Category Archives: Uncategorized

May 11, 2010 · 10:12 am

Changing Your Narrative in Counseling?


If you have gone to counseling, then you probably wanted something to change in you or something connected to your life. If you have counseled someone or been their wise friend, you also wanted something to change. There are a variety of ways to try to calculate or observe change. Is there a reduction of unwanted behavior or an increase of hoped for behavior? Is there a change in affective or perceptual change (i.e., do I feel better or have more hope?)? Is there more insight? More acceptance of what cannot be changed? Greater responsibility taking for what can be changed? Is there greater congruence between faith and practice, head and heart?

While everyone (counselor, counselee, insurance company) wants objective evidence of positive change to prove that counseling was worth the cost and effort, the most powerful and most valuable change gets little attention. What is that change? Script or narrative change. We all live by a storyline. We use that story line to make sense of our world and of ourselves. However realistic we think we are, we never really use all the data to determine our reality. Rather, we use scripts to fill in blanks and supply us with the “truth.” Don’t think this is true? Just examine the common fights of a couple. Most likely you can remove the content of the fight and you will find an enduring pattern of feelings and perceptions about self and other in each spouse.

How did we get these scripts? We have experiences of self in the world? We make interpretations of what we experience. Others communicate interpretations for us. But we are not blank slates, we come to these experiences with a distorted imago dei–a God-given image and agency that is both active and yet distorted due to Sin.

So, how does counseling change a script or life narrative? There are a couple of options. You can begin with behavior change. Changes in behavior may cause someone to re-evaluate view of self and other. For example, a person may move from “I can’t” to “I can” based on the evidence in behavior change. You can begin with insight. What is my dominant life narrative and is that really accurate or is there a better one to live by? You can begin with relationship. This form of intervention is less clear but probably more powerful than the first two. By focusing on the “here and now” you are having an impact on narrative as it plays out in the moment. In opposition to insight which pulls narratives apart, this form of intervention is predominantly an experience that shapes the narrative in a more implicit fashion. In other words, we realize the change sometime after the fact.

What you cannot do is exhort someone into a new script. When we try (and we do sure try: “Don’t be afraid of ____ …It isn’t that bad…”), we fail. Even if the counselee “buys” the new script, they have only listened to you say it. They have not yet written it on their heart. Passive acceptance ought not be mistaken for real change. In fact, sometimes hearing the needed change over and over only makes the person more resistant to it. A change in script must be practiced and owned for it to become real. That is why an addict may well become sober by accepting the limits imposed by others and still yet remain an addict at heart.

Narrative changes usually take time. It is possible for powerful experiences to create instant change in our view of self and other. Certainly conversion experiences are evidence of massive script changes. Many of us have had powerful “a-ha” moments that also change our perception of self and the world. But most of our script changes happen via the drip method–water dripping on rock does indeed make changes when viewed over the long haul. When we look back on our lives, we often note places where we have indeed changed–sometimes for the better, sometimes not.

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For more on intervention points in counseling, check out this post I wrote 2 years ago. I tried my hand at illustrating both the script and the intervention points.

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May 7, 2010 · 11:23 am

Decisions by the numbers or by the gut?


We all make decisions every day. And most of us like to think that our decisions are based on adequate data. We consider going to college or grad school. Which school has the best degree, best profs? Which will give be the best options post graduation? We consider getting married. Will ____ be a good spouse? We consider buying a car. Should I buy a Toyota because their history of longevity and safety are well documented or do I skip them because of the gas pedal situation? We consider which counselor to use for our problems. Do I choose a christian or someone who is board certified (I know, I know, they can be both)?

We make decisions all the time but they are NEVER based on enough data. This is where faith or our gut is involved. For example, I didn’t know my wife would be the best wife to have. Well, I’ll tell you I did but I didn’t.

What I am aware of is how we have so much more data available to us these days to make our decisions. At times, the data can be helpful but it can also deceive us into thinking that we have more control over the outcome.

