Category Archives: Psychology

New book for those who wonder about the value of diagnoses and medications in biblical counseling


What kind of messages about mental health diagnoses and medications do you receive in your community? What do you hear about these in the church? Silence? Warm embrace? Implicit or explicit rejection?

Mike Emlet, a former family practice physician and now counselor, has written a small book to introduce readers to a nuanced and biblical take on the value of diagnoses and medications. Descriptions and Prescriptions: A Biblical Perspective on Psychiatric Diagnoses & Medications (New Growth Press, 2017) comprises 22 short chapters exploring the pros and cons of both arenas for those who are “too cold” or “too warm” towards the use of mental health diagnoses and medications.

In the first section Mike explores some of the weaknesses of the current DSM (psychiatric diagnostic system). Those who are “too cold” and who think the system is fraught with problems may find themselves saying “yes, exactly.” But rather than just stop there, he begins to articulate implications for ministry responses—how to go deep to understand the person behind the diagnosis. There is much the pastor or counselor can learn.

One key point is made here and in later chapters: we live in bodies and Scripture takes this seriously. So learn about the symptoms a person experiences.

So, you might think this book is negative on the value of diagnoses. It is not. Chapter 9 begins to describe the potential value of diagnoses, especially to those who tend to see mental health problems ONLY as spiritual and ONLY or usually involving just the will. If there is one thing the reader should get from this chapter is that humility is in order. If you don’t put much stock in diagnoses you likely don’t put much stock in published research exploring symptom clusters. As an example, Mike briefly discusses the multivariate experiences of those with obsessions and compulsions. This little window into the problem of OCD should remind us that we must work hard to understand the many subtle forms of obsessional thinking and consider how best to describe and care for the person suffering with them.

On the final page of chapter 9, Mike takes on one crucial criticism—that since you can’t see structural differences in the brain that implicate a particular diagnosis then the diagnosis isn’t real. From his point of view, this is a simplistic understanding of biology and diagnoses.

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The second section explores the challenges and benefits of psychiatric medications. Mike gives a very brief overview of the categories of medications and how they work (what we know and what we don’t know). He summarizes the research as indicating a modest positive effect, though also showing that other means are quite effective (placebo and counseling). Such results show us that there are a range of helpful responses. While it is true that medications for anxiety and depression aren’t cures and aren’t without their side effects, it is important to remember that the individual in front of you may in fact benefit immensely. Thus it is good to remember that we don’t offer advice to others based on population statistics. Rather wisdom is in order for this particular person.

 

 

In probably the best part of the book, Mike walks the reader through a wisdom approach to the use of medications—walking the tightrope as he suggests. Too much suffering and too little suffering can be hazardous to our spiritual health. We can make idols out of medications or out of not taking them. Medications aren’t good or bad on their own. It is how we approach them that matters.

He makes this statement nearing the end of the book,

“I hope you have seen that there is not a clear-cut “right” or “wrong” answer. There is no universal “rule” that we can apply to all people at all times. There is no simple algorithm. Rather, the use of these medications is a wisdom issue, to be addressed individually with those we counsel. There will always be a mix of pros and cons, costs and benefits to carefully consider.”  (p. 87)

This answer may frustrate those who want a clear-cut “this is right/wrong” response. However, counselors are not umpires calling what is “fair” or “foul.” Instead we are walking with and helping others look for relief (what can I do to make the moment better?) and look for acceptance (what is God up to in my life?).  Sometimes relief means medications, other times it means examining thoughts, habits, perceptions, etc. Sometimes acceptance means pursuing other goals beyond symptom relief, other times it means understanding accepting that God has, in his providence, allowed them to have a body that needs external supports.

Book Recommendation: Great first text for those who either over-estimate the value of mental health diagnoses or medications or those who minimize their value. Author leans to a conservative approach and probably spends more time speaking to those who might over-value medications. Yet, he also repeatedly affirms that biblical counseling must take seriously the fact that humans are embodied souls and that diagnoses and medications have value, albeit limited value. Great text to start the conversation and lead to deeper study about our responses to suffering, especially for beginning pastoral counselors and lay helpers.

