For my counselor readers, I want to let you know of a free counselor journal. Click here for free access with search capacity. It is published by NBCC and is open access to anyone who wants to try to stay current on counseling literature.
Category Archives: counseling
PTSD “A Disease of Time”
David Davies, part of the staff of “Fresh Air” on NPR, has conducted an 35 minute interview with David Morris, a journalist who was embedded in a unit in Iraq and who suffers from PTSD resulting from an explosion he survived. David has written a book, The Evil Hours: A Biography Of Post-Traumatic Stress Disorder. If you want to better understand the experience of PTSD and its impact on a person, you should listen to this show (or read the transcript). For therapists, Morris discusses his experiences with Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). He also describes the use of propranolol when repeating trauma stories.
Here’s a couple of my take-aways:
- PTSD is a disease of time.
“…in some ways, PTSD is a disease of time. And a lot of people – PTSD is many things, but one of the things it is a failure to live fully in the present. And I think what happens a lot of times with traumatic – survivors of trauma is they have these compulsive returns to awful events, and they are unable to live in the now.”
- The best treatment never removes all symptoms of PTSD
“The best we can do is work to contain the pain. Draw a line around it. Name it. Domesticate it, and try to transform what lays on the other side of that line into a kind of knowledge, a knowledge of the mechanics of loss that might be put to use for future generations.”
- Honest reflections of the impact of PE and CPT (and why so many dropout from PE treatment)
- Honest admission about the most common “treatment” of PTSD–alcohol (and evidence why so many end up abusing it!)
- War traumatizes far too many but rape is 5x more traumatizing
[in discussing how helplessness/lack of control is a significant factor in the development of PTSD] “Yeah, the helplessness is one of the main predictors of who’s going to end up with PTSD and who doesn’t. And the idea that you have absolutely no control over your environment is very hard for people to deal with because, you know, you are basically completely helpless and unable to control your destiny and your survival….and that’s one thing I discovered in the book is I thought – you know, we sort of assume that PTSD is sort of the realm of soldiers and veterans, when in fact, the most common and most toxic form of trauma is rape.
…a soldier may have some control over his or her environment. They have a weapon with them; they can move; they can take cover. But oftentimes in the cases of rape, the victim is completely overwhelmed and trapped and cornered. And from the moment the attack begins, they are rendered almost completely helpless, which is interesting. And you see that in the diagnosable rates of who gets PTSD and who doesn’t. Rape survivors tend to have it almost 50 percent of the time, whereas your average war veteran – particularly for Iraq and Afghanistan veterans – the rate of PTSD diagnosis is more around 10 to 12 percent. So a rape victim – rape is, in a manner of speaking, five times more traumatic than combat.”
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Conference Opportunity: Redeeming the Impact of Sexual Abuse (10/31-11/1)
![the%20change%20seminar%20flyer-001[1]](https://philipmonroe.com/wp-content/uploads/2014/10/the20change20seminar20flyer-0011.jpg){kind=small}
I have the privilege of participating in the Change Seminar at the end of this month. Designed for survivors, family members, church leaders, friends, and clinicians, this Friday afternoon/Saturday seminar will Feature myself and Mary DeMuth and her husband, Patrick. Mary, author of Not Marked: Finding Hope and Healing After Sexual Abuse, will be speaking on church communities and their role in helping victims and their families recover. She will be speaking Saturday, November 1 from 9-2. I will be speaking on Friday afternoon, October 31, on the topic of making the church a safe place for trauma survivors (those who have been trafficked, sexually abused, or have PTSD from other causes.
To register: www.chelten.org/changeseminar or call to 21.5.646.5588.
For those of you in the Philadelphia area, you can’t get continuing education for much cheaper than this: 6 CEs for $100 (NBCC approved). If you don’t need CEs then the price is even lower, $45 for couples, $35 for couples if one is a ministry leader, $25 for individuals.
Isn’t it time the church became know for the leading edge of caring for (and preventing!) sexual violence?
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Filed under Abuse, counseling, sexual abuse, Violence
Trauma education by txt msg? Therapy support by txt msg?
This week I came across Journal of Family and Community Ministries (free subscription required) describing the use of text messages (160 characters or less) to trainees in Rwanda and Kenya. The trainees, having received face-to-face business education, then received one text message each business day for four weeks. 4 of the text messages each week contained a local proverb used to remind and/or enhance the business education they received. Each Friday they received a text containing a multiple choice quiz question to see whether learning was taking place. This pilot study seemed to provide a “proof of concept.”
