Category Archives: mental health

June 17, 2024 · 5:52 am

Why am I STILL afraid? Some thoughts on what recovery from chronic anxiety looks like


I provide psychotherapy for many with chronic and debilitating anxiety. Anxiety is the most common malady in the world and comes in all sizes and shapes: panic, phobias, OCD, GAD, social anxiety, PTSD and more. For some it is very context driven (e.g., fear of flying) and for others it is constant and wide-ranging (e.g., OCD, PTSD).

Frequently, when a person comes to therapy, their first and enduring question is, “Can you make this go away? I just need it to stop.” They have struggled for a long time and have tried many things. Some have tried medications, others tried to limit exposure and avoid situations that would trigger the anxiety, and almost everyone has tried to talk (aka berate) themselves out of their feelings. “If I really trusted God this would not be happening!”

This desire to extinguish anxiety is completely understandable. Anxiety is horrible, consuming, and exhausting! We want it to go away and never come back. But–and this may seem absolutely disappointing to many—having the goal of zero anxiety is actually detrimental to a positive outcome and recovery.

Let’s explore what therapy is/does and why changing your relationship to anxiety is a better goal than trying to extinguish it.

What does therapy for anxiety look like?

Therapy for anxiety (at least what I practice) tends to have these common features1:

  • Compassion, understanding and curiosity about the physiology of anxiety
  • Experimentation on what short-circuits anxiety and identifying what intensifies the sensations
  • Practice relaxation/mindfulness/distraction with increasing exposure to feared stimuli
  • Exploring experiences/beliefs/values that may contribute to ongoing anxiety (e.g., a part is burdened with shame, perfectionism, assumptions of failure, etc.)

Notice the flow and trajectory. Compassion…Understand…Experiment…Practice…Examine (held beliefs). The flow isn’t really linear but it is hard to examine underlying beliefs or childhood experiences when you are in the middle of a panic attack.

Sessions early on look like understanding what is happening in our bodies when we are anxious. As we progress, we explore successes and challenges. We notice things that helped a little, or things that may have intensified anxiety. For example, having a friend try to convince you that your worries are unfounded may feel good at first but then leave you feeling more shame and more helpless. Or, maybe listening to a great podcast on the way to work reduces anxiety by a good 30 percent. This is, in essence, somatic psychotherapy.

The goal: PIVOT

When I am afraid, I put my trust in you. Ps 56:3

Notice the verse above says, “when.” Not if. When. We will be afraid, maybe often. And when that happens, we will do something. But what? How? In practical terms, we pivot.

What is pivoting and why do we do it? Pivoting is moving our mind/body/attention away from the cascade of fears. Instead of trying to dialogue with anxiety, we pivot away. Why do we pivot? We do so because anxiety is a TERRIBLE and completely unfair and unreasonable discussion partner. And since anxiety intrudes without your permission, you are not obligated to talk with it nor accept it as if anxiety is you.

Here is how it might work for me once I have recognized that what is happening is that my mind and body are locking onto an intrusive fear. I name the fear, then I pivot my mind by looking intently at the Ansel Adams photograph of El Capitan next to me. I describe the shadows and features I see. Or, I pivot my body by getting up and feeling the sensation of walking. I may pivot to my senses by smelling my coffee and taking a deep breath in and out. I do this pivot again and again in order to de-couple from the thoughts. And I actively use my body to lower felt tension. At first, this many seem about as successful as jumping off a cliff while flapping your arms. And yet, over time, your pivot will decrease your anxiety.

Notice what I do not do. I do not,

  • debate the fears
  • beat myself up for having fears
  • assume success is the cessation of anxiety

Why does it take so much work to fight anxiety?

We have been habituated into fear. Changing the automatic response takes work. It wasn’t our choice to be afraid but now we have to find a way to pivot out of something we never wanted. It isn’t our fault but now it is something we must respond to, just like someone with a migraine didn’t choose it but now will have to discover what helps curtail one. As we practice our pivots we will find they become slightly easier and more effective, just as when you practice a sport or an art, you will notice you are becoming more skilled.

What if my goal is not extinguishing anxiety?

