Category Archives: counseling

May 4, 2010 · 10:47 am

Clicking with your counselee


In every first session with a client I tell them that part of their job is evaluate whether I am the right therapist for them. While it is very important that your counselor is well-trained, if you don’t click with your counselor, the work you are trying to do will be much harder. Now, of course it often takes a few sessions to determine whether you can form a trusting, collaborative relationship or not.

I am always thankful when a client is willing to raise the “fit” problem with me. It gives us an opportunity to explore the disconnect, fix it if possible or happily refer to someone else. Too frequently disconnected clients choose to either keep plugging away (but being less and less vulnerable) or just fade away and you never know what went wrong.

But what if the counselor doesn’t connect with the client…and the client doesn’t know it? What should the counselor do?

1. Use supervision or consultation to explore the disconnect. Maybe the disconnect will reveal something useful about the counselee. Maybe it will reveal some pride or prejudice in the counselor. Maybe it will reveal some naiveté or lack of competency or empathy or conflict over goals. Or, maybe it will reveal some cultural differentness that is really hard to overcome.

2. Assess whether or not (again using supervision) whether progress is being made. Is the counselee growing in insight? Gaining control? Showing more fruits of the Spirit? Seeing a decrease in anxiety or depression? The counselor may need to reassess their goals for the client.

3. Consider attempting more “here and now” to explore what is going on in the relationship between counselor and counselee. HOWEVER, do not do this to tell them how you are feeling NOR to be condescending. This action is designed to help both of you to be more present and decrease disconnection.

4. If all else fails, refer. This would be appropriate if (a) you believe you are not competent to help them or impaired in some way (and you should communicate your lack–in a limited way–to the client when discussing referral), or (b) you believe the problem is that counseling is harmful (and again you should discuss why you think this way and what the options might look like for them. Remember to avoid abandoning them. Referrals are specific, take time, and are for their best interest, not yours.

The bottom line is that the onus is on the counselor to work through the disconnect and to do all that he or she can to fix the problem or to tolerate it if the client is making good progress. This is what it means to “love one another.” We fail to do so if we either ignore the problem or use the disconnect to get rid of counselees that do not feed our egos.

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April 28, 2010 · 9:15 am

Should you Google your clients?


Dr. Zur has a new blog post on this topic that raises question (no answers at this point). Should you Google your clients? Dr. Zur wants to consider the ethics of this. There are two ways to try to explore this topic from an ethical point of view.

  1. What do the ethics codes say? Codes say nothing directly about this. Indirectly, we are to work to protect their dignity and human freedom. We are to act beneficently. We are to seek consent before we provide treatment or access private and protected information. We are not to give out their information without consent. Questions to ask: oes googling a client risk revealing their identity to others? It might if you use a shared computer. Would Googling access private and protected information? It shouldn’t. However, many people blog and post private information that might shock them if others in their various circles found out. Many do not consider this when posting comments or personal information.
  2. Beyond the codes, is it good practice to search for information about your clients? Or put another way, how might searching for information about your clients cause harm? Might it change the relationship? Change your opinion of them? Make you less interested in helping them? What if the information you find isn’t accurate? Might it cause you to use that information in a coercive manner? Might it be used to practice a form of voyeurism (which is a form of using clients for our own pleasure)? These kinds of questions raise moral and theoretical issues as much as ethical ones.

Dr. Zur lists a number of vignettes that might well cause you to answer yes to our initial question. Googling might reveal safety issues, legal issues, even life issues that would be helpful to know. So, our answer will never be that it is unethical.

I would leave you with this question. How will you feel if your clients know you have googled them? Will you be embarrassed? If so, you ought not to do it. Similarly, if a client comes in knowing lots of things about you that they gleaned from the Internet (work history, family, etc.), do you feel stalked? Maybe we should consider the “Do unto others…” command here.

One last pragmatic point. It is sometimes possible today to find out who is Googling you. Keep that in mind as you think about this issue.

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April 26, 2010 · 7:46 pm

First session requirements?


Today marks the third week of my Practicum and Professional Orientation class. This is the first opportunity for many of my students to begin live counseling experiences in their Practicum settings. Most seem to be settling in nicely.

If you have been a green counselor in your first session then you know the terror of: “What will they say???? What will I say????” It doesn’t matter if you have a 10 year file on the client or a 1 sentence “presenting problem”, the green counselor cannot predict the outcome of the session–hence the fear.

To alleviate some of the fear, let’s review what makes for a good first session.

