Category Archives: Psychology

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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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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Filed under counseling, counseling science, Post-Traumatic Stress Disorder, Psychiatric Medications, Psychology, stories

How labels we use reveal self-deception


 

Someone sent me one of Ken Pope’s summaries of a recent essay about the differences in research findings when asking men if they have ever used force and held someone down during sex versus asking them if they had ever raped another person. You can read the original research he was discussing here, which is by some researchers at the University of North Dakota.

No, I’m not a rapist, but I have used force to make someone to have sex.

Let that previous line sink in a bit.  We’ll discuss it in a minute. But first, you might not want to read the article so let me tell you what the authors were interested in knowing. They wanted to know if there were differences between men who are hostile towards women and accept the label of rape and those who have used force but deny the label.

This allows us to test whether there are differences in men who do not identify with the “rape” label on sexual aggression surveys, although they have committed acts that would be defined as rape. Men who admit intentions to force women to have sexual intercourse only, but do not believe that this act constitutes rape, might not be primarily motivated by a desire to retaliate and overpower women. Their behavior could be guided by other factors in line with stereotypically masculine gender roles such as having a high desire for sexual activity, viewing sexuality as a competition and a way to gain respect among peers, and lacking consideration for women or viewing them as sexual objects. Therefore, we hypothesize that men do not endorse any intentions for sexual aggression will differ from the other two groups of men primarily on a dimension characterized by hostility toward women as the strongest loading factor. (emphasis mine)

What did they find?

As hypothesized, a sizable number of participants indicated that they might use force to obtain intercourse, but would not rape a woman. Men who indicate intentions to use force but deny intentions to rape exhibit a unique disposition featuring an inverse construct of hostility toward women but high levels of callous sexual attitudes (Check 1985). Given that hostility toward women involves resentment, bitterness, rejection sensitivity, and paranoia about women’s motives, we consider the inverse of hostility toward women in men that intend to use force to be indicative of an affable, trusting, and nonreactive affect toward women. When combined with callous sexual attitudes, we interpret this function as representing personality characteristics that might lend themselves to allowing men to not perceive his actions as rape and may even view the forced intercourse as an achievement. The primary motivation in this case could be sexual gratification, accomplishment, and/or perceived compliance with stereotypical masculine gender norms. The use of force in these cases might be seen as an acceptable mean to reach one’s goal, or the woman’s “no” is perceived as a token resistance consistent with stereotypical gender norms. While the ultimate outcome of either act constitutes rape, this pattern of results suggests that there might be different types of offenders with potential differences in underlying motivation, cognition, and/or personality traits.

So, not every rapist does so for the same motives (and therefore our interventions will need to be different). Some knowingly rape and are not self-deceived about their actions. Others who are willing to acknowledge “forceful intercourse” group reveal deceptions  (probably both in view of self and other) that enable rape to be considered something less than it really is.

Labels and what they may reveal

What labels do you use and what do they reveal about yourself and your proclivity to self-deceive? Here are some examples

  • I exercise (once in a great while)
  • I stand up for myself (I attack anyone who disagrees with me)
  • I used to struggle with porn (well, I look about once a month but I don’t think I will do it again)
  • I eat healthy (I’m obsessed with food labels)
  • I am good at doing my taxes (I underreport income)
  • I’m a Christian (I go to church but never really talk to God)
  • Let’s just call it sin rather than abuse (because I won’t accept my actions are abusive)
  • I need (I want/demand)

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Filed under Abuse, counseling science, deception, Psychology, Rape

Institutional betrayal: Secret ingredient to PTSD


We live in the world where human frailty and pathology is viewed in individual terms. When we see sickness we imagine that the person must have some weakness in biology, faith, or behavior. Rarely do we think about the role the system or community has played in the development of that person’s pathology. This is true when we think about a person diagnosed with PTSD. We therapists hypothesize about individual factors (personality factors, early childhood experiences (a slight nod to external causes) and neurobiological risk factors) and situation factors (the frequency, duration, and intensity of overwhelming trauma events) when we try to answer the “why” of the development of PTSD in a person.

The problem with this kind of thinking is that it fails to take into consideration of known research that suggests that environmental response to an individual’s trauma experiences may be a determining factor in whether PTSD or chronic traumatic reactions form.

In the most recent American Psychologist (2014, 69:6, 575-587), Carly Parnitzke Smith and Jennifer Freyd write about the concept of institutional betrayal. Traumatologists recognize Freyd’s name as the researcher who developed “betrayal trauma theory”, pointing to the especially toxic form of PTSD caused by those who were supposed to be safe and protective. These begin to examine “institutional action and inaction that exacerbate the impact of traumatic experiences…”

How can an institution betray a victim?

When a person trusts that a system designed to defend, respond, protect, or seek justice will do its job after an interpersonal trauma, and when that system either chooses not to respond (omission) or worse, chooses to lay blame at the feet of the victim (commission), institutional betrayal occurs. Examples include law enforcement accusing rape victims of “asking for it” with their clothing, church leaders allowing offender clergy to “leave with their reputations” or refusal to investigate a case of date rape when the reported offender is an important leader in the community.