In short, it is building a new relationship with anxiety where you accept that it exists but does determine how you will live. You acknowledge it but do not engage it. In doing so, you accept the challenge of building a competing neurocircuit alongside the fear pathway and activating that experience on repeat. The best competing circuits have deep meaning and connections with others. Here are some examples:

  1. Instead of trying to avoid making mistakes, look for mystery and experimentation
  2. Instead of trying to avoid panic, lean into doing something with your body that you have not doe (advanced yoga or stretching, increased weight lifting, knitting)

I want to leave you with one thought. If you learned something new about how anxiety is expressed in your body and if you learned how to gain even a little mastery over your body’s anxiety response then you have already begun to change your relationship to fear! You are beginning to be in charge rather than feeling controlled by fear. Your success is not always winning against fear but knowing that when you are afraid, you will put your trust in God and in the body he has given you.

_____

1These are common factors to all anxiety therapies though they may differ when focused on a particular kind of anxiety. In addition, I always recommend a medical evaluation to rule out other potential causes of anxiety as well as consideration of medications that may help support recovery.

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April 2, 2024 · 6:01 am

Did you forgive? Recovering faith from toxic theology, ep 2


Forgiveness is often misunderstood and misrepresented as a recipe to stop hurting after a betrayal. In this 2 minute podcast, I define forgiveness and bitterness since so often when we want to talk about our pain someone asks us if we are embittered and if we have forgiven the one who wounded us.

Thanks to those who gave me ideas about lengthening the podcast. I’m considering that but will trial out a few more of these shorter episodes first.

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October 29, 2023 · 12:57 pm

Am I doing this Trauma Healing Thing Right? Part 5, Finding a therapy and a therapist


So, now that we have identified some barriers to recovery (myths and red flag moves by helpers) and noted essential items you need for this journey—like compassion and curiosity, let’s conclude this series by exploring how to choose a therapist and a model. 

It can feel impossible to find a quality therapist and downright overwhelming to choose a particular model of trauma care. If you have started to look you probably began first to explore credentials and general styles of therapy (models). 

Do you choose Christian or biblical or secular? How much does licensing and credentials matter? 

Which model? CBT, TF-CBT, DBT, PE, EMDR, Tapping, CPT, Brain spotting, NET, PFA, Debriefing, and somatic psychotherapy? Neurofeedback? IFS?

Medications? Ketamine? Transcranial magnetic stimulation?

Or maybe skip the therapy altogether and focus on yoga, mindfulness, meditation, art, or acupressure?

Feeling overwhelmed yet? 

If you have been looking for very long, you probably heard someone sing the praises of one of these types of therapists or models over others and noted it to be a miraculous cure for them. And just as likely you have heard, “that didn’t work for me.” 

Cutting through the fog

Several of the models listed have some scientific support. And some others have a lot of hype and anecdotes but little in the way of actual substantiated research. Randomized control trials, the gold standard of research, attempt to look past correlational data to determine if a positive result can be attributed to the intervention used. Sometimes we learn that a particular model is effective even while we do not fully understand why or what part of the model is having a positive impact. But, it should be noted that many RCTs tend to be small in sample size and somewhat limited in generalizability. In other words, it worked for the research group but until it is replicated many times with different populations, we won’t yet know if it works for most or for you or me. 

One more frustrating part is that disciples of a model may suggest to you that an intervention they use is more successful than the researchers who developed and studied said model. We have this annoying habit of overestimating the value of the thing we have learned to do. 

Pick your person first

So, don’t start with which model you should choose from. Yes, models and ideologies matter and influence the work done in session. But there is something more important to consider. It is…drum roll…the character and person of the counselor. Trust and connection in therapy has more to do with success than the model being used. We have already identified the characteristics of a good therapist in the last post: 

  • Goes at your pace.
  • Is curious about what you need. 
  • Wants to learn what helps you more than tell you what you should do.
  • Is aware of and adjusts when you are overwhelmed.
  • Invites your pushback and doesn’t get defensive.
  • Listens more than talks.
  • Checks in to make sure you are talking about the things that matter to you the most.
  • Does not criticize your faith journey.