Consider these counseling related examples:

1. Home Sleep study devices. I saw an ad for a radio alarm clock sized device that records your time to sleep, your REM time, your number of awakenings and your wake point. Assuming the device works, you can really track your sleep in a much more accurate way (rather than just going by how it felt). There might be some benefit to this, especially if it helped you be more consistent in your bedtime rituals. But, data doesn’t stop anxiety nor does it alter sleep apnea.

2. Scales. I have a new scale at home that gives me all sorts of data. So, I weigh myself more frequently just to see what changes. Of course, it has yet to change my eating habits nor really tell me much that I didn’t already know.

3. Pop Psych treatments. I suppose some will challenge me here on this category. But there are a number of popular forms of treatments or assessments out there that purport to pinpoint your problem, remove your problem, or illustrate the healing you just received. Each of these forms of treatment have stories, anecdotes, even statistical data. But few have been researched in controlled studies. So, the data may be accurate and yet meaningless to you at the same time. These interventions may well be useful but often the promise outstrips what is really known at the present time.

I might sound like I’m down on data. I’m not at all. We have some wonderful tools now to track information. Data can give us direction. But, in the end, we have to decide and there are other kinds of “data” that we use to make these decisions: feelings, recent experiences (our own or others), first reactions, amount of energy, hope, etc. Let us not deceive ourselves that we truly live by the numbers.

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May 6, 2010 · 11:28 am

What to say to suffering people: When truth isn’t helpful


Is the truth always helpful? Always the best option?

I think it is. But when we humans seek to convey truth, we never capture it all. As a result, what truth we do share may not be the truth that is most helpful. There are two things that have me thinking about this today:

1. On Monday night I shared with a class some of our experience with infertility. Some things said to us were downright stupid and wrong. Other things were true. In fact, God does have a wonderful plan for us. But it wasn’t helpful to tell us that when we were hurting. Scripture teaches us that when we sing songs of joy to the downcast it is like drinking vinegar or adding baking soda to it. Kaboom!

2. In recent weeks, CCEF has posted a couple of things on their website that need to be read together. This week they posted David Powlison and John Piper’s “Don’t Waste Your Cancer” to their homepage. This was written by both men when they were in the throes of Prostate cancer. I encourage you to read it from the perspective I am reading it. My wife has breast cancer. We hope to beat it. But we are in the throes of chemo right now. How does this sound to you. True? Helpful? Now, when you have read that, go read Ed Welch’s post: “What Not To Say To Suffering People.” He wrote a follow-up here.  How does this sound to you? True? Helpful?

Seems the first could be seriously misused and does not address all of what you say for comfort in the heat of the battle. Surely we need to be a bit careful about what the person needs to hear. Yes, we can “waste” the cancer in a “woe is me” mentality. But be careful not to go there too quickly! Know your audience and what they need NOW from you.

What do you think? I’d like your feedback.

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May 5, 2010 · 5:56 am

Summer Counseling Courses


Want to learn more about counseling this summer? Are you in ministry and want to sharpen your skills? Already a licensed mental health provider and need CEUs*? Want to explore…

  • How to counsel people diagnosed with Borderline Personality Disorder?
  • How to help those diagnosed with a chronic condition?
  • How to use the Old Testament better in counseling?
  • How to better understand and evaluate the major models of counseling?

Just a reminder that this summer Biblical is offering 4 electives for students, alum and any auditors who might find the topics of interest. The first three of the four courses are only one credit and delivered in a weekend formats(Friday night and Saturday) with some pre-class reading/assignments. The fourth is a two credit course delivered in a completely on-line format.

For information about each of these course, the professors, the costs, and how to apply, click this link. It will take you to the Biblical website and a PDF of our flyer.

* Note: For those seeking CEUs, there are two ways you may be able to count them as fulfillment of your licensure requirements. Biblical Seminary is an accredited graduate institution and these courses are offered as graduate education in counseling and psychology. Most mental health licensure bodies accept graduate courses (shown on a transcript) as meeting the requirements for approved CE providers. You will need to check with your board to see if that applies to you. Second, we have applied for CE provider status for my class (Borderline Personality Disorder) from the State Board of Social Work, Marriage & Family Therapy, & Professional Counseling. If approved, we will be able to provide licensed attendees with 9 clock hours at the cost of ONLY $175.

