read it from the perspective I am reading it. My wife has breast cancer. We hope to beat it. But we are in the throes of chemo right now. How does this sound to you. True? Helpful? Now, when you have read that, go read Ed Welch’s post: “What Not To Say To Suffering People.” He wrote a follow-up here.  How does this sound to you? True? Helpful?

Seems the first could be seriously misused and does not address all of what you say for comfort in the heat of the battle. Surely we need to be a bit careful about what the person needs to hear. Yes, we can “waste” the cancer in a “woe is me” mentality. But be careful not to go there too quickly! Know your audience and what they need NOW from you.

What do you think? I’d like your feedback.

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