Category Archives: counseling

January 18, 2010 · 10:54 am

Counseling skills help pastors cope?


A couple of people sent me links to a recent news item out of Britain concerning the value of teaching counseling skills to pastors. Researchers there found that pastors who do a lot of emotion laden work with parishioners bear a heavy load (pretty obvious so it is nice to see that research doesn’t say otherwise). Those pastors with counseling skills training seem to cope better with the distress. I’ve not seen any in-depth description of the study so I can’t comment on why this might be the case. It could be that pastors with counseling training are more self-aware. It could be they are more positive on the benefits of talk therapy and so utilize it for themselves. It could be they feel more effective in their counseling work and therefore feel less helpless.

Whatever the case, I’m happy that it supports my coursework teaching counseling skills to pastors.

Read about the research:  CT’s news blurb, Medical News blurb

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January 11, 2010 · 2:02 pm

Psychiatric labeling: The problem isn’t the label


Christians tend to have some strong feelings about counseling, psychology, psychiatry and similar terms. Come to think of it, most people, regardless of faith, have strong feelings about these topics. Experiences dictate much of these reactions. Experiences, such as:

  • experiencing or hearing of a mental health representative (mhp) belittling Christianity
  • experiencing or hearing of an arrogant, controlling, or completely incompetent mhp
  • experiencing or hearing of a positive experience where someone found relief or change or insight
  • feeling either helped or stigmatized by a received diagnosis or a use of medication

In psychopathology class tonight, we will explore the background behind psychiatric classifications. How did we get the Diagnostic and Statistical Manual? What are its underpinnings? There are a couple of common concerns about the DSM

  • It purports to be atheoretical and descriptive only
  • Diagnoses suggest objective and distinct “things”
  • It medicalizes problems in living
  • Under one diagnosis (e.g., depression) you can have such wide variety of symptoms
  • Therapists have sizeable disagreements on diagnoses so are they all that helpful?
  • It is leveraged by insurance in ways that make it a liability
  • It doesn’t address matters of the heart or spirit
  • It has political overtones
  • It treats most problems in an individualistic fashion without account for family systems

Every one of these concerns has merit. However, the biggest problem I have is not with the DSM itself but with many of its users. The complaints that are raised about the DSM usually come from someone mis-using the DSM.

Remember the simple explanation of a problem almost always distorts it. Thus, the simplistic use of diagnostic labels almost always does damage.

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January 6, 2010 · 11:33 am

Some thoughts on “This Emotional Life”


Caught part II of a 3 part, 6 hour, series on PBS last night. This Emotional Life, moderated by Dr. Dan Gilbert. I recommend you check out, at minimum their website but if you get a chance, tonight your local pbs station may air the 3rd part. The website includes lots of info about the various topics, individuals interviewed, and the whole first episode (which I have yet to watch). The series focuses on love and family relationships and attachment (#1), negative emotions such as anger, fear, and depression (#2), and happiness (#3).

Now, there are a number of irritations I have about the program but the good outweighs the bad. What don’t I like?  I don’t like the way they say, “Science says…” and then do not discriminate between data and interpretation of said data. I don’t like the repetitive evolutionary comments. For example, “the newer part of your brain can’t communicate with the older part” assumes that because we have a cerebral cortex and animals don’t have as well-developed cortexes, that part of our brain is “newer.” Further, the view of humanity in episode 2 seems to be that of the human physical robot. There is no space for the spiritual. One quote from the episode, “Mental illness is nothing less than a physical illness that has psychological consequences.” It is as if emotions are only chemical.

But these small problems can be easily forgiven. Here’s what I like from episode 2:

  • The honest admissions of struggles of celebrities (e.g., Katie Couric’s admission she has intrusive thoughts of jumping off high balconies, Chevy Chase’s admission of depression, etc.)
  • The gripping stories of struggler’s with anger, anxiety, and depression (especially two vet’s struggle with PTSD) and the significant impact of the struggles on the other family members
  • You really get a window into their interactions with their therapists. Lots of good video that is rare to see!
  • The scientific discoveries relating to the brain and the experiences of these negative emotions. For example:
    • Stress hormones seem to strengthen memory formation. Thus traumatic experiences likely etch bad memories much deeper than other memories.
    • Re-appraisal (neutral re-evaluation) of events where you experience negative emotions supports more control of these emotions whereas rumination causes us to be more reactive
    • Prolonged exposure therapy (telling, retelling and retelling again) for PTSD patients seems to have significant positive benefits (though it defies logic–most people want to get away from their bad memories)
    • Depressed individuals tend to have reduced hippocampus volume. Antidepressants and ECT seem not merely to change brain chemistry but actually increase cell growth. Depression actually seems to change the brain and antidepressant use stops hippocampus shrinkage

