Category Archives: Psychology

Disorders of Extreme Stress Not Otherwise Specified (DESNOS)


I recently scanned a book, Healing Trauma(published by Norton in 2003), and ran across a new name (for me) for the problem of complex PTSD–Disorders of Extreme Stress NOS or DESNOS.  Because many christian counselors are only marginally aware of the research on complex PTSD I’ve decided to give a brief summary here.

The following symptom presentation may be found in those with prolonged and severe personal abuse (and often starting at an early age): 

  1. alterations in the regulation of affective impulses, including difficulty with modulation of anger and being self-destructive,
  2. alterations in attention and consciousness, leading to amnesias and dissociative and depersonalization episodes,
  3. alterations in self perception, such as a chronic sense of guilt and responsibility, and chronically feeling ashamed,
  4. alterations in relationships with others, such as not being able to trust and not being able to feel intimate with people,
  5. somatizating the problem: feeling symptoms on a somatic level when medical explanations can’t be found, and
  6. alterations in systems of meaning (loss of meaning or distorted beliefs)

Some folks include a 7th characteristic: (alterations of perceptions of perpetrator(s).

Check out the this paper(44 pages long) written on the assessment and treatment of DESNOS.  Though written for psychiatrists, I found the language easy to understand. The authors do a nice job of helping counselors differentiate between Borderline Personality Disorder and DESNOS. While they recognize significant overlap between the two constellation of symptoms, DESNOS folks tend to experience less relational push/pull (less manipulative behavior) and more push behaviors coupled with more intense sadness and grief.

Counseling work falls (per this paper) into 3 categories: stabilization, trauma processing, and re-integration into their world.

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Filed under Abuse, Anxiety, counseling, counseling science, counseling skills, Post-Traumatic Stress Disorder, Psychology

The danger of “why” questions


Most thoughtful counselees want to ask “why” questions. Why do I do what I do? Why did she do what she did? Why am I the way I am? Why am I so depressed? Why isn’t my life going the way it should or seems to go for others? Counselors too ask “why” questions. Why did you blow up at her? Why is this child afraid of going to school? And closer to home, why did my client drop out of therapy?

On the surface why questions seem to want to get to the bottom of things. We assume that if we understand the nature of the problem, we’ll know how best to respond. And there is much truth in this assumption. 

But consider their danger. Some answers to the “why” are so complex that the answer to the “why” doesn’t really point to any one answer. Further, we frequently prejudge the question with implicit answers (e.g., it is because something is wrong with me…I’m a loser…God doesn’t want me to be happy…I can’t help it that I’m this way…).

Why questions also make us passive. We look for answers; we mull over the “facts.” We are less likely to become active to do something about our situation when we are in a “why…” mode.

Let me suggest a better kind of question: What questions

What is happening? What am I feeling/thinking/doing? What is it that I want? What do others want? What am I doing about my situation? What goals do my behaviors emphasize? (this is a why question that forces us to look at our behaviors and see if they match up with our stated desires) What options are before me? Be descriptive rather than interpretive. Notice that why questions jump to interpretation but seldom activate a person to do what is in their power to do.

Frequently, by asking descriptive “what” questions, we find it easier to activate the will and begin doing something about our situation. In addition, we often come to posthoc understanding of the “why” when we have some distance from the situation.

So, the next time you find yourself stuck in the “why” set of questions, stop and try to ask yourself some what questions instead. Observe the impact of distancing from the passive whys? Does it help?

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Filed under Anxiety, christian counseling, christian psychology, counseling, counseling skills, Psychology

Case consultation by videoconference?


For my counselor readers…how interested would you be in participating in videoconferenced case consultations with an expert in your field for the purpose of discussing client cases with that expert? Bear in mind that this kind of activity would have to meet ethical guidelines (e.g., no identifying information about any clients could be revealed, clear distinction that this is consultation and not supervision, etc.), but would you be interested? Would something like this reduce your sense of isolation?  Consider answering the following questions:

1. Would you be interested in getting consultation for some of your cases via videoconference (private video exchange with an expert, such as skype or other service)?

2. Would you still be interested if the videoconference was a group of no more than 4 (and everyone got to present something)? If it was a group of about 10 and not everyone got to present but all got to participate in the discussion)

3. Would you be willing to pay for such a consultation? 

4. If yes to above questions, how frequently would you think you might use this type of service? Monthly? Quarterly? Other?