If you have such a person now, ask yourself if you are holding back. Don’t judge yourself if you are, but ask what it might mean. It may mean there is something you are not ready to talk about. Good for you to know what you need. It may mean there is some bit of safety that still needs to be built in the session. It may mean something is off in the therapy. See if you can find a way to discuss this dynamic without talking about the thing you are holding back. How your therapist navigates this bit of information will tell you much about the safety and trust in the relationship. 

But I don’t have this person yet, how do I find them?

I recommend you start by asking people who you trust, who they have heard does good work. Get firsthand reports whenever possible. You want to ask, 

“Who would you go to or send your family member to if you knew they needed a good therapist? What makes them a good therapist?”

Once you locate someone who seems to fit the bill—experience…known to be a good listener…has credentials and training—you will still need to find out if this person is going to be right for YOU. 

Once you get an appointment, interview them in that first session and keep in mind these questions as you progress in your therapy. 

  1. What models/authors do you most likely follow?
  2. What are early signs that therapy is working? Signs that maybe something else is needed?
  3. What do therapy sessions look like? Hopefully, their answers include some form of:
    • Grounding/calming. Before/during/after triggers in session and practiced at home. It should be tailored to your needs and flexible. 
    • Small exposure to trauma via your story—not rushed in the therapy process—with more grounding sandwiched around the exposure. This should be well-planned and short, and not a whole session focused on traumatic stories and triggers. The goal is not reliving trauma but remembering, lamenting, and then shifting weight to the present.
    • Narrative or meaning focus (who am I? who is God? Was it my fault?). Exploring and grounding in new narratives This often comes later in therapy work.  
    • Grief work. Most therapies will have some exploration of grief and lament. Naming what was lost and what has been suffered is necessary for good healing.  
    • Finding and celebrating strengths and resilience. An important part of recovery is seeing where and how you have grown and developed new capacities. 

But, what model should I be looking for?

I won’t be able to tell you what works for you. But use the following questions to determine what works for you now. It might be that you need one supportive therapy now and a different one later. 

  • Are you struggling with being on high alert all the time? Do you want to find something that helps you calm your body? Consider something that helps you practice calming and stabilizing your body. Somatic psychotherapies that follow work by Janina Fisher may be most appropriate for you. 
  • Are you a writer? Consider more narrative focused treatment like NET or CPT. 
  • Do you find yourself stuck in patterns of bad relationships and self-harming behaviors? Consider a DBT oriented group or therapist.
  • Do you find yourself in a frozen state (vs flight/fight/fawn)? Consider something that is less exposure oriented. You may find that certain exposure-oriented interventions (CBT/EMDR/PE) are unhelpful in early phases. Similarly, if you have many traumas versus one, consider something that goes much more slowly and helps you stay connected to parts of yourself. You may find that someone who follows the work of Diane Langberg or Judith Herman is a better fit for you. Also, the work of IFS can help you make some safe room for exiled/shamed parts.   

Concluding thought

The work of trauma recovery is slow, repetitive work. You learn something, then need to learn it again. You feel some growth,  and then feel yourself slipping, especially when you hit anniversaries and reminders. Give yourself permission to keep trying old and new things. 

The journey of recovery (whether in therapy or just waking up to another day) is an ongoing reminder that something has died. Maybe for you it is a relationship or trust or a body that didn’t bear the invisible wounds. You will grieve these things. Try to grieve without confusing grief with shame and guilt. You may have to relearn that grief does not mean shame. 

Remember also that your journey will show you that you are still alive. You survived. Slow your breathing and feel your aliveness. Feel your aliveness—even the pain—telling you that you are here, and you reflect courage and beauty. Take note of the small things growing in and around you. These are the bits of beautiful creation that tell us you reflect God’s glory. You may not feel the beauty but consider that it is still true. 

For further reading about the healing journey, consider reading “Wounded, I am More Awake.” You can read my thoughts on this book beginning here.

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June 30, 2017 · 5:32 am

Single session debriefing sessions? Helpful or harmful? 