A couple of other interesting tidbits:

  • Emotion regulation: not trying to turn off emotion but tools to change the course of emotion
  • “Don’t believe everything you think.” But, we tend to nonetheless
  • Struggling with overwhelming anxiety? Accept that you have these feelings (crying, tension, fear), accept that they are physiological experiences, avoid labeling them as awful. You will have scary thoughts and you can live with them
  • “What is the worst thing that could happen right now?” I might cry. “And what if you do?” That would be bad. By accepting these emotions you can distance from the meaning you are applying to them.
  • There are biological indicators in those who are highly reactive to stress. These folks can’t help their reaction but they can recognize their tendencies and respond differently to them.
  • Untreated mental illness is harder to treat if left untreated for long periods of time.
  • Richard Lewis on the benefits of therapy and getting to talk about things he never talked about with anyone: “Maybe for the time I left her (his therapist) office til I got in my car I was floating on air”. Hmm, is that worth the 150 dollars he probably paid?

Finally, I leave you with this. Perceptions of progress, or lack thereof, have a huge impact on your perceptions of happiness. One young girl thought her ECT would help sooner than it did. When it did not, she crashed even worse. Even more than our physiology of emotions, our perceptions of our well-being and our progress often dictate our beliefs about ourselves and our futures.

If you saw it, what did you think?

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January 4, 2010 · 12:39 pm

Psychopathology Monday


Happy New Year all. Our semester begins today with the first session of Psychopathology for the first year students. Before launching into the various forms of mental illness and emotional maladies, we consider the larger concept of suffering. Without a careful understanding of (a) the nature, causes, and theology of suffering, (b) the meanings of suffering, and (c) our beliefs and responses to suffering, we counselors become a dangerous lot. We fall prey to simplistic understandings and responses–and fall prey to false hope and false despair.

Sound like a great way to start of the New Year? It does to me because we now have an opportunity to look at ourselves and our world with more realistic eyes than we may have during the stress of the holidays.

Coincidentally, we had a Sunday School class yesterday on the topic of suffering. Our church has buried 10 people who died before their time (so it seems to us!) in the past 5 years. Not only have we had these tragedies, we’ve also splanted a church and been in a transitional malaise for maybe 7 years? The class allowed individuals to talk about suffering and heartache. Good class. We heard those who felt that what was going on was a message from the Lord, from those who just felt confused and in pain, from those who felt the nearness of the Lord during these normal ups and downs of life in a fallen world.

What was said in multiple ways was that one’s perspective or expectations about suffering really impact how one feels about the struggle of life. If you expect life to always be healthy then repeated sicknesses and death will set you back. Someone said there that if you lived in a dirt hut that moving into a trailer would seem wonderful but if you lived in a palace, the trailer would seem a terrible thing.

So, what should we think about suffering and the seeming explosion of death and heartache?

  1. God is saying something AND yet He may not be sending some special message to us
  2. Our actions may cause some of our own suffering but living more righteous lives does not prevent suffering
  3. Suffering is to be expected in this world AND yet it is NOT THE WAY IT IS SUPPOSED TO BE
  4. Isolation and failure to connect to others in suffering ALWAYS makes that suffering worse
  5. Even those who only observe those in suffering suffer as well and need to connect with others in order to avoid despair
  6. Good may come out of suffering, but suffering itself is not good
  7. God, through the cross, bears our suffering and yet it still hurts
  8. It will not last forever

Finally, how do you respond to suffering? Turn away? Become numb? Angry? Probably all the above, right? Take a moment to consider how you respond to suffering right in front of you and watch yourself for those trite statements that can hurt those who are already in pain.

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December 22, 2009 · 2:57 pm

Interesting article in the American Psychologist


Just got my December issue of the American Psychologist (64:9). In it is an article but Brenda Major (and others) entitled, “Abortion and Mental Health.” These authors wrote a report in 2008 for the APA task force on Mental Health and Abortion (available at here). What I find interesting in the article is the discussion of the research on the association of mental health problems with abortion. Set aside, just for a moment, your strong feelings about the topic and consider this question: how would you go about studying the effects of abortion on women using robust measures?