1. Introductions. Make sure they know who you are and who is supervising you. Give them a chance to tell you why they are coming for counseling. Sometimes what they say differs from what they wrote on the forms.

2. Help the client tell their story without too much interruption. Don’t be too quick to jump in and direct with too many questions.

3. Gathering the following data (again, without too much interruption):

  • content and scope of problem (frequency, duration, intensity)
  • solutions attempted, things that help/harm, prior counseling attempts
  • current family/community make-up
  • other mental illness
  • relevant medical history, current meds, sleep quality
  • substance abuse
  • spiritual dynamics
  • supports, strengths
  • typical mood, suicidality
  • Other important factors (employment, finances, relational conflicts, etc)
  • dreams, hopes, goals

4. Summarize (briefly) and discuss possible initial directions or goals as well as alternatives they may wish to consider

5. Counseling model and nuts and bolts of professional care (confidentiality limits, scheduling, contacting you, payment options, etc.)

That will be more than enough for an hour. Most likely, you get great data in some areas and just a tad in others that will require you to follow-up in the next week. The more talkative the client is, the less data you can gather. The less talkative, the more likely you will get the data but the less likely you’ll form a good connection (Q & A leads to very passive clients more often than not).

It is good to have these very general categories in mind as you start that first session. Be wary of either forgetting the categories or obsessively forcing the client to answer all the history questions. You may end up with a wonderful piece of history for a client who never returns.

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April 22, 2010 · 5:23 pm

Staff Mtg on Prolonged Exposure treatment for PTSD


Had a fabulous staff meeting at our practice today given by fellow colleague, Marta MacDougall. Marta also works at the Philadelphia area VA. She presented an overview of Edna Foa’s Prolonged Exposure Therapy for PTSD. You can find the book here.

PE looks at trauma this way: PTSD is maintained by avoidance behaviors. One avoids memories, triggers, emotions, places of traumatic experiences. While avoidance works in the short-term, it exacerbates the symptoms over the long haul since they are not fully processed. In fact, the better able one can avoid these feelings, the more likely their PTSD will be worse later. Hence why you can have some very functional people become unable to function later in life. She used this illustration. For many Vietnam Vets, Vietnam is part of a book they keep trying not to read. They shove it away over and over but it has a habit of falling off the shelf and opening to the same page, even the same couple of very painful sentences. Thus, despite their attempt to avoid, the only thing they keep rereading is the same couple of sentences; thereby reinforcing and even rewriting the whole experience as if it were only those two sentences.

Thus, the goal is break the “phobic reaction” to painful thoughts and feelings. How? By two prongs: (a) imaginal exposure (memory encounters), and (b) in-vivo exposure to avoidant stuff in the present.

The therapy consists of 12-20 sessions (1.5 to 2 hours each). In the sessions, the person develops a current list of avoidance in their life  or other subtle safety behaviors. They begin to daily pick easy to hard avoidant tendencies to expose themself to in order to break the fear pattern. Now, these are things that aren’t actually dangerous. Second, in session 3 they begin to recount the most salient trauma from the point in the story where they were safe to unsafe to safe again. So, it could be a story of waking up to a rape, going out for a particular traumatic battle, etc.). This portion of the story may only take 5-10 minutes to recount. That same memory is recounted, in the first person with eyes shut, repeatedly for up to 45 minutes. During the exposure, the therapist asks for their subjective units of distress level (0-100) every five minutes. This exposure to the same memory is repeated in each session with time to talk about and process at the end. The levels of distress are tracked over time (both from imaginal and in-vivo exposure experiences. On top the therapy intervention, the in office imaginal exposure experience is recorded and the client is to listen daily to that recording.

Sound like torture to you? It does to me. Here’s the reaction rationale. The avoidance of memories and emotions tied to them is causes even greater distress. Thus, getting the client to face that distress and process the emotions as well as uncover subtle lies believed about self and other is only dealing with reality directly.

You can imagine that many refuse this kind of therapy. Those who do it…about 80% see a significant reduction in PTSD.

Not sure I’m going to begin doing this kind of therapy as I’m not set up for it being in the office only 1 day per week. However, I will pay more attention to the ways avoidance behaviors or safety seeking behaviors accentuates PTSD and will be more likely to give daily homework to address this problem.

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April 9, 2010 · 9:58 am

Seeing clients outside the office


Much of what we do in counseling or therapy is enculturated. Confidentiality, the 50 minute session, avoiding dual relationships…these things developed out of the culture of psychoanalysis. Now, that is not a criticism. I personally agree that good therapy requires privacy and the assurance of confidentiality. Who would talk about the deepest matters of the heart if they thought it would be broadcast to the world? And it isn’t as if this is a modern invention. Pastors have been practicing this since the early church.