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Filed under Psychiatric Medications, Psychology, Uncategorized

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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Is it trauma or is it intensity/identity loss?


The current definition of PTSD requires an exposure to an intensely distressing event or events (either witnessed or told about in great detail) resulting in a pattern of intrusive re-experiencing, attempts to avoid such experiences and an ongoing negative cognitive/mood pattern. Such a diagnosis might be made after domestic and sexual violence, accidents, natural disasters, war, betrayal traumas, and even after hearing repeated stories of traumatic experiences to others (called secondary trauma).

Someone experiencing PTSD after life-threatening events might feel disconnected from family/friends, find it difficult to sleep, experience repeated nightmares, have difficulty not thinking about events during and after the traumatic experience, choose unhealthy coping patterns like alcohol abuse, or place themselves in situations where they re-enact parts of their trauma story.

But not everyone who has intrusive thoughts about a challenging situation, feels disconnected from their community (and previous self), drinks too much, or impulsively jumps back into danger have PTSD. Some of these same behaviors and experiences also show up in those who have left dangerous and all-consuming experiences and now do not know how to re-engage in regular life.

Consider these words of Dr. Steven Hatch, who spent time in Ebola clinics in Liberia at the height of the 2014 pandemic crisis in West Africa. He describes his experience after returning to his job at the University of Massachusetts.

To match the outside weather, my mood willingly turned dark. I withdrew from people, wandered about in a daze, and avoided public gatherings. When I did venture out, I carried myself in a completely different manner than I had before in my life.


The simple explanation was that I had post-traumatic stress disorder, and a few people, including some whose job it is to make such diagnoses, thought this to be true. (p. 239, Inferno)

He goes on to dispute his experience fighting Ebola as trauma. While difficult, he did not think it rose to the level of trauma experienced in war or even other more overwhelming Ebola clinics.

I could, however, recall the event [death of a toddler] in my mind without being emotionally overwhelmed, but also just as importantly I was able to still experience emotions about it, feeling appropriately somber. I just didn’t feel traumatized. (p 240)

So, what was his problem?

What I did share with many other volunteers was a sense that I didn’t belong in the States, for the work in West Africa was far from over. I desperately wanted to return, and almost within days of coming home I was trying to figure out how I could get back to an ETU [crisis Ebola center]. What I missed was the profound sense of purpose that such work had provided, and I slowly realized why people talked of “missing the war,” a phrase that always seemed discordant to my ears. You miss being in the midst of senseless butchery? Great. But I belatedly realized it was that purposefulness, the sense that you were doing something that was deeply and truly meaningful, that drove people back to such unstable situations. (p. 240-41)

There you have it. The seeming loss of crystal clarity or purpose in life can be very painful. When you are in an intense helping situation as Dr. Hatch was, every movement leads towards life or death. At the end of a day, you can count who lived and who died. No ambiguity. In addition, you are doing it with a team of people all committed to the same thing. You share the same vision, goal, and daily experience. You do not have to explain anything. And in these intense situations, you can have the kinds of intimacy not often experienced even in your immediate family. Also subtract mundane activities (grocery shopping, cleaning, taking care of children, etc.) that may not need to be done.

This is a recipe for distress upon return.

Return to regular life where you are expected to do these seemingly inconsequential activities AND where you have no one around to save AND no one who was present with your toughest experience…and you have a recipe for trouble. You may find it difficult to find joy in light of intrusive thoughts of recent emotionally intense experiences. You may long for a return to that sense of purpose and value. Because others do not understand and aren’t part of your “tribe” you may withdraw or find other ways to numb the pain.