You cannot do a randomized, double-blind study (you subjects get an abortion while you other subjects have your baby). Thus, you cannot fully control pre-existing or co-occurring risk factors. So, what do most researchers do? Try to indicate risk markers–correlations–that may point to possible but not proven causes. The writers of this article point out that the downside of correlation or associations is that folk tend to mistake them as causes. They give one specific example: If age is the “most important known risk factor for Alzheimer’s disease (AD)” one might assume that age causes AD. But it does not. Similarly, one can do a study that shows 100% of convicted sex offenders have their own sexual victimization and wrongly assume that sexual abuse leads to sex offending. Not so.

These authors emphasize the benefits of asking two other questions (on p. 865):

1. What is the relative risk of mental health problems associated with abortion compared to the same risks associated with having an unwanted baby (whether keeping or adopting out)?

2. What predicts individual variation in women’s psychological experiences following abortion?

The authors go on to say that the hypothesis of the researcher really impacts the kinds of research questions asked (and thus conclusions). Some research focuses on traumatic experiences, others on stress and coping, still others on the sociocultural context.

By the way, it is a long article but concludes this way (p. 886):

Mental health among women who experience an unwanted pregnancy reflects a number of factors. It reflects preexisting and co-occurring conditions in a woman’s life that place her at greater or lesser risk for poor mental health in general regardless of how she resolves her pregnancy. It reflects her appraisals of the meaning of a pregnancy and abortion and her appraisals of her ability to cope with either option.

There’s more to their final thoughts but you get the point. How you look at pregnancy, abortion, adoption is likely to have a big impact on your immediate mental health. Sadly, I suspect the research also reflects the biases of the researcher (how could it not?).

I found this article interesting because it does a great job illustrating the benefits AND drawbacks of research. Researching mental health of women with unwanted pregnancies is a good idea but will fail to address the moral and ethical questions that, in my mind, take precedence in the public debate.

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December 8, 2009 · 1:54 pm

End of semester thoughts


Looking at a stack of papers I need to grade and yet not feeling the energy to do so. Late night classes take more out of me than I care to admit. My physiology class ended with student presentations and a look at bipolar disorder. As we concluded the class, I asked them to remember that,

  1. Even with all the advances in neuroscience, we must humbly admit we still know little how we are fearfully and wonderfully made.
  2. It is good for counselors to keep learning about the body and at the same time hold what they know lightly. Tomorrow may bring evidence to the contrary
  3. Yet, what we know about the body can be helpful. We ought not to look down upon our ignorance but remember that doctors do not always explain or walk with patients
  4. There are great medical interventions available, but (and that but shouldn’t diminish what I said before it),
  5. Over and over we saw that the basics (maintaining balance in life, self-care, mindfulness) are so important to health, perspective, etc. No, they aren’t magic interventions. Yes, they pay-off over time rather than immediately.

On this last point I am pondering a bit and so let me be hyperbolic. Most people who come to see me for paid counseling come because they think (naively) I have some expertise that will shed light on their situation and a solution to their problems. They want me to do something. Why else pay that kind of money? And yet much of what I have to offer isn’t rocket science. Beyond a few fun techniques, what I have to offer is a listening ear, a willingness to walk with the other person in their travail, and encouragement to keep going back to the basics. Most people like the first two but balk at the last one. Why do we balk at going back to the basics? Two reasons: (1) we want something that will fix the problem NOW, and (2) we’ve tried the basics and they didn’t seem to work (see reason 1).

Examples of what I mean.

  • If you are a parent and you go to a counselor to deal with your young child’s behavior problem. More than likely, you will get some counselor telling you to use some reinforcement strategies. And what do many parents say? “I tried that and it didn’t work.” Chances are they did try it and either they didn’t keep at it or they didn’t realize they were doing something that reinforced the wrong thing, or they had a misguided view of what success should look like
  • A couple is struggling with fighting. They go to the counselor who encourages them to return to the basics of respectful talk. Usually, they will feel like they have already tried it–and it didn’t work. Chances are… You get the picture.

In physiology, we see that care for the body includes mindful meditation (My friend and former professor says a substitute word would be “watchfulness”) on the world as God sees it, developing and maintaining good circadian rhythms, watching food intake, exercise, maintaining healthy relationships and social supports. In every mental illness, these things are shown to decrease the severity of symptoms and delay relapse.