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May 4, 2010 · 10:47 am

Clicking with your counselee


In every first session with a client I tell them that part of their job is evaluate whether I am the right therapist for them. While it is very important that your counselor is well-trained, if you don’t click with your counselor, the work you are trying to do will be much harder. Now, of course it often takes a few sessions to determine whether you can form a trusting, collaborative relationship or not.

I am always thankful when a client is willing to raise the “fit” problem with me. It gives us an opportunity to explore the disconnect, fix it if possible or happily refer to someone else. Too frequently disconnected clients choose to either keep plugging away (but being less and less vulnerable) or just fade away and you never know what went wrong.

But what if the counselor doesn’t connect with the client…and the client doesn’t know it? What should the counselor do?

1. Use supervision or consultation to explore the disconnect. Maybe the disconnect will reveal something useful about the counselee. Maybe it will reveal some pride or prejudice in the counselor. Maybe it will reveal some naiveté or lack of competency or empathy or conflict over goals. Or, maybe it will reveal some cultural differentness that is really hard to overcome.

2. Assess whether or not (again using supervision) whether progress is being made. Is the counselee growing in insight? Gaining control? Showing more fruits of the Spirit? Seeing a decrease in anxiety or depression? The counselor may need to reassess their goals for the client.

3. Consider attempting more “here and now” to explore what is going on in the relationship between counselor and counselee. HOWEVER, do not do this to tell them how you are feeling NOR to be condescending. This action is designed to help both of you to be more present and decrease disconnection.

4. If all else fails, refer. This would be appropriate if (a) you believe you are not competent to help them or impaired in some way (and you should communicate your lack–in a limited way–to the client when discussing referral), or (b) you believe the problem is that counseling is harmful (and again you should discuss why you think this way and what the options might look like for them. Remember to avoid abandoning them. Referrals are specific, take time, and are for their best interest, not yours.

The bottom line is that the onus is on the counselor to work through the disconnect and to do all that he or she can to fix the problem or to tolerate it if the client is making good progress. This is what it means to “love one another.” We fail to do so if we either ignore the problem or use the disconnect to get rid of counselees that do not feed our egos.

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April 28, 2010 · 9:15 am

Should you Google your clients?


Dr. Zur has a new blog post on this topic that raises question (no answers at this point). Should you Google your clients? Dr. Zur wants to consider the ethics of this. There are two ways to try to explore this topic from an ethical point of view.

  1. What do the ethics codes say? Codes say nothing directly about this. Indirectly, we are to work to protect their dignity and human freedom. We are to act beneficently. We are to seek consent before we provide treatment or access private and protected information. We are not to give out their information without consent. Questions to ask: oes googling a client risk revealing their identity to others? It might if you use a shared computer. Would Googling access private and protected information? It shouldn’t. However, many people blog and post private information that might shock them if others in their various circles found out. Many do not consider this when posting comments or personal information.
  2. Beyond the codes, is it good practice to search for information about your clients? Or put another way, how might searching for information about your clients cause harm? Might it change the relationship? Change your opinion of them? Make you less interested in helping them? What if the information you find isn’t accurate? Might it cause you to use that information in a coercive manner? Might it be used to practice a form of voyeurism (which is a form of using clients for our own pleasure)? These kinds of questions raise moral and theoretical issues as much as ethical ones.

Dr. Zur lists a number of vignettes that might well cause you to answer yes to our initial question. Googling might reveal safety issues, legal issues, even life issues that would be helpful to know. So, our answer will never be that it is unethical.

I would leave you with this question. How will you feel if your clients know you have googled them? Will you be embarrassed? If so, you ought not to do it. Similarly, if a client comes in knowing lots of things about you that they gleaned from the Internet (work history, family, etc.), do you feel stalked? Maybe we should consider the “Do unto others…” command here.

One last pragmatic point. It is sometimes possible today to find out who is Googling you. Keep that in mind as you think about this issue.

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April 26, 2010 · 7:46 pm

First session requirements?