One of those culture founded practices is seeing patients only in the office setting. Supposedly, this would maintain the “frame” of the counseling hour so as to avoid unnecessary outward intrusions. Further, it maintains one picture of the therapist. Having coffee with your therapist at the local diner would completely change that frame–and reduce confidentiality when your neighbor comes up and says, “Oh, I saw you go into the diner with Dr. Monroe. How do you know him?”

But there are some reasons why a counselor might intentionally see a client outside the office. Here are some reasons I have:

  1. Observation of a child in a school or home setting as part of an assessment
  2. Visiting a client in the hospital (either as a courtesy call or as part of a treatment continuity plan)
  3. Joint meeting with other providers (therapists, pastors, care team) at another location
  4. Part of a treatment plan (e.g., to practice walking over a bridge, get on an elevator, etc.

I have been asked to have coffee by current clients. I have been invited to house-warming parties. I have been asked to attend other celebrations. I’m more inclined to attend celebrations for kids or if the relationship is quite limited (wedding of a pre-marital client seen for 6 sessions only). I have taken clients outside my office for one reason or another (a brief walk, thrown a ball with a kid, etc.).

Whatever you choose to do. Be sure to evaluate the effect it will have on your relationship with the client. What potential pit-falls exist? Talk to them about it. Afterwards, continue to see if such actions introduce any relationship confusion. Be wary of informality. You don’t have to be stiff but informality breeds complacency and soon you are doing things you never dreamed of doing. Also be especially wary if the client has any history of abuse or boundary violations. Take care to protect those boundaries for their sake.

While psychological ethics are built on “Do no harm,” we know that the bible also supports this. Watch out for your weaker brother or sister!

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April 8, 2010 · 9:51 am

Counseling Ethics and Electronic media


Once before I wrote a bit on this topic. Just how much should we use electronic media to work with clients? While most counseling takes place face to face, counselors speak with their clients using the phone, e-mail, texts, live chat, video conferencing, even through “second life” formats using avatars.

In the latest edition of the Pennsylvania Psychologist, I saw another little article reminding us counselors how to manage these electronic methods. Rachael Baturin suggests the following tips:

  1. Always clarify what kind electronic connectivity you will have and the nature of those interactions. For example, use of email to receive documents and make scheduling changes but wary of too long or too informal style emails. If you look like a friend (sharing personal stuff back to the client), it blurs boundaries
  2. Anticipate and respond to abuses of your policy (e.g., frequent texting, demanding emails)
  3. Avoiding the use of e-mails and texts for emergency contacts from clients. Use the phone or answering service for that
  4. Establish a general turnaround policy (how long you will likely take to respond to emails)
  5. Inform clients about privacy issues. Such as, use of work email to contact them, possibility of a shared email.
  6. Maintain a copy of every email or electronic contact. Or summarize them in the next case note.
  7. Use the standard text at end of email msgs to remind them of confidentiality and the possibility of errors in sending.
  8. Remember, tone of voice is missing in emails. Be sure to be extra careful about this

A couple of additional matters not mentioned:

Be clear on whether you bill for time on emails BEFORE you start emailing back and forth. Recognize that SKYPE or other kinds of video conferencing to other countries may not be as private as you might think. Other countries may do more to monitor NGOs and others serving abroad. If you get emailed journals, ask the person to use an agreed upon password for their Word documents. That way, if the email goes awry, no-one else can view the contents but you and your client.

Bottom line? Don’t be lulled into unprofessional activities on-line. Assume everything you send (chat, texts, email) may be printed out or shared with someone else. How would what you are saying or doing look to a court of law determining whether you acted in the best interests of your client and whether or not you held yourself to a high standard of care?

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April 6, 2010 · 11:13 am

The burden of a secret


I once ran across a website posting short video clips of individuals revealing some deep secret. Some of these secrets were funny (developing a fake friend on a social networking site to make an ex girlfriend jealous), some were eye-brow raising (eating contents of nose), and some were downright painful (revealing affairs, addictions, sexual abuse and the like).

Keeping a secret (your own or someone else’s) requires that you carry a burden. You know something and can’t share it. You can’t talk about it. You might like to, but the consequences seem dire if you share it. You might lose a friend. You might lose your reputation. You might lose your security.