In summarizing a couple of studies, Smith and Freyd point out that institutional betrayal after a trauma experience leads to higher rates of dissociation, sexual problems, and health difficulties. This is even more likely when the trauma takes place in an environment where protection of the members is trumpeted (i.e., church or military).

What are the common characteristics of betraying institutions?

Smith and Freyd note several characteristics found in institutions at greater risk for betraying members.

  • membership requirements to define in group identity. This produces a need for members to act in ways to maintain such an identity
  • Prestige (both leaders and institutions). Prestige produces both trust and fear, dependency and power
  • Priorities. “Institutional betrayal may remain unchecked when performance or reputation is valued over, or divorced from the well-being of members.” As the authors note, maintaining reputation as a priority will lead to neglect or attack of those who challenge reputation
  • Institutional denial. Blame a few bad apples, avoid institutional blame or responsibility

Those institutions that do make efforts to prevent abuse within its community may still yet fail to respond well. They may fail to use adequate screening procedures, normalize abuse, fail to utilize or follow appropriate response procedures, punish whistleblowers, and aid cover-ups.

What to do?

Smith and Freyd argue that transparency (about past actions/failures to act as well as power structures) and priority to protect the well-being of all members will move institutions away from the risk of betraying individual members. I would argue that the shift to protect moves from the institution as a whole to protection of the most vulnerable.

Let me recommend a few resources that have appeared here in the past:

  1. Diane Langberg’s 5 part video about narcissistic leaders and the institutions they lead. She too describes systemic narcissism.
  2. Why some spiritual leaders abuse (and systems allow it)
  3. Narcissistic systems
  4. Resources to combat narcissism one person at a time

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Filed under Abuse, personality, Post-Traumatic Stress Disorder, Psychology

Criticism of Biblical Counseling: Are Joyce’s Concerns Valid?


Katheryn Joyce has recently published a long post about the rise of Biblical counseling and the concerns some have about the movement [read it here].

Most people who have thoughts about counseling and Christianity tend to fall into one of to categories: Those who oppose biblical counseling as dangerous and those who oppose the various versions of Christian psychology as shallow and full of humanistic ideology. Very few people try to maintain identity in both worlds. If you have read my “about me” you will find I’m one of those who does accept the label of biblical counseling and Christian psychology (more on this below)

I encourage both proponents and opponents of Biblical Counseling to read her essay. Let me even take the liberty to suggest some starting questions to keep in mind as you read. While the essay may not answer the questions, having them in mind will keep you from solidifying stereotypes of either sides.§ If you are inclined to reject biblical counseling, consider these questions:

  1. Where might I find a more thorough history of biblical counseling and its various permutations?
  2. What main biblical counseling author voices are missing in this piece? [Note that the mentioned ACBC was, until recently, known as NANC (National Association of Nouthetic Counselors)]
  3. What failures in Christian psychology movement(s) led to the need for a biblical counseling movement?

If you are inclined to defend biblical counseling, consider these questions

  1. Even if some of the bad examples of biblical counseling do not represent you or the heart of the movement, what aspects of the movement may support or encourage some of these distortions?
  2. How might you better communicate “sufficiency of Scripture” to outsiders?
  3. Does biblical counseling seek to eliminate symptoms or improve spiritual responses to symptoms? How might it better acknowledge the body when talking about the causes of mental health problems?
  4. Where does fear of “integration” hinder the maturation of biblical counseling as a movement?

Indeed, these questions have already been asked and answers given in a variety of locations. Readers unfamiliar with biblical counseling should start with websites such as this one, CCEF, ACBC, BCC, and the Society of Christian Psychology to find further and deeper readings on related topics.

Where the Concerns are Valid

Not acknowledging benefits from psychological research. Joyce notes that a good biblical counseling session looks a lot like a good professional counseling session. Why? Well, it is obvious that change happens best in the context of kind, compassionate relationships. Why the similarity? While it is true that psychotherapists didn’t discover empathy, it is true that psychotherapy research has expanded our understanding of the best way to encourage trust relationships in therapy. In addition, some of the cognitive, affective, and dynamic interventions developed from these models are used within biblical counseling. I have absolutely no problem from biblical counseling deriving benefit from interventions developed in other models of therapy. I only desire biblical counselors or acknowledge that benefit. It is clear Jay Adams benefited from Mowrer (and said so to boot). We can do the same. We can admit that Marsha Linehan has revolutionized our understanding of how we work with people exhibiting symptoms of borderline personality disorder.

Emphasizing false dichotomies. Joyce quotes Heath Lambert in this piece (near the end),

“I’m concerned [that] if we say, ‘Oh my goodness, people with hard problems need physicians and need a drug,’ we’re going to lose much of what the Bible has to say about hard problems.”