5. Finally, what questions or concerns does this idea raise for you?

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Filed under biblical counseling, christian counseling, christian psychology, counseling, counseling skills, Psychology

Cultural sensitivity or watered down


Having been in meetings yesterday and today about our next steps regarding counseling training in Rwanda, I’m wrestling with the best way to address cultural differences in whatever training we do. And specifically I’m wrestling with a particular dilemma forming in my mind:

Teach what we know about counseling NOW but be unaware of subtle but important cultural differences vs. listen, learn, and teach LATER what we know (but in culturally relevent terms)

It is not the first time that I have been asked to do something sooner rather than later with these words. “Don’t worry about the cultural relevance. We’ll tell you when something doesn’t work or our students will do the application to their own situations. If you try to be culturally sensitive, it will end up being watered down. We want our students to get the best education, something that the US would recognize.”

Why do I struggle with this request? Well, in my head it sounds like, “hey, come bring your colonialistic methods of evangelism and we’ll handle it.” I struggle with it because I know American counseling culture has significant problems with it. And, I struggle with it because I know that some students (this is a universal truth!) are really good at critical thinking while others blindly ape what we say without much thought at all. AND YET, I know that waiting until I’m culturally aware enough to teach means I wouldn’t do so for a very long time.  

So, part of my struggle is not wanting to look like a culture boob by just assuming that what I teach US students is what Rwandans would need. I suspect the answer is (a) being courageous enough to risk looking like a fool, but (b) flexible enough to change on a dime when I am aware of a disconnect.

Hmmm. I may have a problem with both.

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Filed under christian counseling, christian psychology, counseling skills, Cultural Anthropology, Psychology

The APA on identity therapy and conversion therapy


[Let me wade into something that tends to fire up lots of feelings and lead to controversy. And let me ask all to be civil. Civility seems to be the first thing that disappears when we discuss matters near and dear to our hearts. But let us be different and listen to each other rather than talk at or past each other. As James tells us, let us be quick to listen and slow to speak.]

In recent days media outlets have picked up the story of the American Psychological Association’s release of a report and declaration of their official stance on reparative or conversion therapies for individuals seeking to change their sexual orientation. You can read their press release and find their 100 page research review here. Being a member of the organization, knowing a few of the players in the research side of things, and knowing how easy it is to get caught up in debate and miss some of the finer points, I thought I might make a few comments that may not make it to the public eye.

1. Researchers are beginning to distinguish between sexual identity and orientation. This is a good thing. I dare say that the public lags far behind on this matter. Separating these two different aspects of sexuality allows for individuals to consider and interpret their sexual feelings in accord with their beliefs and NOT as how either the minority or majority of the world tells them to define themselves. This is akin to biracial people determining how they want to self-identify rather than be forced to say they are black or white.  Consider the following quote by one of the players (whom  I don’t know),

The distinction between orientation and identity (or attraction and identity as we often describe it here) is key, in my view, in order for us to understand the experience of those who say they have changed while at the same time experiencing same-sex attraction….I hope we can agree that sexual attraction patterns may be one thing while meaning making aspects may lead two people with the same attraction pattern to identity in disparate ways. (emphasis mine; from http://www.crosswalk.com/blogs/EWThrockmorton/11607271/)

If I understand the relationship between identity and orientation, it would seem that one forms identity from a variety of “data” which leads to an orientation. This is true outside of sexual identity. A number of factors come together for a person to see themself in a particular way (this may include biology, family, life experiences, key “flashbulb” moments, etc) and in cementing that particular identity they develop an orientation towards the world. SO, this may explain why trying to change orientation has little positive effect. Until the person reviews, explores, and reconsiders their identity (something that happens in nearly every counselee I’ve ever worked with) and begins to practice another way of seeing self, not much is going to change in attraction and orientation. Further, what may change is one’s sense of importance (and therefore meaning) of various parts of themself. When my clients explore their identity, it is rare they come to understand that they were completely mis-perceiving their feelings or experiences. Rather, they begin to see those experiences and feelings from a different vantage point.  

2. Change. What constitutes change is still up in the air. Ask a depressed person if they have changed even if they are only 50% less depressed and they will say likely say yes. Ask someone else and they may say “no,  I’m still depressed.” In the realm of sexual orientation, however, many see orientation as all/nothing. All same sex or all opposite sex orientation. Many will tell you this is just not their particular experience. So, IF someone wanted to change their direction of sexual attraction, what standard would they use to determine if change had taken place? Would 50% change be good? Who would decide this?

There is another analogous scenario in psychology. Should psychologists provide weight loss treatment? Given that an extremely large portion of those who lose weight gain it back and more, many have felt it unethical for a psychologist to offer weight loss therapies when they know that success is extremely low. So, how long do you need to keep the weight off to make a treatment worthwhile? How much do you need to lose? Who decides?

My gut feel is that the APA is not accurate in saying that there isn’t evidence that individuals can change. There is some evidence. Not complete change, but let us not deny what is there. Neither are they accurate about their reporting of harm. Harm reports are difficult to objectify. The best research will show you that some are harmed and some are not. Instead of assuming harm, let us evaluate more closely how some are harmed and how some are helped. Just as one might do with the weight loss scenario.  