Today marks the third week of my Practicum and Professional Orientation class. This is the first opportunity for many of my students to begin live counseling experiences in their Practicum settings. Most seem to be settling in nicely.

If you have been a green counselor in your first session then you know the terror of: “What will they say???? What will I say????” It doesn’t matter if you have a 10 year file on the client or a 1 sentence “presenting problem”, the green counselor cannot predict the outcome of the session–hence the fear.

To alleviate some of the fear, let’s review what makes for a good first session.

1. Introductions. Make sure they know who you are and who is supervising you. Give them a chance to tell you why they are coming for counseling. Sometimes what they say differs from what they wrote on the forms.

2. Help the client tell their story without too much interruption. Don’t be too quick to jump in and direct with too many questions.

3. Gathering the following data (again, without too much interruption):

  • content and scope of problem (frequency, duration, intensity)
  • solutions attempted, things that help/harm, prior counseling attempts
  • current family/community make-up
  • other mental illness
  • relevant medical history, current meds, sleep quality
  • substance abuse
  • spiritual dynamics
  • supports, strengths
  • typical mood, suicidality
  • Other important factors (employment, finances, relational conflicts, etc)
  • dreams, hopes, goals

4. Summarize (briefly) and discuss possible initial directions or goals as well as alternatives they may wish to consider

5. Counseling model and nuts and bolts of professional care (confidentiality limits, scheduling, contacting you, payment options, etc.)

That will be more than enough for an hour. Most likely, you get great data in some areas and just a tad in others that will require you to follow-up in the next week. The more talkative the client is, the less data you can gather. The less talkative, the more likely you will get the data but the less likely you’ll form a good connection (Q & A leads to very passive clients more often than not).

It is good to have these very general categories in mind as you start that first session. Be wary of either forgetting the categories or obsessively forcing the client to answer all the history questions. You may end up with a wonderful piece of history for a client who never returns.

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April 22, 2010 · 5:23 pm

Staff Mtg on Prolonged Exposure treatment for PTSD


Had a fabulous staff meeting at our practice today given by fellow colleague, Marta MacDougall. Marta also works at the Philadelphia area VA. She presented an overview of Edna Foa’s Prolonged Exposure Therapy for PTSD. You can find the book here.

PE looks at trauma this way: PTSD is maintained by avoidance behaviors. One avoids memories, triggers, emotions, places of traumatic experiences. While avoidance works in the short-term, it exacerbates the symptoms over the long haul since they are not fully processed. In fact, the better able one can avoid these feelings, the more likely their PTSD will be worse later. Hence why you can have some very functional people become unable to function later in life. She used this illustration. For many Vietnam Vets, Vietnam is part of a book they keep trying not to read. They shove it away over and over but it has a habit of falling off the shelf and opening to the same page, even the same couple of very painful sentences. Thus, despite their attempt to avoid, the only thing they keep rereading is the same couple of sentences; thereby reinforcing and even rewriting the whole experience as if it were only those two sentences.

Thus, the goal is break the “phobic reaction” to painful thoughts and feelings. How? By two prongs: (a) imaginal exposure (memory encounters), and (b) in-vivo exposure to avoidant stuff in the present.

The therapy consists of 12-20 sessions (1.5 to 2 hours each). In the sessions, the person develops a current list of avoidance in their life  or other subtle safety behaviors. They begin to daily pick easy to hard avoidant tendencies to expose themself to in order to break the fear pattern. Now, these are things that aren’t actually dangerous. Second, in session 3 they begin to recount the most salient trauma from the point in the story where they were safe to unsafe to safe again. So, it could be a story of waking up to a rape, going out for a particular traumatic battle, etc.). This portion of the story may only take 5-10 minutes to recount. That same memory is recounted, in the first person with eyes shut, repeatedly for up to 45 minutes. During the exposure, the therapist asks for their subjective units of distress level (0-100) every five minutes. This exposure to the same memory is repeated in each session with time to talk about and process at the end. The levels of distress are tracked over time (both from imaginal and in-vivo exposure experiences. On top the therapy intervention, the in office imaginal exposure experience is recorded and the client is to listen daily to that recording.