Loss of identity and intensity may mimic trauma symptoms. They may be significant to need treatment. Military ending tours of duty, missionaries returning from field, humanitarians returning from doing crisis work, church planters leaving high stakes urban church plants, and trauma healing trainers returning from intense experiences may be at risk.

What can be done to prevent this distress?

  1. Probably nothing will take care of the problem. One could not go do intense work. Or one could become a crisis junkie. Neither are good options.
  2. But developing re-acclimation plans can help. Yes, training done before entering the intense experience will set the stage for healthy returns but post-tour of duty re-entry work is more important. The Army has develop protocols for re-entry by beginning the process even before leaving the “theatre.” Creating space for coming off the “high” giving time to process and following-up in the early days back can help. Involving family in the re-entry planning and building activities that can elevate family intimacy upon return will help immensely.
  3. Encouraging time and space to lament and process in group settings. This is where a therapist can help. Group process helps to put words to experiences and acknowledges impact on identity. This can also help re-connect with meaningful activities and experiences at home. One has to re-learn that meaning is not solely connected to intensity.

I have some very small personal experience with this. I’ve had intense experiences in international settings. When I have returned, I have sometimes found it hard to be at home when my head was still overseas. Being able to share with Kim and others helped. Practicing lament helped. Learning to be mindful of the present also helped me remember what has meaning and value in everyday life.

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Filed under Post-Traumatic Stress Disorder, Psychology, trauma, Uncategorized

Reading the bible through the lens of trauma?


What if you read the bible through the lens of trauma? Some are quite obvious–catastrophes are all throughout the bible. But are these stories of trauma in the bible merely keeping a record of it or attempts to deal with the trauma, to put the world back proper perspective after chaos?

Consider this 2015 video by Rev. Dr. Robert Schreiter entitled: Trauma in The Biblical Record. He gives some background about this newer way to read the bible through this lens and then ends with 3 examples. I’ve just ordered this book on the subject, but those wanting to jump ahead may wish to know about it as well.

 

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Filed under Abuse, American Bible Society, counseling, Doctrine/Theology, Post-Traumatic Stress Disorder, Psychology, ptsd, trauma

Can Mental Health Practitioners Predict Future Violence?


Yesterday, a gunmen killed five and wounded at least eight others at the baggage claim for a Florida airport. Initial news reports allege the shooter had recently experienced psychotic-like symptoms. I am sure that in the coming days we will learn more details about the shooting and about the recent history of the shooter. Among the details there will be plenty of questions. Did anyone know this might happen? Could someone—especially in positions of power (FBI? Mental Health?)—have prevented it by reporting or removing access to guns?

Of course, it is easy to ask these questions and develop opinions after the fact. And yet we need to ask them if there are possibilities to learn from possible mistakes. What follows attempts to give the public a brief but better understanding of risk assessment when mental illness and violence combine. (NOTE: this is not a comment on the above sad situation or those cases where violence is unrelated to mental health.)

A little history of predicting future violence

Violence risk assessment is part of the sub-division of forensic psychology and psychiatry. Expert witnesses are used in court proceedings to report on the existence of mental illness, the probability of imminent dangerous behavior, and the options for most effective/least restrictive treatment required to reduce illness and increase safety.

How do clinicians make these opinions? In the not-too-distant past, expert witnesses usually used their wisdom shaped by years of experience. Much to the chagrin of experts, it turns out that clinical intuition isn’t all that effective. For some professionals, it is little better than chance! (Interested readers can check out Monahan’s 1984 oft-quoted research quoted in this rebuttal article.) Other options include actuarial methods (collecting risk factors just like an insurance company does to determine how much to charge your 18 year old son for car insurance) and test data. Both of these methods seek to eliminate feelings in the decision-making process. Actuarial data can certainly help us. Knowing someone has a history of violence and criminal behavior helps us predict future behavior. Knowing someone has schizophrenia may slightly increase risk of violence, but no more than it would for those who have problems managing impulses. And this would not be a reason to lock someone up (though it may be a reason to limit access to handguns). Assessment tools filled out by the person suspected of violence have a couple of problems with them but the main one is that very few of the most violent have been identified in treatment as possibly benefiting from assessment. And when we do give these assessments, the data rarely is clear—this kind of response means they will be violent, this one means they will not. We’re far better at identifying “faking good” or “faking bad” results than we are in determining whether the results mean future violence.