3.  APA makes an attempt to make room for the work of helping one to find congruence between faith commitments and sexual feelings. This is also a good thing. Now, just how a psychologist does this matters greatly. Does he or she evangelize here? By that I mean (a) encourage a client to choose a different faith or change it to fit one’s sexual feelings, or (b) encourage a client to deny feelings and deny the suffering one might have by choosing not to act on a desire? My personal opininon is that option c (stay neutral) does not exist and is not possible. So, where does that leave us? Informing clients of our personal positions and yet not attempting to force individuals into our view of the situation. In other words, truthful but humble without being demanding.   

This is a divisive topic. Do individuals seeking to change their sexual orientation have the right to try to do so with the help of psychologists? Is change possible? Desirable? Damaging? And of course in trying to answer these questions you have a number of players on each side–each reading the “evidence” the way they would like to see it. You have those who have personal experiences in one direction or another. You have those with political or philosophical agendas. And, on top of that, you have media players interested in creating controversy where they can. I observed this last one myself where a local talk show host did his level best to create differences between two parties that weren’t disagreeing with each other as much he wanted them to.

So, what do you make of the difference between identity and orientation? Is it meaningful? How do we speak of change? Can we admit that it happens for some and not for others no matter our personal opinion whether change is good or not? And finally, can we avoid the “what if…” tendency in our conversations so that we deal with what is happening and not what we fear might happen?

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Filed under APA, Christianity, counseling science, ethics, homosexuality, Psychology, sexual identity, sexuality, Uncategorized

Are you a genetic fatalist?


Definition of a genetic fatalist: If I have genetic markers for _____, then I will have _____ problem.

Maybe this doesn’t happen to you but I find that when I have conversations about a wide variety of counseling related issues, they end up hitting upon the genetic question? Whether we are discussing anxiety, depression, alcoholism, sexual identity or similar concerns, I can count on being asked,

“Do you think it is genetic?”

The questioner seems to think that if the answer is “Yes,” then the individual in question has no responsibility for the situation–or no control over what is taking place. “If my alcoholism is genetic then it wasn’t my fault.” “If my son’s sexual identity confusion is genetic then he can’t do anything about it.”

Here’s what I want to say to most of these questions:

1. Probably but we don’t really know. There are lots of researchers trying to discover genetic markers and how our genes express themselves. Some we understand really well (like eye and hair color) and others we understand less well.

But even if tomorrow we discover that your husband’s OCD is genetically based, what does that mean? Is he forever trapped in acting on his OCD?

2. Thinking about genes this way doesn’t really help us right now. We all have genetic markers for various cancers and diseases but not all of us contract the problems. Women may have markers for breast cancer but never have the disease. How can that be? It can be that way because disease states or mental health matters are multifactorial in their origination. There may be genetic markers as well as environmental insults as well as psychological stressors that all work together to either protect from the disease or cause it to get started.

So, are you a genetic fatalist? Do you give your deciding vote to genetic markers when considering responsibility and control regarding behavioral issues, mental health problems, personality?

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Filed under christian psychology, counseling, News and politics, personality, Psychology

credentialing rant


Having spent most of yesterday trying to complete an on-line application to become an authorized, in-network provider for an insurance company, I’m fighting to remember why I started down this path.

Yes, I absolutely know it benefits clients in that they do not have to pay my entire fee out of pocket and only hope to get some money back later (if they have an out-of-network benefit). They merely have to pay a co-pay and so counseling is an affordable option.

But, being a selfish individual I’m thinking mostly about my own interests at this moment. Let me count the ways this process irritates me:

1. Collecting all my old information (addresses for pre and post docs and all education back to undergrad). Don’t they know that happened eons ago?

2. Repetitive entries. I think I entered my fax number at least 20 times.

3. Tax ids, SS ids, NPIs, etc. Numbers to find and enter correctly. I’m ready for the iris scan and probe now. My underwear size is…

4. And the real irritation is…(the previous ones really aren’t the issue as the on-line application wasn’t so bad–just time consuming)…I know that if I’m approved I get the following welcome gifts

  •  
    • Reduced income per hour
    • Delayed income (improperly rejected claims, delayed claims, claims sent to the wrong address, etc.)
    • More paperwork to fill out to beg for sessions

Whine, whine, whine. It’s all about me. So much for caring for my clients’ best interests…

Okay. I’m better now. This is a good thing and one bonus is the company collecting the information will bank it so that I can use it in the future for other insurance companies should I so choose.

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Filed under christian psychology, Psychology

Most common sexual dysfunction?