Having read the article, I began to think about two applications, sustaining trauma healing training and supporting ongoing therapy efforts.
Sustaining Trauma Healing Training
We all know the experience of attending a great training but then finding months later that we have forgotten some important concepts—or can no longer explain them as well as we would like. Life can get in the way and we lose the ideas and skills we wanted to retain.
For the last several years I have been involved in providing conference-based training to counselors and caregivers in Rwanda. Our focus in to “top-up” knowledge and skills related to trauma recovery and other related topics (especially domestic violence, child abuse prevention, addictions, etc.) Each time I am impressed by the quality of the participants and the ability to overcome personal and logistical challenges to do the work they do. But some of our topics touch on pretty new or controversial material that may not be as immediately usable by our participants. One possible solution to this problem would be to use existing proverbs (or modify a bit) and send as reminders of ideas learned. It stands to reason that these short reminders might help solidify learning. In addition, it may also help maintain connections between trainer and trainee as well as trainee and trainee between annual meetings.
Supporting Ongoing Therapy
Most counselors have the experience that their clients “get” a new skill in session only to “forget” it later in the week. What if clients could receive short texts reminding them to practice a skill, or reminding them a thought that they wanted to remember? For example, if a counselor had a specialty dealing with anxiety disorders, clients could choose to sign up to receive a daily text reminder to use common or remember key truths.
Life tends to push out what we are trying to remember. Those who journal sometimes review old writings and remember anew something that they really wanted to retain. A text message might just might provide this kind of reminder and keep the learning fresh and present.
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Filed under counseling, counseling skills, Rwanda
GTRI 2014: Day 12 Kigeme Refugee Camp
July 12, 2014. Kigeme Refugee Camp to Kigali
For all who travelled with us, our visit to the refugee camp was moving in many ways. We saw deep poverty and yet deep resilien
Heather with her new friends
ce. The following observations are from Heather Drew, a counselor and one of my GTRI students and who begins her tenure as Fieldwork Coordinator in my seminary department today! Please welcome Heather and check out her blog as she is a gifted communicator in her own right.
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Today was our last full day in Rwanda. We woke up in Butare, got one last cup of the best coffee I’ve ever tasted at a lovely coffee shop called Cafe Connexions, then rode our bus to a UN refugee camp in Kigeme. Around 20,000 Kinyarwandan speaking Congolese
Kigeme camp children
refugees live in this camp, 12,000 of which are children, we were told. The abundance of children was immediately apparent to us as we were greeted by dozens of sweet smiles peering into our bus, waiting for us to climb out. Some of us took photos of/with the children and showed them the photo (they love that). 
The children followed us around like we were pied pipers. The parents followed us with their eyes, and greeted us kindly. The camp was made up of rows upon rows of small mud houses with metal roofs – living spaces the size of a small American living room – containing 6-8 (or more) family members each. Our group wove through the narrow, red-dusty walkways between houses, climbing up slippery hills with the help of our small chaperones. They taught us some additional phrases in Kinyarwandan, showed us their beautifully-made and efficient water collection/filtration system, and held our hands. The 
children who could speak a few words in English were eager to do so. The ones who knew no English spoke to us without any words, showing us their homemade toys constructed with old bottles and broken pieces of things. It made me realize that the less a person has, the more resourceful and creative they become. This is a very prevalent characteristic throughout Rwanda.
At the base of the hill on which the camp sits is a meeting space where our team met with several leaders within the camp who lead trauma healing groups with fellow refugees. We were traveling with our friend Harriet Hill, one of the writers/developers of the Healing Wounds of Trauma material put out by American Bible Society, which this group has found so useful. (This book has been translated into several languages and is effectively used to facilitate around the world.) I had greatly anticipated this day, and in the moment the depth of it was not lost on me at all; here we were sitting in a room with about 50 Congolese refugees who use this book to lead healing groups in one of the most trauma-impacted areas of the world with Harriet Hill, the woman who had a dream over a decade ago to develop the material. It was extremely moving.
Leaders/facilitators gave testimonies about the groups and about personal healing, and presented questions they had. One person shared, “We are all traumatized…This material heals us and then we can help others heal.” Another shared, “During the genocide, so many of us – on both sides of the conflict – had hearts like animals. The Bible takes away our animal hearts.” Not all of these testimonies were ones of “arrival,” however. A few shared how they are still in the midst of the long healing process. The truthfulness of this impacted and inspired us.