The best assessment to date requires that we have adequate history, survey of known risk factors, interviews, and test data. But as I said above, if the person suspected has not been in treatment or has done well to present as being merely disturbed but not dangerous, what can be done?

One More Complication

In our current society, we believe deeply that individuals have the right to self-determination. This means they have the right to refuse treatment. This right trumps nearly every other value. It doesn’t matter if the treatment would really help. The person is permitted to refuse. The only exceptions are involuntary commitments to address imminent danger to self or other. And as soon as the danger passes, the treatment can be refused again even if the treatment might avoid a relapse.

Bottom line for Practitioners

We can do better in responding to risk factors that might lead some to violence. We can learn more about these factors. We can equally promote confidentiality and privacy for our most distressed clients and yet be quick to warn others when signs of imminent violence are present. We can ask better questions. We can use non-cognitive approaches to get a better picture of their internal experiences. And yet, we can only work with the information we have. Contrary to popular belief, we are not prophets. In addition, most of our outpatient clients are not even remotely dangerous (in 27 years of clinical work, I have only needed to report two clients for imminent risk to others).

What we can do is assert the need for better and more available treatment options.

Family members are really the frontline of help for most distressed individuals. They are more likely to hear the murmurings that might indicate violence. This requires greater public education about the nature of mental illness and violence risk assessment and the kinds of ways to respond. Church leaders can also be better educated as to what kinds of options are available for those parishioners who are struggling with similar kinds of emotional distress. Let us be willing to lead the way in educating our communities and churches about mental health challenges and healthy responses. If we did a better job surrounding those with severe mental illness (and isolating them less) we would likely have less mental health induced violence.

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Filed under counseling, counseling science, counseling skills, News and politics, Psychology, teaching counseling, Training, Uncategorized, Violence

Is your empathy really self-serving?


Empathy, or feelings of understanding or identification with another, seems to be a primary vehicle of human expression of love and compassion. In the world of therapy, empathy seems the foundation for all good counselor work. Sure, we can act in kind, compassionate, yet robotic ways but knowing that someone gets you and helps you is better.

But this begs two questions: Are empathy and altruism connected and parallel? And, is our empathy really self-serving? Taking the second question further, could our empathic responses be destructive to the very people with whom we want to help? Psychologist Paul Bloom thinks so (short video of his contra empathy point of view). While I think his argument against empathy is seriously flawed and really merely an argument against naïve, superficial, and self-serving do-gooderism–a significant problem in our society where we solve problems on emotion and often without taking the time to understand either cause or consequence–the bigger question is whether or not we ever really have concern for others outside of self-interest. And if we discover that all empathy is self-serving, does that deny the Christian virtue of self-denial and voluntary submission to others?

What is at the heart of our empathic, altruistic behavior?

We all have numerous instances where we have witnessed self-sacrificing behavior. The reason these instances stand out in our memories is that they are unusual and somewhat rare experiences. But consider the more run-of-the-mill expressions of empathy. You see a GoFundMe page for a friend in need and you give. Your church is seeking donations for Thanksgiving baskets and you buy groceries. Your neighbor is sick and you mow her lawn. Do we do these behaviors for them? Or do we do it, in large part, for ourselves?

Josh Litman’s paper “Is Empathy Ultimately Just Narcissism?” seeks to summarize the research literature about whether empathy and altruism are positively correlated and whether empathy is really about the other or about self-interest. His answer? Empathy and altruism may not be all that connected. Empathy is better understood as feelings of “oneness” or connectedness to the other. When I identify more with someone, I’m more likely to feel empathy and do self-sacrificial for them.