As someone who listens to secrets for a living I’ve a few observations about the secrets people hold:

1. Even in the confidential setting of counseling, it is near impossible to lay down the burden of some secrets. These secrets are covered in shame. Sexual abuse; Unwanted sexual thoughts and feelings; addictions.

2. Secrets shape our identity in some powerful ways–maybe even more than known truths.

3. The longer a secret is kept, the harder it is to tell, or the harder it is to tell truthfully. Time has a way of distorting facts and feelings in some cases. Similarly, we make lots of excuses for why we keep secrets. Some excuses are cover for shame (e.g., “It would hurt her to know that I…”).

4. When someone has a guilty secret (e.g., an affair), they often tell it to finally throw off the burden of guilt. So, when they tell their spouse, they often feel better right away. Unfortunately, the spouse does NOT feel better. In these cases I find the guilty spouse has a hard time relating to the new burden they’ve just loaded on to their mate. They feel free and wish their spouse would now also feel free too. It is always good for the guilty spouse to question why they wish to confess. Is it to promote truth and long-term possibility of healing? Then, they should tell (carefully). If it is to just be relieved of their guilt, then such a confession may not lead to repentance and healing.

5. Even little secrets kept from a loved one can hurt when revealed. If you lie to me about how many Easter eggs you ate on Sunday, maybe you are lying to me about more weighty matters.

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March 31, 2010 · 2:20 pm

OP Ed piece on pornography you should read


I subscribe to a listserv that documents abuse and exploitation around the world. Recently, I received notice of an article in the National Review (by an anonymous psychologist) entitled, “Getting Serious about Pornography”. The writer documents the known impact of pornography on men (i.e., the objectification of women) and at the same time tells of her own experience of being abandoned by her husband due to his porn addiction. I include her first paragraph. Click the link above for the essay on the original website.

Imagine a drug so powerful it can destroy a family simply by distorting a man’s perception of his wife. Picture an addiction so lethal it has the potential to render an entire generation incapable of forming lasting marriages and so widespread that it produces more annual revenue ­ $97 billion worldwide in 2006 ­ than all of the leading technology companies combined. Consider a narcotic so insidious that it evades serious scientific study and legislative action for decades, thriving instead under the ever-expanding banner of the First Amendment.

According to an online statistics firm, an estimated 40 million people use this drug on a regular basis. It doesn’t come in pill form. It can’t be smoked, injected, or snorted. And yet neurological data suggest its effects on the brain are strikingly similar to those of synthetic drugs. Indeed, two authorities on the neurochemistry of addiction, Harvey Milkman and Stanley Sunderwirth, claim it is the ability of this drug to influence all three pleasure systems in the brain ­ arousal, satiation, and fantasy ­ that makes it “the pièce de résistance among the addictions.”

For more click the link above. It is well worth the effort.

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March 30, 2010 · 11:22 am

Book Note: Linkages between stress, inflammation, and mental illness


I am in the process of clearing my desk of semester debris. Well, truth be told, I am in the process of clearing a portion of my desk from said debris. The rest will have to wait. In the process, I came across a book I’ve been meaning to read since the dept. purchased it for me: The Psychoneuroimmunology of Chronic Disease: Exploring the Links Between Inflammation, Stress, and Illness (APA, 2010).

Before you all stop reading, it really is an important work! You should care if you are someone experiencing high levels of stress or if you counsel those who do. AND, there IS an answer (you won’t like it!) that can help given at the end of this post.

Yes, it is very technical. You can’t skim this book easily unless you read only the chapter summaries (not a bad idea!). However, I find it very interesting to read about how well-connected (too well!) our minds are with our bodies. Here are a couple of book highlights

1. Chapter one: Stress activates primary and secondary responses that may actually increase our vulnerability to disease. Secondary? Examples given include alcohol abuse, poor diet, non-compliance with treatments. Primary? Your body does a couple of things in reaction to stress. First, your sympathetic system starts looking for inflammation. Immune cells look for an injury. You have more glucose available to burn and cortisol increases which also works to activate anti-inflammatory responses. Inflammation is the problem (a “rapid and nonspecific response to danger”). Too much inflammation? damaged tissue. Too much anti-inflammatory response? Damaged tissue. Those with depression may have become less sensitive to cortisol and so end up with lots of non-specific inflammation. Maybe this is why depression hurts so much!

2. Chapter 3: Poor sleep has serious health consequences, especially concerning chronic diseases. One study indicates that disordered sleep has a direct link to type 2 diabetes, independent of age and body size. Individuals with sleep apneas have a greater production of inflammatory bio-markers. Women may be at greater risk for cardiovascular diseases due to sleep problems than men. One problem (sleep problems) begets the other (inflammation) which creates a vicious cycle.