Here’s the problem: we forget the basics and because they don’t give immediate results, we go searching for other fast-acting mechanisms. For example, I want to feel safe. Instead of engaging in centering prayer over the long haul, I fall prey to the temptation to act in such a way to avoid all possible danger–thereby increasing my fears of danger.

If I don’t exercise (and I don’t much) I rarely get immediate feedback that my body is falling apart. If I don’t eat right, I don’t immediately gain 10 pounds. If I don’t pray, I don’t immediately get embittered. So, I assume that these basics aren’t all that important. Or, I know they are important but since they don’t pay off now, I don’t do them. I only do what demands I do it to avoid a crisis.

How do we stay on track with the basics? We need another person(s) willing to keep us on a short leash. As a kid I ran because I had a friend who was going to wonder where I was. As a doctoral student, I played basketball at 6 am because my peers would  ask me where I was. I lost some weight a couple of years ago because my wife and I worked together. Notice that the social accountability is a key facet to help us build the disciplines long enough to see that the pay off is more than can be delivered by an exciting new technique.

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December 4, 2009 · 5:56 am

Prevention services for pastors?


Ran across a new set of stats about pastor health in the last few weeks. Nothing surprising, just more confirmation of the same story. A Cheryl Shireman reports on data from over a thousand pastors who attended 2 conferences. Some of her stats…

  • 57% of pastors would leave if they had a better place to go–including secular work
  • 77% report not having a good marriage
  • 72% felt they were unqualified or poorly trained by seminaries to lead the church or counsel others
  • Only 38% report personal devotions outside of sermon prep
  • 38% are divorced or going through one
  • 30% admitted a sexual encounter with a parishioner

Let’s assume that most pastors enter the ministry fit (false assumption!) for the trials and tribulations and spiritually mature. What can a church do to maintain that pastor’s health (and his/her family as well)? We surely don’t give them combat pay. While most get vacation and health benefits, few report getting ongoing discipleship or training beyond the annual preaching conference.

Here’s an idea I’ve surfaced here before. What if pastors were required to have a mentor? What if churches provided $1000 a year for use in preventative counseling or confidential spiritual direction? What if pastors had to complete a confidential “check-up” each year? On this last item, I suspect that I could provide an assessment (cheap, easy to complete questionnaires for pastor and spouse plus 3 hours of follow-up interview and goal setting) for under $400.

If these recommendations came before your congregation, what would the reaction be? Would there be resistance? Worry about expenses? Openness? I’m curious…

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December 1, 2009 · 12:04 pm

Chronic pain and the Christian faith


Last night’s Counseling & Physiology class covered the topic of chronic pain. There are a number of syndromes and disorders that cluster around pain as the presenting problem: Chronic Fatigue, Fibromyalgia, Irritable Bowel Syndrome, Rheumatoid Arthritis, Osteoarthritis, back pain, etc. Depending on which research study you read, some 9-17% of the population struggles with some form of chronic pain.

While these various forms of pain are quite different, there are some commonalities. Chronic and diffuse pain sufferers frequently experience some form of inflammation, fatigue, sleep disruption, negative mood, and poor memory (its hard to pay attention to new information when you are weighed down by pain). We don’t really know what causes what but we do know that these symptoms form a vicious cycle. If you don’t get restorative sleep, you experience more fatigue, you are more prone to negative thought patterns, your pain levels go up, memory goes down…and thus you don’t sleep well the next night, and so on. Researchers describe this vicious cycle in terms of “allostatic load”–the deleterious effects of chronic stress hormones without restorative sleep.

Because of the diffuse nature of pain (vs. focal) and the lack of obvious objective evidence of that pain (a big red spot, a swollen limb, etc.), chronic pain sufferers and their families struggle to understand whether or not the pain is real and what they are truly capable of doing. How do you measure pain levels? It’s pretty subjective! Thus, it encourages more “I should be able to…” thinking in all parties. Those not suffering chronic pain do more damage by implying that the person is just looking for attention, is just being lazy. Those suffering pain who either deny the pain and try to do too much or refuse to engage the world and withdraw from it do damage to themselves–real physical damage.