After their testimony time Phil, Diane, Harriet, and their two leaders were invited to speak. Remarks were encouraging and thankful. Harriet Hill shared how much it meant to her that they have such bravery to share the comfort they themselves have received from Christ. She also shared Psalm 126, words that resonate with their stories. Finally, at the end of the meeting, we shared Fanta and
Zenko with Marianne Millen
snacks together (a tradition of hospitality in Rwanda), then we said our goodbyes – even to Zenko, our dear new friend, which we were very sad about! – and boarded our bus for a 2 hour ride back to Kigali. I tried to focus on taking in the breathtaking beauty of the country as we made our last drive, because no photo can capture it.
Our final night was spent at East African Villas in Kigali. This was a hotel in Rwanda managed by a lovely Christian man called Ezekiel who was wearing a Georgia Bulldogs shirt when we arrived, which we enjoyed. We rested and enjoyed hot showers (a luxury I will no longer take for granted) during the few hours before dinner. Then we settled together in the dining room, ate our final Rwandan dinner feast, then Phil initiated our final team debriefing & sharing time.
We all shared 3 words that we each felt best expressed what we had learned in Rwanda. Among the things shared: new meaning of “celebrating the recovery of life” and also of “groans that words cannot express,” what it means to embrace Jesus’s invitation to “watch with Him,” the privilege of carrying people’s stories with them, how impactful people’s eyes and testimonies were, how much courage we saw, how much desperation we saw and how that was pointed at God in many cases. It was a much-needed time of sharing. To my knowledge, there wasn’t a dry eye among us.
We ended our night by taking a few group photos on the balcony.
GTRI 2014 Team
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Filed under christian psychology, counseling, counseling skills, Rwanda, Uncategorized
GTRI 2014: Day 11, Muhanga to Butare/Huye
July 11, 2014.
We ended the Community of Practice at noon and said our goodbyes. The morning consisted of a short devotional comparing the good and the false shepherd described in John 10. We explored how helpers may end up becoming “hirelings” due to burn-out and
Community of Practice
loss of vision. After the devotional, our tables each became case consultations with caregivers discussing their hard cases and receiving encouragement, support, prayer, and a bit of advice. In a number of instances, caregivers brought up the issue of those who have mixed parentage (Hutu/Tutsi) and the struggle to deal with their identity. I and others have noted that this group has been far more vocal talking about the different “tribes” where previous groups have rarely even mentioned these groupings. It makes me wonder whether this is unique to this group or whether there is something going on in the country that makes it okay to discuss identity.
After our goodbyes, we traveled south for 2 hours to the university town of Butare. Butare is the home of the National University. First stop in Butare consisted of an ice cream at Sweet Dreams just down the road from the Shalom Guest house where we are staying (known internationally as the project with the female drumming corp). Our purpose here is to meet with Anglican Bishop Nathan Gasatura and some of the pastors/leaders of his diocese to discuss the trauma recovery needs. Bishop Nathan has been a friend and attended some of our previous training. Diane spoke a bit about “talking, tears, and time” and the process of healing through trauma. We had a good dialogue where one question was raised, how can a Hutu counselor help a Tutsi victim (or vice versa)? I was thankful that Baraka Paulette, the new president of the new Rwandan Association of Christian Counselors, was present as she answered in a very beautiful way, putting all at ease. Though our time was short, we squeezed in a bit of singing and dancing in the cathedral.
Before our meeting, a few of us purchased locally roasted inexpensive Rwandan coffee and an espresso at Café Connexion across the street from the cathedral and guesthouse. This cafe was not something most would venture into in the United States. It contained dingy walls, a couch and a couple of stuffed chairs, a shelf full of brown bags of coffee, a large coffee roaster and the center of the room was a small desk with an espresso machine. Yet, this was possibly the best coffee I tasted on the trip. [the return trip the next morning and bag of coffee brought home and now gone supports this opinion!] After dinner, many of us walked down the dimly lit main street in the dark passing the university. It was good to walk and good to deepen relationships with fellow GTRI mates.
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Filed under counseling, counseling skills, Uncategorized
Brooks on journaling about emotions
Friend Jeff McMullen pointed out a recent David Brooks op ed in the New York Times. (Read it here). While I’m not sure I agree fully with his journaling/not journaling point he says something very important about the timing of writing one’s emotions after a traumatic event. He says,
When people examine themselves from too close, they often end up ruminating or oversimplifying. Rumination is like that middle-of-the-night thinking — when the rest of the world is hidden by darkness and the mind descends into a spiral of endless reaction to itself. People have repetitive thoughts, but don’t take action. Depressed ruminators end up making themselves more depressed.