In conclusion, this paper defends a non-altruistic, egoistic strain of empathic concern. It might be heavy-handed to call it narcissism, but evidence has shown that empathic concern is certainly motivated by self-interested factors rather than selflessness.

Could this be the reason why more people changed their Facebook profile images to a French flag after the Paris bombings and far fewer chose a Turkish flag after the most recent airport bombing? Do we more closely identify with one group over another and thus feel more empathy and make more statements of support and care?

Does this proclivity to more strongly identify with some more than others reveal self-interest and self-concern? If so, does that make our caring of others all about ourselves and cause us to suspect the warmth and empathy we get from others?

So you, too, must show love to foreigners, for you yourselves were once foreigners in the land of Egypt. (Deut 10:19, NLT)

Oneness and love in the created and the Creator

I think empathy can be self-serving (I care for you because I want to be cared for) but I do not think it must be this way. Rather, I would argue that we have been designed to understand our world by means of our experiences. Because I understand what it could feel like to lose my home to a flood I am moved to donate time and talent to help rebuild a home. Because I see your humanness, I am able to empathize with your losses and then consider what possible ways I might respond.

Oneness does help us empathize. But empathy is not the same thing as love. True love, as an action verb, requires a willingness to expend self for the sake of another. True love enlarges the population you are one with. So, straight people find themselves in the experiences of gay people; Christians in the experience of Muslims; liberals in the experience of conservatives. True love moves beyond simplistic understandingfile-nov-02-12-21-19-pms with oneness and best reflects the character of God who self-sacrificially loves beyond measure, choosing to take up our infirmities as his own.

In your relationships with one another, have the same mindset as Christ Jesus: Who, being in very nature God, did not consider equality with God something to be used to his own advantage; rather, he made himself nothing by taking the very nature of a servant, being made in human likeness. And being found in appearance as a man, he humbled himself by becoming obedient to death—even death on a cross! (Phil 2:5-8, NIV)

For we do not have a high priest who is unable to empathize with our weaknesses, but we have one who has been tempted in every way, just as we are—yet he did not sin.(Heb 4:15, NIV)

 

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3 negative consequences of having too many options


I prefer having choices to make over not having the option to choose how I spend my time. And yet, just like any medication you might take, the freedom to choose brings with it some potentially dangerous side effects. I’d like you to think about 3 and then consider a couple of modifications about how you make choices.

Consider the differences between choosing a mate today versus 50 years ago. According to Daniel Jones (listen at the 17 minute mark), in previous generations people chose mates from close proximity–from their block, building, or neighborhood. Now, we have endless choices if we are willing to use the Internet.  Consider the differences in choosing professions. In the past, your father was a farmer, you became a farmer. Now, not only can you pursue any career, you have to choose from endless post-secondary educational schools on your way to that career.

How can having choices/options lead to negative consequences?

  • Dissatisfied. You are always wondering if there is something better out there. Again, consider Daniel Jones as he discusses online dating sites,

“…it turns you into a flaky person who is always looking for something better, that can become a kind of mania…if you have a moment of boredom, you think there are 12 more possibilities in your inbox…”

Later in the same interview, Jones tells us that the issue of today is “not labeling relationships. Based on his college student interviews, many young people today are loathe to identify someone as their partner or lover. They tend to resist labeling someone as a boy or girlfriend. The failure to accept normal labels not only lead to potential of chronic dissatisfaction but also confusion–if you don’t know when a relationship begins, ends or what it is founded upon. It would seem that commitment to a relationship would suffer if it never is named as such.

Dissatisfaction leads to comparing self against others and both lead to depression.

  • Anxious. Coupled with the tendency towards feeling dissatisfied with life, more choices lead many to anxiety. What if I made the wrong decision? What if the next person I meet would make a better spouse? What if I’m missing out on something important? Continual choice and/or rumination over choices increases the sense of importance for the choices we have.