I’m doing some prep for a November talk at CCEF‘s annual conference which I am entitling, “When sex in marriage doesn’t work.” I’ll be giving a brief overview of how counselors can be a help to couples facing sexual dysfunction (whether biological, psychological, or relational). But in my prep today I ran across this little telephone survey result from 2002 where callers asked married men and women between the ages of 40 and 80 about their most frequently experienced sexual problem.

Any guesses yet?

For men, 26.2% reported problems with “early” ejaculation. [No definition given for “early.” Usually early or premature means earlier than he wanted.] Another 22% said the problem was ED. It is interesting that we are bombarded with ED commercials but I can’t say that I’ve ever seen PE treatments advertised in mainstream media. This is probably due to the number of baby boomers with cash seeking to turn back the hands of time.

For women? No surprises. 33% report problems with interest/desire and nearly 22% report problems with lubrication.

Did the respondents seek help? 75% had not.  Another study of men after prostate surgery reveals that those who do seek help quit soon after. Seems that while there are a number of medical and psychological interventions that can help to a degree, nothing turns back the clock to one’s twenties.

A caveat. The researchers only got a 9% response rate for their random calls. Why didn’t more participate? Did those who participated have more or less problems than those who refused?

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Filed under christian counseling, counseling, counseling skills, marriage, Psychology, Sex, sexuality

Itchy?


I have poison ivy. During the day I’m able, sort of, to distract from the constant itch. I want to scratch but I refuse to give in to the temptation. But at night, the itch seems to quadruple in strength. It screams at me: “Scratch me NOW!” And without much thought, I scratch away. Further, itches appear in other spots and I begin to wonder if I will have breakouts elsewhere. Did I touch my eye? What if it shows up there? Oh, and there’s that itch in my groin…” Certainly my mood takes a hit.

This experience got me thinking about cognitive/emotional and relational “itches” that all of us have. They may be desires, fears, beliefs, etc. During the day work enables us to set them aside for a time. But then evening arrives and with less to distract us, they come rushing at us with a vengeance. And we begin to scratch at the itch by ruminating, fantasizing that you have a different life, predicting the worst outcome, impulsively trying to get rid of the problem, or drowning with alcohol, food, or media.

What is your “itch?” Do you have mechanisms to deal with the itch without making it worse by “scratching?” How might you identify the underlying beliefs and “conversations” you have with the itch that make it much more difficult to deal with?

Soon, my poison ivy will be long gone. But many of our emotional itches never stop. Like Nash in the movie version of “A Beautiful Mind”, the itch did not go away even though he was able to distance himself from it and remind himself that he did not need to respond to it.  

This is a part of what it means to “take every thought captive.”

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Filed under christian psychology, counseling, Mindfulness, Psychology

The grace of restriction?


I admit it, I hate restrictions. I like the freedom to do what I want. When someone tells me I can’t do something, I want to do it all the more. Have you ever wanted to NOT “keep off the grass” just because the sign was there? Or, have you thought you should be able to handle saying no to a great temptation all by yourself?

In working with men who have done things that have caused their loved ones or church community to trust them less, I sometimes see significant push back when it comes to natural consequences or restrictions put in place to protect the man from himself.  These push backs come in the form of

  • But I said I was sorry. Why won’t you forgive me?
  • You don’t believe in grace. If you did you wouldn’t keep me from having free access to the church (said by a convicted sex offender)
  • I shouldn’t have to have someone checking up on me or controlling my Internet access. If I don’t control myself and say no, then I’ll never learn to do it myself.

This last one is a bit murky. On the surface, the man is accurate. If he doesn’t learn to manage his own impulses, the moment he isn’t under restriction, he’s likely to act out. But here is the deeper issue. He doesn’t want restrictions because he sees them as painful reminders of his past transgressions.

Let me suggest that grace comes in the form of limits and restrictions. A man who abused his power as public school teacher and sexualized a child has served his time. He loves children and “only” offended once. He wants to work with kids in his church and is angry that the church has said no. “But I’m gifted with helping troubled children and I’ve had 15 years of great reports and plenty of parents who tell me they would trust me with their children. Why can’t I do what God made me to do?”

Now, there may be some explanation as to how this man might not ever be a threat again. And yet, might he also realize that restrictions from certain populations of people might actually be a grace to him–a freedom from temptation, from deception, from stresses that formerly led him down a path of fantasy and rumination about being a hero to children?

I haven’t worked this out fully in my head but I do think there can be much grace in restriction. I certainly see my children receiving a grace from not being allowed to watch certain shows or have unfiltered Internet access.

What grace have you received from a restriction? Was it both a blessing and a suffering?

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Filed under christian psychology, Christianity, counseling, deception, Psychology