Then later, this important distinction between immediate processing of emotions and later processing,
We are better self-perceivers if we can create distance and see the general contours of our emergent system selves — rather than trying to unpack constituent parts. This can be done in several ways.
First, you can distance yourself by time. A program called Critical Incident Stress Debriefing had victims of trauma write down their emotions right after the event. (The idea was they shouldn’t bottle up their feelings.) But people who did so suffered more post-traumatic stress and were more depressed in the ensuing weeks. Their intimate reflections impeded healing and froze the pain. But people who write about trauma later on can place a broader perspective on things. Their lives are improved by the exercise.
David points to some research that exists that suggest CISD is unhelpful for some participants. Some are made worse. Yet, narrating one’s trauma in the broader context of a life tend to see a reduction of symptoms. The difference seems to be whether the focus in on life or mostly on the trauma. Trauma in perspective is the goal. Just reviewing trauma may in fact strengthen the traumatic reaction rather than weaken it.
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Filed under Abuse, counseling, counseling science, Post-Traumatic Stress Disorder, Psychology, ptsd
GTRI 2014: Day 8 Kigali
July 8, 2014
Tuesday. Yesterday was a deep dive into Rwanda for GTRI students. They heard directly from Rwandan caregivers and spent time trying to weigh the genocide and its ongoing impact. Today we begin meeting and interacting with trauma healing and recovery caregivers in a conference setting. At a local hotel about 100 Rwandans gathered to kick off the Bible Society’s trauma healing community of practice and the inauguration of the Rwandan Association of Christian Counselors. The purpose of this meeting was to introduce both projects to the public and to invite the media and dignitaries to be present. The Rev. Emmanuel Kayijuka game some opening remarks and an Anglican Bishop offered a brief bible study of John 4:1-3, the woman at the well. He pointed out that she was likely a prostitute and an 
abused woman, abused by men, by society and desperate. Why else gather water at noon. He also pointed out that after her healing, she became a woman on a mission of healing, seeking social contact for the purpose of evangelism. After these reflections, Dr. Jean Mutabaruka presented a paper looking at the relationship between trauma, PTSD, and complicated grief. He pointed to 12 types of trauma in Rwanda, including sexual/physical/emotional abuse, witnessing violence, discrimination, poverty, etc. At the end, he raised a few general questions regarding the management of the mourning period/process each year.
After the professor finished, both Diane Langberg and I made a few brief remarks in response. Dr. Harriet Hill presented an overview of trauma healing project, in Rwanda and around the world. She showed the latest trailer of a documentary (much about the Congo project) about bible based trauma healing slated to be aired on ABC network this fall. Fun to see people I know in this trailer. David from the Rwandan Bible Society reviewed the progress to date: 2,918 trained people using Healing Wounds of Trauma material. Many of these are able to train others while the rest are better able to care for themselves.
New President: Baraka Credit: Heather Evans
The second half of the day included a presentation by Baraka Paulette Unwingeneye about the efforts thus far to form the Rwandan Association of Christian Counselors. This group of counselors and caregivers have been meeting with us since 2011 and are ready to be birthed. As Baraka said it, it may be like an elephant’s gestation, but now we are near the final month. We had presentations from Narcisse about the needed documents to be filed to make the association official, myself about the benefits and processes to form an associations. Then, those in attendance voted in a president, vice-president, secretary, treasurer, advisors, and conflict managers. This may not sound very moving, but I assure it was!
Fun too
While we come to Rwanda for serious matters, not everything has to be intense. As our day was ending, we quickly changed from our conference clothes to go out for a bit of shopping: the Simba market for coffee and tea, and another market selling typical Rwandan traditional items (clothes, woven bowls, banana leaf art. I looked and looked for a blue African traditional shirt but came up empty.
This marks our last night at Solace. Tomorrow we move on to the conference proper about 50 minutes or so south in Muhanga (Southern Province). Though we are about to begin the training in earnest, I think I am beginning to relax. A year’s worth of planning is now well under way. Despite a few surprises and schedule changes, most everything is working as planned. No problems with transportation, food, water, housing. Meetings planned have more or less happened.
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Filed under Africa, counseling, counseling skills, Rwanda
What is your response to graduation?
Tomorrow marks the end of the road for students of the 8th cohort of our MA counseling program here at Biblical. After two years of hard labor, er studying and practice, they are now set free to do other things like read for pleasure or hang with family on Monday nights. Of course, some will transition to a few final online licensure courses and others will continue to accrue supervised hours to meet licensure requirements, but the intensity of learning and the cohort life will not be the same.