I write this from Uganda having just completed a Community of Practice conference hosted by the Ugandan Bible Society. This community of practice is for bible-based trauma healing facilitators and local mental and public health experts. I presented on an update to PTSD causes, effects, and treatment. We looked at the value of Scripture engagement around the topics of trauma, loss, and recovery as well as how it fits into the larger picture of trauma counseling. 

Much of what we clinicians know and do for treatment for PTSD symptoms is based on partial research but a significant dose of “clinical judgment.” What is that? Well, it is treatment models that may have some empirical support but mostly formed over long-held assumptions in the field. One of those assumptions is that we may be able to prevent PTSD if we provide group or individual debriefing sessions soon after a traumatic experience. These debriefing sessions have been offered for decades to first responders, humanitarians, and missionaries after exposure to traumatic and tragic events. In recent years we have seen some evidence that some may not be helped but these sessions. In fact, some may even be harmed. 

The evidence of possible harm is not new. Yet, debriefing is still offered indiscriminately. We find it hard to let go what seems to work. Today I was able to read a 2006 study published in the British Journal of Psychiatry (citation below). This bit of research compared emotional debriefing, educational only debriefing, and no treatment. This study of Dutch civilians who had experienced a single episode of trauma within the last two weeks found that all three groups (emotion oriented debriefing, education only, and no treatment) saw a decrease of symptoms at 2 and 6 weeks post intervention. There was no benefit from either form of debriefing found in this study. 

In addition to no benefit, those individuals with high arounsal trauma symptoms who completed emotional debriefing showed higher rates of PTSD symptoms than the those with higher arousal who did nothing or only the educational oriented debriefing intervention. So, some forms of debriefing may actually worsen symptoms. Why? The authors surmise, 

In previous studies it has been established that high degrees of arousal in the immediate aftermath of a traumatic event are associated with an increased risk for the development of PTSD, measured both by self-report (Carlier et al, 1997; Schell et al, 2004) and physiologically by means of heart rate response (Shalev et al, 1998; Bryant et al, 2000; Zatzick et al, 2005). Encouraging highly aroused trauma survivors to express their feeling and emotions concerning the trauma might activate the sympathetic nervous system to such a degree that successful encoding of the traumatic memory is disrupted. Moreover, during an emotional debriefing session negative appraisal of one’s sense of mastery may be promoted (Weisaeth, 2000). This is assumed to keep the hyperreactive individual in a state of high arousal which may cause symptoms of PTSD to escalate rather than resolve (McCleery & Harvey, 2004). 

So, what should we do with this information? Nothing? No. But what we do should not harm, especially when we know some may be harmed. I suggest a few possible outcomes:

  1. Education about PTSD and trauma should continue. This study does not reveal harm for this intervention and given the relatively low trauma symptoms in this study (and the possibility some may have already been aware of what trauma is), education is likely to be helpful. Education is not only about trauma but also about good coping skills and activities. It does not focus on the events of the trauma experienced.
  2. Bible-based trauma healing begins not with a person’s story but looks at culture and common reactions. It normalizes pain and suffering and connects people to God and others. We do not yet have great empirical evidence (it is being collected) that such an intervention is helpful or harmful. But it appears that giving people permission to ask questions of their faith and to see that God encourages lament may still be helpful. 
  3. We need assessment of the growing movement and art oriented responses to trauma. What do these non-talk therapies add to the prevention or intervention strategies? 
  4. Debriefing or talking about a trauma that has just happened should focus less on replaying the details and more on current cognitive and affective impact with focus on resilience and boosting existing capacities. Brief assessment of arousal symptoms may well be warranted by those who promote processing trauma stories. This may be why NET, CPT and DBT oriented PE have lower drop-out rates than classic PE (prolonged exposure) therapy. 

Citation: Emotional or educational debriefing after psychological trauma (Randomised controlled trial) by MARIT SIJBRANDIJ, MIRANDA OLFF, JOHANNES B. REITSMA, INGRID V. E. CARLIER and BERTHOLD P. R. GERSONS. In BRITISH JOURNAL OF PSYCHIATRY (2006), 189, 150-155. doi: 10.1192/bjp.bp.105.021121

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October 11, 2016 · 11:03 am

Ruminating: The Mental Health Killer


I teach a course on psychopathology. Each week we consider a different family of problems. We explore anxiety disorders, mood disorders (depression, mania), and anger/explosive disorders in the first few weeks in the class. Later on, we look at eating disorders, addictions, trauma, and psychosis.