Sound like torture to you? It does to me. Here’s the reaction rationale. The avoidance of memories and emotions tied to them is causes even greater distress. Thus, getting the client to face that distress and process the emotions as well as uncover subtle lies believed about self and other is only dealing with reality directly.

You can imagine that many refuse this kind of therapy. Those who do it…about 80% see a significant reduction in PTSD.

Not sure I’m going to begin doing this kind of therapy as I’m not set up for it being in the office only 1 day per week. However, I will pay more attention to the ways avoidance behaviors or safety seeking behaviors accentuates PTSD and will be more likely to give daily homework to address this problem.

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April 19, 2010 · 6:06 pm

How perspective changes everything


“Your wife has breast cancer…She’ll need chemotherapy.”

The first time you hear that, you only feel the blow of a seeming death sentence. You see your future as a widower flash before your eyes. Doesn’t everyone die who is diagnosed? No. But the anecdotes we carry would say so since we remember the awful stories and forget the great outcomes. You cry and ask God for a different story, a different outcome. Let the diagnosis be wrong.

It isn’t. And so you begin to accept the facts of breast cancer and learn what your story contains. You learn some people have wonderful post diagnosis stories and others have painful stories. You wait for confirmation. You talk with doctors, get the scans done and then talk some more.

After surgeries, scans, and appointments, you begin to accept the chemo path. But, you want a second opinion to be sure. Now, instead of praying for no cancer, you pray for the 2nd Doc to give you clear advice–either to confirm the first doc’s advice or to give something so clear that you know that one of the paths is so obviously right for you.

The second doc confirms every piece of advice the first doc recommends. You have consensus. Funny thing, when you hear that chemo is your best option, you are happy and relieved–not because chemo makes you happy but that it really does seem like the best option. Notice the much different response from the first mention of those words less than 2 months ago.

Perspective sure changes how you hear words. Now, instead of a death sentence, it is a way to work towards a cure. Odd, don’t you think. Yes, but also an answer to prayer.

I suspect many of us have a story like this. Initially we can’t believe what we are hearing. Later, we hear it completely differently based on the things we learn, the options we see before us, and a whole lot of prayer.

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March 26, 2010 · 9:00 am

Life as a preacher’s wife? book notes


I received a free copy of You Can Still Wear Cute Shoes: And Other Unlikely Great Advice from An Unlikely Preacher’s Wife from the publisher (David C Cook, 2010). The author is Lisa McKay. You can find her at http://www.apreacherswife.com.

Since there are few books out there for pastor’s wives, I decide to check it out. Right out of the starting blocks, Lisa addresses two common concerns:

1. Is his calling my calling too? I’ve heard a number of pastor’s wives who appreciate their husband’s ministry calling but do not own it for themselves. Others do. Is this essential?

2. Appearances. What are the pressures for appearing as a pastor’s wife? Can I be me?

To the first issue, she says one of the reasons is this (quoting another pastor’s wife): “The hardest thing for me is everyone wanting a piece of my husband and not acknowledging me in the least…I feel like the person in the background who is here only to take care of the kids so he can be free to take care of everyone else.” (p. 24). Lisa goes on to articulate through story and verse that the wife is called too. Don’t get hung up in the how but that the calling, at a minimum includes trust, obedience to Christ, and hope. To the second issue, no you don’t have to wear doilies. Be more concerned with cultivating Godly character.

The books won’t knock your socks off with new ideas. However, Lisa does a great job identifying the key challenges pastor’s wives face, pointing them to Scripture, focusing on simple truthes and being wary of the stuff that can build up inside her heart. She covers everything from parenting to having friends in the church to not defending pastor husbands (not having hissy fits in the church). This is an easy read and a good reminder for all on how to live under pressure.

Her final chapter is written for the pastor. My only disappointment in this book is that she didn’t triple the length of this chapter and really speak boldly to pastors about their care of their wives.

One great aspect of the book is that she includes so many quotes from other wives and application questions at the end of each chapter for the reader to consider.  On top of that, she’s quite humorous. No bitter pastor’s wife here!

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