The quote above is in the context of dealing with difficult or serious mental illness. He worries that if the church creates two categories of problems (normal and special), those with serious problems will no believe that the bible has things to say about those suffering with suicidal ideation or schizophrenia. It seems that some biblical counselors take a negative stance on psychiatry and medical intervention because they fear doing so will hinder the work of the Spirit through the bible. I would argue that this dichotomy does not need to exist. I agree that the bible speaks to everyone, whether they are having difficulty or easy problems. I don’t think that use of medications or medical practitioners has to hinder pastoral care. The message that others get when we suggest that medical intervention need to be avoided is that somehow it is less spiritual to seek a medical intervention. This is patently false. Now, not every medicine is worth taking. Some may create more problems then they solve. But that fact should not cause us to lump all professional/medical care into the same category.

Where the Concerns are Overplayed

Heath Lambert gets it right when he claims that all counseling models will fail, due primarily to the quality of the practitioner. Biblical Counselors do much work that is commendable and successful. Joyce’s piece may suggest that most biblical counselors are ineffective and incompetent. This is not true. Matthew Stanford suggest he has never seen a biblical counselor do well with difficult cases. That may be the experience of my friend, but I can attest to seeing biblical counselors working well with people with serious personality disorders, delusions and other difficult mental illnesses. Now, the truth is, these counselors have succeeded because they did not follow the stereotype and reject learning from professional psychology. Further, these same counselors did not take “sufficiency” to mean that they could only use the bible in considering how to respond to their clients.

Take a moment and read her piece. Review the questions above and keep an open mind to both sides of this story.

[§ I have written on the relationship between Christian psychology and biblical counseling in the Journal of Psychology and Theology, volume 25, 1997. You can buy that essay here.]

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Why Oppressed People May Not Jump At Chance For Freedom


Ever wonder why those who experience systematic abuse and violence don’t jump when they get a chance for freedom? Consider the abused teen choosing not to reveal the abuse to an inquiring teacher but rather stays in the abusive home in silence. Consider the victim who refuses the help of a friend in order to leave a domestically violent spouse. What is the psychology that supports these responses to oppression?

Brilliant Mhlanga has written a short memoir of his experience of being from an oppressed people group in Zimbabwe. Under the guise of “independence” his people and his family suffered tremendous violence. Family members were raped and murdered in grisly fashion. He labels what happens a genocide (from 1980-1987).

Here’s how he describes the impact of this systematic oppression (emphasis mine, British spellings his)

The psychology of oppression, then, becomes a phenomenon derived from the state where the oppressed, given their existential experience, adopt the attitude of ‘adhesion’ to the oppressor (ibid: 45). Freire adds that under these circumstances the oppressed cannot consider their situation clearly and objectively in a bid to discover themselves outside the spectacles of their oppressor. As discussed earlier, the oppressed rationalise and internalise their suffering. Their state of mental warping makes them appear as walking symbols of conformity. Such conformity makes them reject their enlightened brethren whom they tend to perceive as ‘trouble makers’. To them anyone who advocates change of their state of being is likely to bring them more trouble, as they cannot know the likely outcome. They fear change. This is the state of people who have lost a sense of hope in their full potential without the help of the oppressor.

Notice some of the features of the oppressed:

  • Identity tied to oppressor
  • Belief that one cannot exist outside this relationship (fear of being in relationship, fear of not being in relationship)
  • Internalize suffering (blame self)
  • See those who would fight for their freedom as dangerous (the devil you know may be better than the one you don’t know)
  • Reject change as dangerous

Now these features are not found in everyone who is abused but they are worth noting. Those who would want to help the oppressed must consider these challenges and develop interventions that do not automatically trigger the fear reactions. This might include,

  • Identifying self-blame and raising doubts
  • Giving freedom to control response to oppressor (not coercing leaving oppressor)
  • Identifying possible future
  • Validate change as scary

Quote: Mhlanga, B. (2009) On the psychology of oppression: Blame me on history! Critical Arts, 23:1,106 — 112

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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

Military trauma and traumatic brain injury: Challenges and Opportunities


Colleague and veteran Steve Smith has let me know about this web article regarding the state of PTSD/TBI injury among active duty military personnel. The essay points to some very startling numbers:

  • 59% report no improvement or worsened symptoms after undergoing treatment for PTSD and TBI
  • 30% dropped out before treatment was complete
  • A large portion of patients are on up to 10 meds at a time

The news item goes on to summarize presentations made a few days ago at the American Legion symposium on care for TBI and PTSD veterans. What makes this worth reading is that the actual slides from the presentations are provided in links at the end of the piece. I encourage you to go and read up. You can see what is being done using complementary treatments, the numbers of veterans with head injuries (interestingly, 80% are NOT received during combat) and/or PTSD, what services are available and what recommendations are made to DoD and the VA system to improve patient care.

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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.

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Filed under christian counseling, christian psychology, Christianity, counseling, counseling science, counseling skills, Post-Traumatic Stress Disorder, Psychology, Uncategorized