Anxiety leads to chronic stress and chronic stress begins to break down our immune system.

  • Fatigued (cognitive and emotional). We find ways to simplify life. A colleague of mine has a system to know what to wear each day so as to avoid the “What am I going to wear today” question. We (try to) put our keys in the same place to avoid the stress of looking for them every time we leave the house. When we live with too many open choices and options, we burn more glucose and our brains become less efficient. We numb our feelings or we become edgy.

Fatigue leads to poor decision-making (impulsive, reactive, unthinking). This is why we blow diets more at 10 pm than we do at 9 am. This is why those with addictions are more likely to use later in the day than early in the morning. When we are emotionally and cognitively fatigued, we are prone to feel greater anxiety and dissatisfaction. The “gift” of choice continues to give.

Can We Do Anything About This?

Now, rest assured that I am not advocating for life to return to a place of no choice (arranged marriage, one career path, etc.). Choice has enabled me to learn about myself and given me many wonderful experiences that as a boy growing up in Vermont I never imagined. But are there ways we can minimize the common negative consequences of too many choices?

  1. Examine your view of God’s will. I meet many people who fear making a choice God does not want them to make. They fear they will somehow end up on plan B of life as punishment from God. While there are many very black and white decisions (should I cheat on my taxes? Is it okay to kill my annoying neighbor?) most decisions are not that clear. What if most of your decisions are neither right nor wrong? Whether you go to university A or B, marry person A or B is less of concern for God than we might think. Typically God seems more interested in our motives than some of our daily choices. Consider seeing God’s will as guardrails on a road rather than a pinpoint decision.
  2. Limit your decision-making time. It can be a habit of some to mull over future decisions long before the decision needs to be made. Do you find yourself worrying about the challenges of next week? While it might seem wise to think through your decisions in a thorough way, anxious rumination is not helpful. Limit when you think about big ticket future decisions. For example, if you are considering a career change, set a specific time during the week to search out available options. Then, when you find your mind mulling over options outside that set time, you can say to yourself, “I’m going to think about that during the scheduled time, not now!” When you do make a decision, use the same technique to limit when you review/evaluate that decision, thereby limiting time for “what ifs.”
  3. Challenge post decision “if only” regrets. I made a major career decision 17 years ago. I chose to become a seminary professor over an Ivy League appointment. For the first few months at Biblical Seminary I found myself wondering if I had made the right choice. I imagine this was the result of financial struggles (the other job paid double) and the overwhelming stress of creating grad courses from scratch (the other job was something I had ample experience to do). So, I could easily see that I chose the harder job for less pay. That became the truth I believed for a bit. But, the real truth is that I chose a job that had immense freedom and opportunity for growth. I would not have been able to travel the world as I do now. Of course, I couldn’t know all that then. So, work to challenge your assumptions about the future. Yes, like me, you will grieve when doors close. But remember, God is at work in providing a future for you, even in tough locations and times.

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Filed under Anxiety, biblical counseling, counseling, counseling science, Psychology, Uncategorized

Alternative to talk or pharmacological therapies for depression?


For many of my clients, medications are necessary for their moderate to severe depression. With SSRIs or mood stabilizers, they are able to function at home and at work and can better benefit from talk therapy. But in every case my clients report side effects from their meds. It is always a bit of art-form to balance benefits and side effects. That is the world we live in and the best we can do now. One of the key problems with all psychopharmacological interventions is that drugs provide a systemic solution when often we may need a targeted approach. Consider a person with ADHD who takes a stimulant that will help them focus in class yet must deal with increased blood pressure, heart rate and potential for insomnia. The stimulant does not just target the frontal lobe but impacts the whole body.

Wouldn’t it be great if we could target an intervention to a particular part of the brain?

“The brain is not a bowl of soup and you add the chemical and you stir,” she says. “Chemicals work within networks, within systems, within pathways. And where in the brain a chemical may be working is as important as knowing what chemical you should use.”