3. Chapter 4: “Western diets typically contain an abundance of proinflammatory omega-6 fatty acids and are low in anti-inflammatory omega-3s.” (p. 96). In other words, dietary fish oil helps promote healing and may lower symptoms due to inflammatory diseases. More fish oil, less vegetable oil.

4. Chapter 5: Links between stress, depression, PTSD, hostility and inflammation. Each of these things increases inflammation, increases sleep disorders which in turn…(you get the picture).

Okay, does anything help l0wer stress and increase healthy immune system functioning? This is the answer I promised at the top of this post. Are you ready? It is so simple you will hate it!* (that will be something to explore at a later date–why do we resist the things we CAN do to help our situation?)

1. Diet. Having a better (lower) ratio of Omega-6s to Omega-3s (more cold water fatty fish) seem to lower rates of depression. Higher Omega-3 consumption predicts lower suicidality, lower depression, and bipolar disease. It appears these amino acids help stop the overactive inflammatory response caused by repeated stress.

2. Exercise. It will initially raise inflammation markers (hence why many with RA feel that any exercise creates more pain), but later lower it if continued on a regular basis.

3. Counseling. Cognitive-Behavioral social support interventions have shown to reduce the inflammation effect by lowering stress. be effective in doing just that.

So, encourage your stressed clients or friends (even better, do it with them) to eat well, exercise (just walk!) and seek social support. In doing so, they will find relief from inflammation and the effects on the mind and body. I guess it is time for me to get up from this desk, skip the doughnut, and walk up to the library for a bit of exercise. On the way, I should stop by a colleague’s desk and get him to come with.

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*Simple? Yes. Quick fix? No. Sure bet to solve all our problems? Absolutely no.

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March 29, 2010 · 2:23 pm

Another shot at understanding integration of psychology and christianity


Over the 40 plus years of our profession’s existence, Christian counselors have tried in numerous ways to model the relationship between Christianity/theology/bible and the study of psychology. Unfortunately, many model building efforts created more barriers than dialogue among brothers and sisters. Counselors staked out territory with titles such as biblical counseling, integration, levels of explanation.

However, in recent years, more authors have tried hard to articulate a distinctly Christian view of persons and a humble articulation of the change process that builds on the good insights of others (e.g., McMinn & Campbell’s Integrative psychotherapy, Johnson’s Foundations of Soul Care, Malony & Augsburger’s Christian Counseling, etc.). These authors have taken the time to examine their control beliefs, theological assumptions, and more in order to make their psychology truly Christian and not merely a rehash of secular ideas.

If you like thinking about epistemology and yet still interested in application to real life, you ought to check out John Coe and Todd Hall’s Psychology in the Spirit: Contours of a Transformational Psychology (IVP, 2010). I’m just getting into it and so do not have much to say just yet. However, this is a great time to be a Christian psychologist. After a decade or more of avoiding these kinds of treatises for being practical (to a fault) and superficially Christian in our psychology, we have something substantive to sink our teeth into. This is no superficial treatment of Christian theology and human efforts (and their failings) to understand the nature of persons-in-relationship. For example,

1. They start out with the Fall. They acknowledge its full impact on human knowing and observing, that psychology from human eyes will always contain some distortion.

2. They acknowledge that redemption and not merely creation is what shapes our identity. “By creation, human love, and natural goods, we discover a “self.” By redemption and transformation, we are enabled to slowly die to our autonomous self and open to our new identity as self-in-God.” (p. 35)

3. “Ultimately, we are not merely arguing for a new model or a way to relate psychology to Christianity; rather, we are arguing for a new transformational model for doing psychology and science, which inherently and intrinsically is already Christian and open to the Spirit.” (ibid)

4.   They are interested in a spiritually formative and relational psychology that cares about the person, the process, and the product (p. 37)

I’m looking forward to the ride. Not sure I’m going to be happy. I’ve read a bit further and am not sure why they spend more time knocking down models that most of us would consider their first cousins (e.g., Christian psychology). That seems to be something from our profession’s past that isn’t as helpful. However, I really appreciate that an early chapter tells both of their stories; their maturation through a period where their faith wasn’t as central to their work as Christian professors of psychology. Often, these kinds of books do NOT include admissions of growth and change. Too often, authors act is if they have always thought this or that way.

I’ll keep you posted with book notes as I go.

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