While each of the presentations of problems vary widely from each other, there is ONE symptom that almost every person with a mental health problem experiences–repetitive, negative thought patterns. Rumination.

The content of the repetitive thoughts may change depending on the type of problem (i.e., anxious fears, depressive negative thoughts, illicit urges, fears of weight gain, hypervigilance, irritability, etc.) but the heart of the problem in most mental health challenges are negative thought patterns leading to an experience of either impulsivity or paralysis. These patterns can look like obsessional worries about germs (triggering ruminative “why” questions as to the root causes of the obsessions). The pattern can look like repeated negative self-attributions for perceived mistakes. Whatever the pattern, the person finds it difficult to break out of the negative thoughts and attempts at distractions seem futile since the thought or feeling returns in seconds to minutes.

Is there anything that helps?

Yes, there are things that you can do to reduce the “noise” level of these repetitive thoughts. It is important, however, to remember two important factors

  • patterns in place for years or decades are harder to change. Give yourself the grace to fail as you work to change them.
  • As with pain management, the goal should not be the complete elimination of negative thoughts and feelings. Realistically, anxious people will have some anxiety. Depressed people will feel darker thoughts. Addicts will have greater temptations. But lest you give up before you start, this does not mean that you must always suffer as you do now.

Consider the following three steps as a plan of action to address the problem of rumination.

  1. Build a solid foundation of health. Every house needs a foundation if it is going to  last. Your mental health foundation starts with your physical body: Exercise, diet, and sleep. Did you know that daily exercise, getting a good 8 hours of sleep each night, and eating a diet rich in protein supports good mental health and may even prevent re-occurrence of prior problems? Will this solve all your problems. No! But failing to get good sleep and eat a balanced diet of proteins will exacerbate your problems. Sleep is especially needed. The lack of it will multiply your problem. Of course, getting sleep is difficult when you are worrying or depressed. Thus, work to develop a different bed-time routine. Shut off your electronics, do mindless activities like Sudoku, develop rituals that help promote sleep. If you are having trouble with this or your diet or exercise, find a trusted person to review your situation. And avoid all/nothing thinking that often leaves us paralyzed when we can’t reach our goals. On this point, read the next step.
  2. Prepare for change by accepting your struggle. What, I thought this was helping me out of my struggle? Acceptance is the beginning of change. Consider this examples. You struggle with intrusive negative thoughts about your belly. You don’t like how it looks. You’ve tried dieting and exercise, but still it is flabby. Every time you look at yourself, every time your hand rests on your belly, you hear (and feel) that negative narrative. The first step in change is to accept the body you have and to find ways to like it, even love it. Sounds impossible but it is necessary to accept all your parts. This does not mean that you won’t continue to exercise and eat well. Marsha Linehan suggests that one part of change is to accept the problem as it is. In her Dialectical Behavior Therapy model she speaks of choosing willingness over willfulness. Willingness opposes the response “I can’t stand this belly” by saying, “my belly is not as I would like but it is not all of who I am.” “I can’t stand it…” becomes a willful and yet paralyzing response. Whereas acceptance acknowledges the reality and chooses goals that are within one’s power to achieve (e.g., healthy eating choices). Acceptance is not giving up but preparing for realistic change.
  3.  Start to move. Consider these action steps as the beginning movements you undertake in a long process towards the goal:
    1. “So what?” Our ruminations are often filled with interpretations and assumptions. There are times we can challenge them by attacking the veracity of the assumptions. But we can also ask, “so what?” So what if I have OCD? So what if have to fight every day to stay sober? So what if I have to manage my schedule so as to not trigger a bipolar episode? Challenge the worst thing that you are afraid of.
    2. Develop a counter narrative. Rumination is a narrative. Begin by writing and rehearsing a counter narrative. It won’t have much power at first compared to your internalized rumination but it will gain power over time. Work to refine it. Choose to repeat it as often as you see the trigger for the rumination. Make sure your counter narrative doesn’t include self-debasing or invalidating comments. If you have trouble writing one, use Scripture passages that speak of God’s narrative, through Christ, for you. Be encouraged that developing alternative storylines has shown capacity to alter chronic nightmares. If nightmares can be changed, then even more thoughts and feelings during the day.
    3. Practice being present. Much of our lives are run on auto-pilot. When we are in that mode, it is easy to fall into rumination. Work to stay present, to be mindful and attuned to your surroundings. Notice ruminations but let them slide on out of view and bring yourself back to the present. Use your senses that God gave you to enjoy the world he made. Smells, sounds, sights, taste, and touch all give you means to enjoy that world. Start practicing staying in tune with it, a few minutes at a time and build your capacity as you go.