I read the above quote in this news item about the problem of rumination in treatment resistant depression. Helen Mayberg, author of the above quote, is researching Broadman Area 25 and its connection to the problem of rumination–where a person struggles to turn off negative thoughts about self and the world. She and other researchers are wondering why some people do well with talk therapy while others seem not to benefit. Instead of looking at the possibility of a less helpful form of talk therapy, they wondered whether the problem is that the person cannot get away from their negative thoughts enough to engage in the work of counseling.

One of the interventions being tried is to practice disconnecting from ruminations by paying attention to what is going on in the present. To help with the learning of this skill one researcher is testing whether 5 sessions of having an electrode on your wrist create an itching sensation while the patient practices paying attention to a decreasing amount of electrical stimulation.

Sound crazy? It just might be. I am always wary of any “5 sessions or less” advertisement. But before we toss out the idea, if a targeted treatment could help turn down the volume on a rumination, wouldn’t that be a help to many?

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Filed under Depression, news, Psychiatric Medications, Psychology, Uncategorized

Useful Book on Narcissism


Craig Malkin of Harvard Medical School has written a popular, easy to read book on the topic of narcissism and its opposite end of the spectrum, “echoists.” Rethinking Narcissism: The Bad–And Surprisingly Good–About Feeling Special (Harper, 2015) is worth your read if you think you might be on the spectrum or if you live with someone who does.

In the beginning he sets out to destroy the myth that narcissism is always destructive and that all narcissists act the same. To help describe the continuum of egocentrism Malkin defines the low side as “echoists,” those who have too little of it who feel special in becoming invisible to others only known for the help they offer to others. Further, he also describes narcissism as something that may ebb and flow, rather than a consistent trait. Malkin describes the continuum well with many real life examples. With a better understanding of the spectrum, it may help us look more closely at less pathological forms of egocentrism and be less likely to lump everyone together.

Worried that you might be a narcissist? Want to see where you fall on the spectrum? Try out his assessment tool.

In his book he describes the root causes and the experience of being around subtle and extreme forms. Unlike other researchers, he outlines ways that egocentric people can grow empathy toward others. This idea flies in the face of conventional wisdom that a narcissist can never change,

The problem is we’ve all had it drummed into our heads that narcissist can’t change. They think they’re perfect just the way they are, the argument goes, so why should they even try? But unquestioningly accepting this idea backs us into an impossibly tight corner….We’ll fall silent or vent our anger, or…we’ll try a little of each. And none of these reactions will make the relationship any healthier

When we withdraw, by swallowing our words or walking on eggshells, we only strengthen people’s narcissism. In fact, echoists and narcissists often pair up to create a “love” that’s toxic to them both.

What can we do? For those who are not extreme narcissists, one way to encourage growth is to validate their experiences even while we say “ouch” letting them know we are hurt. Too often our anger or our silence is the primary response. While validation and pointing out our pain is not a guaranteed solution, combining validation plus vulnerability can enable some to experience compassion for self and other at the same time.

Check out the book!

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Thinking about offering SKYPE counseling? Think twice!


There has been a lot of focus on telepsychology over the last decade. What started out being about counseling over the phone has morphed to counseling via the video chat, text chat, instant message, social media, and even in virtual settings with avatars.

At times it seems like the wild west, that anything goes without regulation.

But now, more counseling related associations have developed standards for telehealthcare delivery. And licensing boards are also beginning to restrict who can offer telecounseling. Did you know that Georgia only allows Georgia licensed mental health providers to provide telecounseling to its citizens?

Ken Pope has an excellent website listing many resources you will need as you consider what you might be allowed to do. He lists standards of care, recent professional articles, and links to state boards who are beginning to regulate telepsychology. I encourage anyone who currently practices “Skype” counseling (BTW, SKYPE is not HIPPA compliant), to become informed.

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Filed under christian psychology, counseling, Psychology