In thinking about my own graduation from a cohort some 15 years ago, I remember the strange feeling of having arrived at the finish line with an empty feeling. I think that feeling came from the fact that I still had a ways to go to get licensed and to land a job.
Or maybe we put too much expectation on the acquisition of a goal, on our accomplishments. Degrees, jobs, houses, marriages, children–all good things–do not provide lasting changes in our outlook on life, our level of happiness, our perception of self. Sure, these things do provide opportunities for re-evaluation of self, the world, values, etc. But they do not exert changes. You can find people with many degrees, titles, things, who are still searching for an elusive sigh of relief, of arrival at some new constant state.
Is there a better response to graduation?
Instead of only looking for arrival or to the future, what if we use this time to see what God has done in our lives over the last two years? Like climbing a mountain, you get time at the top to stop and look out and back to see how far you travelled. During the climb your head is down trying to avoid tripping over rocks or roots. On the journey, you had to keep a steady pace for fear of quitting. But at the top you can stop and ponder. The time doesn’t last long since you will need to climb down soon. But before you go, take a look at the things God has enabled you to do. You weathered losses, had many ah-ha moments, developed courage to try rather scary things, had to admit weakness, received unexpected support, were sustained and able finish tasks that you thought unnecessary.
If you have just reached a goal like a graduation, take a minute to write down what diificulties you survived and what unexpected blessings you experienced. Look back and then write it down. Otherwise, you may forget as you climb back down the mountain.
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Filed under Biblical Seminary, counseling, education, seminary
Traumatic Nightmares? Two Treatment Possibilities
Many who suffer from PTSD or other traumatic reactions also experience chronic nightmares. It is bad enough to have to deal with intrusive memories and triggers during the day but being robbed of peaceful sleep can send you over the edge, both in terms of physical and emotional health. Christian counselors may be tempted to ignore these nightmares (how can you stop something you have little control over?) or overly spiritualize the content of the dream.
But we ought not neglect the problem of nightmares. It is well-known that reductions in quality of sleep make all mental illnesses worse. Nightmare sufferers understandably avoid sleep but of course this creates a vicious cycle of insomnia, anxiety, and increased avoidance strategies.
There are two intervention options (among many) that appear to have fairly robust positive data indicating helpfulness. (For detailed descriptions of these two and others including the analyses of value, see this pdf): Prazosin (medication) and Imagery Rehearsal Therapy (IRT).
Prazosin is an anti-hypertensive (alpha blocker) that may work on the problem of too much norepinephrine in PTSD patients. It seems to improve sleep length and REM time. Interestingly, beta blockers have been found to increase nightmares rather than reduce them. I am no physician and so cannot evaluate the value of this medication for clients but would encourage clients with chronic, severe and re-occurring nightmares to talk with their doctor about whether Prazosin might work for them. The studies I have reviewed primarily examined the value of this medication for veterans with extreme nightmare problems. The most significant downside to medication treatment is that it only works when the medication is taken. Stop the medication, the nightmares may come back. However, some relief may be beneficial and thus the medication then has value.
Imagery Rehearsal Therapy (IRT) is a short-term therapy that does not work on the actual content of the traumatic experience or attempt to treat PTSD. Instead, it treats nightmares as a primary sleep disorder problem. There are variations on IRT but most versions last between 4 and 6 sessions and may be delivered in individual or group formats. Sessions include education about the nature of nightmares, sleep hygiene protocols, and the imagery replacement protocol. While some of the IR protocols are done imaginally, others ask nightmare sufferers to (a) write down the details of the distressing nightmare, and (b) write a new ending to the nightmare. As Bret Moore and Barry Krakow describe, the therapist does not dictate the new outcome of the revised dream but encourage the sufferer to “change the nightmare anyway you wish” (Psychological Trauma, v. 2, 2010). The nightmare sufferer then rehearses (multiple times) the new ending and is instructed to ignore the old nightmare.
Sound goofy? How is it that a person can just decide to have a different dream? However, the evidence that this therapy works is quite robust. Numerous studies with veterans and civilians indicates it is effective in reducing unwanted nightmares. Most treatment protocols suggest starting with nightmares with content unrelated to actual traumatic events.
Thus, Christian counselors ought to review these two treatments and consider learning the IRT protocol to bring relief to chronic nightmare sufferers.
Musings on Faith and Psychology 