As with all physiological problems, one’s mood, one’s perceptions, one’s focus, one’s stress levels impact severity of the problem. While chronic pain is not just in one’s head, how one responds to chronic pain may help alleviate or elevate the pain sensations. Ironically, many pain sufferers resist counseling because they fear that others will believe that their symptoms are all in their head. Those who refuse to acknowledge the psychological factors in pain sensation and management miss out on important means to cope with the pain and to lower pain perceptions.

Chronic pain sufferers must accept the need to adjust their lifestyle to accommodate more rest. They must fight to get the best restorative sleep possible. These are probably their primary practical responses–even above medical treatments (and I’m not knocking medical treatments nor saying that just getting sleep will solve the problem).

One of the biggest challenges for pain sufferers is the matter of hope and faith. When we suffer problems, we often hope they will go away. And when they do not, or only get marginally better, it is easy to slide into despair. Despair usually is the result of things not going the way we hoped or expected they would. Part of dealing with chronic pain is grieving what is lost in order to accept–even enjoy–what strength and health we do have. Without hope, we lose what self-efficacy we once had, thus not doing the basic care-taking activities within our grasp. Interestingly, one of the clearest signs of this struggle is the massive dropouts in pain management research. Frequently, dropouts number about 50% in these studies. This means that before a study gets too far along many are dropping out because they assume the new treatment isn’t going work.

Faith is not that things will go my way right now but that God is in control, cares/protects me, and is working for my ultimate redemption–even when the opposite seems to be true. Faith is acting in a manner consistent with said assumptions even while grieving over real losses. Such faith enables us to be mindful of our thoughts so that we do not practice into beliefs counter to what we have come to know as true.

The chronic pain sufferer who grieves well (asks God for relief, stays in community with others, seeks relief through human means yet has an attitude of waiting on the Lord, and yet still willing to explore and confront hidden sin in self) begins to see that in the midst of the pain, God is there and providing momentary help. Such a person need not act as if the pain were nothing but will look for and rejoice in 5% improvement, 10% more comfort, etc, rather than demanding complete healing as the determinant as to whether God is present with them in their distress.

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November 20, 2009 · 1:40 pm

Edwin Friedman on the search for solutions…


Consider Edwin Friedman’s counsel to leaders in book, A Failure of Nerve (Seabury Books, 2007)

In the search for the solution to any problem, questions are always more important than answers because the way one frames the question, or the problem,  already predetermines the range of answers one can conceive in response. (p. 37)

Seems true for counselors as well. How a counselor begins the exploration of a client’s problem narrows the field of answers as to the problem and solutions. Now, assumptions are always present–especially in questions. So, asking questions doesn’t keep the field of view open unless one is willing to ask questions not normally conceived. It is difficult to remember to ask questions that run counter to our initial hypotheses. And yet such questions are necessary if we are going to counsel actual individuals and not mere figments of our imaginations.

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November 16, 2009 · 5:02 am

Why we fail to act (sins of complicity)


In the wake of the Ft. Hood massacre we are now hearing evidence of a very troubled man–trouble that it appears many observed over the last few years of the Maj. General’s life. Some of his former teachers and supervisors took note of his strange behavior, his loner tendencies, his rages. They even mused about his possible move into psychosis. Despite these notations, they moved him on to a place they thought (so the reporting is going) he would not get into trouble. In the words of one person, where his dangerousness would be limited by the number of mental health professionals serving alongside him.

Lest we pick on the military alone, we could level charges of ignoring problems on those around Madoff, the mortgage crisis, and any other recent scandal.

The truth is this: we see things that need our attention; our voice. And yet, we often fail to act. Why? Here are some reasons:

  1. We’re not sure what we are seeing or feeling. We have trouble adding up the problem
  2. We don’t want to make a mistake and look foolish
  3. We hesitate due to empathy
  4. We don’t want to intrude on the rights of others
  5. We assume someone else is more responsible
  6. We don’t want to make waves, we want to avoid conflict
  7. We think the person we are concerned about it will take care of it on their own
  8. We deem the situation not relating to our own interests
  9. We underestimate that Satan intends to deceive us into doing nothing so that evil may reign

I’ve had a couple of experiences where I didn’t act and should have–a client “playing” around with life threatening behaviors, a friend beginning an emotional affair with someone not her husband. After the fact, everything looks clear and obvious. Duh, hospitalize the client, confront the friend. And yet in both cases I acted but more slowly than I should. If there is one big reason: I think things were fine in the past and so they will be fine in the future, and so I fail to adequately assess the present.

 

 

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