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August 3, 2016 · 3:11 pm

What is trauma-informed care? Filling a gap within care ministries


Yesterday I had the good pleasure of sitting with key leaders of organizations involved in trauma healing around the world. Much of our focus was on what these organizations were doing around the world (successes and challenges) and how would we function together in an alliance. You might expect we spent most of our time talking about projects and activities. You would be right.

However, I was given a few minutes in the afternoon to open up a dialogue about how we ensure that our organizations are adequately trauma-informed, for the sake of both our target populations as well as our own staff members.

What is trauma-informed care?

Last year I did this podcast for The Samaritan Women to introduce the topic of TIC. The idea, in short is that organizations serving traumatized individuals and communities would have a base understanding of trauma (what it is, how it impacts bodies, behaviors, spirits, relationships, etc.) and how to provide quality care that does not re-traumatize or hinder recovery. Of course, all human service and ministry agencies want to help. But, we know that not all that we do, even when well-intended, is helpful. Thus, there is a need to review policies and procedures to see how well we are serving others. If trauma victims tend to lose voice (power), relationships, and meaning, then do our organizational activities support the reversal of these losses?

For agencies seeking to self-evaluate around TIC categories (safety, trustworthy and transparent, peer-support, mutuality, empowerment/choice, and considering culture) start with assessment tools found at samhsa.gov or other TIC websites. The tools can help you consider gaps in training, policies, and interventions.

But don’t forget…

No organization will be adequately trauma-informed without caring also for staff members. It is tempting to put all the focus on how we care for our target population and completely forget about the staff who are doing the work of trauma-recovery. We can neglect their self-care, neglect the reality of secondary trauma. Most who are attracted to trauma healing (or as we said yesterday, those who get bit by the bug) are likely to neglect their  own emotional and physical health for the sake of helping others.

So, ask a few questions:

  1. Are your trauma healing specialists given voice for how to serve others, in building strategic plans?
  2. Are their ample opportunity for staff to voice concerns and complaints from staff policies to implementation? Can they evaluate their superiors in appropriate ways?
  3. What organic self-care opportunities are built into the organization?
  4. If a staff member begins to show signs of their own trauma, will they be cared for or will they be seen as weak and suspect? Is help only provided after the fact or as a prevention strategy?
  5. What opportunities for continuing education and mentoring exist?
  6. When was the last time you surveyed emotional, relational, spiritual safety within your organization?

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October 21, 2015 · 7:00 am

Spiritual Competencies for Clinicians


I will be presenting a 2 hour seminar at Penn Foundation today on Spiritually Informed Practitioners: Exploring Challenges and Opportunities. Over the last year or so I have been part of a multi-faith working group, Standing on Sacred Ground, that has been thinking about how to educate mental health practitioners to recognize, value, and work with the faith of clients (rather than see it as something automatically pathological or insignificant). Given the historic divide between mental health and faith communities (there have been haters on both sides) few clinicians have much training in understanding faith, religion, and spirituality beyond “be respectful.” Thus, religiously committed individuals often have had their faith marginalized or pathologized.

This presentation will look at roots of the historic divide, explore the complex relationship between faith and recovery, provide opportunities for MHPs to examine their own biases, and examine several key spiritual competencies needed for adequate provision of care.

Interested in the slides, check them out: Spiritually Informed Care.

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