Category Archives: Uncategorized

January 12, 2017 · 5:43 am

PTSD: A New Theory? An Old Treatment


Researchers Liberzon and Abelson at the University of Michigan have published an essay articulating a new way of conceptualizing what is happening in the brains of those with Posttraumatic Stress Disorder. While you can’t read their essay for free, you can read this good summary here.

What is their new theory? the neurobiological problem of PTSD is “disrupted context processing.” In simple terms, I fail to respond to the “stimulus” in its proper context when I am triggered by old experiences in a new setting. Even more simply, when I wake up on full alert in the middle of the night after smelling wood-smoke in my sleep I initially fail to recognize the context (my neighbor burns wood) and immediately think my house is on fire (as it once was). Thankfully, the alertness is less than it used to be and I don’t always get up to check on my house.

The authors suggest that 3 separate and current brain models are inadequate in their scope of understanding the brain’s activities in PTSD. From their perspective the “fear model” (Fight/flight learning), the “overactive threat detection model” and the “executive functioning model” work best when integrated into one unified theory with their new label. And, in true humble researcher fashion, they request help in testing this model to see if indeed it can carry the freight.

An Old But Essential Treatment?

It is good to have a better handle on what is happening in the brain when someone experiences PTSD. Neurobiological research is growing by leaps and bounds. It is hard, frankly, to keep up. And yet, let us not forget an old but essential part of PTSD treatment, the person of the therapist. Humans are designed to be in relationship. PTSD has a way of shattering connections with others and thus the treatment must reverse the disconnect. Being present and bearing witness to trauma will always be the first and primary intervention every therapist must learn. Our temptation is that we want to move beyond the bearing witness phase into change phases. While this is understandable (we want others to get better as fast as possible), we sometimes want this for our own reasons–to avoid the pain we experience in sitting with traumatic experiences of others.

Let us remember that we therapists (and pastors, friends, etc.) are the primary intervention when we are present with those who suffer, when we become a student of their suffering. All other treatment activities stem from this foundation. To use a different analogy, consider Dr. Diane Langberg’s meditation, “Translators for God” (Day 26 of In our Lives First). In this meditation she describes the experience of being translated in a seminar. The translator must fully understand both languages in order to accurately communicate the speaker’s words into the heart language of the hearers. Counselors are translators for God and for healing. And yet, if they do not deeply learn the heart language (pain and trauma experience) of the client, they will not be able to connect the client to healing and to the God who heals.

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January 7, 2017 · 2:05 pm

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

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December 24, 2016 · 8:00 am

Your lack of self-care harms others, so what are you going to do about it?


Advent and the end of the year provide opportunities for some self-reflection in preparation for the start of the coming year. So…how are you doing? Are you taking care of yourself? This is especially important if you are a service provider such as a counselor or caregiver. 

Last October, a meta analysis of healthcare providers’ self-care (or lack thereof) and its relationship to quality of service indicates a clear negative relationship: lack of self-care leads to great likelihood of harm to patients. 

Eighty-two studies including 210,669 healthcare providers were included. Statistically significant negative relationships emerged between burnout and quality (r = −0.26, 95 % CI [−0.29, −0.23]) and safety (r = −0.23, 95 % CI [−0.28, −0.17]). In both cases, the negative relationship implied that greater burnout among healthcare providers was associated with poorer-quality healthcare and reduced safety for patients. 

What is even more telling is that patients can tell and do perceive when we are burned out. You think your bitterness, your lack of sleep, your losing your first love of helping isn’t showing? It is. 

Now, there are many reasons why we don’t steward ourselves (hearts, bodies, and minds) well. Sometimes we are in systems that actively discourage taking care of the self. In Christian settings, focusing on the self doesn’t seem to comport with “being poured out like a drink offering.” Others of us never learned how. Still others struggle with guilt. How can I take care of me if others have less help than I do? Yet others don’t take time to pour back in to self because it isn’t comfortable. Serving others is easier and provides more immediate rewards.  

What is your reason? 

If you were going to do something on a consistent basis to recognize your need to be cared for, what would you do? For your spiritual needs? Professional growth? Physical needs? Relational needs? See if you can come up with one thing for each arena–things you can do on a consistent basis. For example, you might decide to read Diane Langberg’s daily devotional for the next 40 days, In Our Lives First, as a means to do something for both your ministry skills growth and spiritual vitality. 

Don’t over-think it. What is just one thing you can do (or stop doing if it isn’t helping) to make your self a bit more refreshed? 

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Filed under christian counseling, continuing education, Meditations, Uncategorized

December 16, 2016 · 11:15 pm

Over-confidence? Under-confidence? Assessing counselor tendencies


Every counselor desires to be effective, to handle client concerns and problems with competency. We do this work because we long to see others recover quickly and we do not want to get in the way of needed and desired growth. Early career counselors often feel out of their league and so seek out all the help they can get: supervision, books, essays, and peer-consultation. This is the proper way to learn and become better at our craft.

But what happens when we begin to feel competent and confident? Do we stop feeling needy? Stop seeking input? If we do stop pursuing growth and increased competency, skills and capacities will erode. We might think all is well, we’ve got this under control, but in reality we would enter dangerous territory. Imagine wanting to be an Olympic athlete and yet forgoing training.

Erosion happens.

So, should we want to feel less competent? No. The goal is not to feel ineffective nor to lack confidence in what we do. I would not want a second-guessing surgeon to operate on me. Rather, it is important to maintain regular (not obsessive!) self-examination and invitation to others to give you input and feedback.

For the possibly under-confident counselor:

Where do you feel you need help, are less competent than you would like? What are your common responses to that feeling? Who have you talked to about this problem? Where have you sought help? What continuing education have you completed? While it is good to get help to “know what to do” don’t forget that a large portion of therapeutic success is attributed to who you are in the session. Be sure to focus on your listening, and “bearing-witness” skills. Remember to be a student of the client.

For the possibly over-confident counselor:

Do you still have supervision? If not, why not? Look over your caseload. Who are you working with who you have not reviewed assessment, diagnosis and treatment plans with another (note: peer supervision can be done without revealing confidential or private information)? When was the last time you verbalized your case conceptualizations with a critical eye to the potential myopia that plagues us all? What continuing education have you completed that can revise and improve your skills?  While relationship-building skills are the most important, do not stop learning and growing in knowledge and understanding.

It is good to remember that  our skills WILL erode without attention, just like muscles with grow flabby without exercise. One such muscle for the Christian counselor is that of prayer. Consider your recent counseling activities and ask how prayer has fit into your work. Is it a perfunctory or an afterthought? Does is change depending on how you feel about your competency? What does it reveal about your therapeutic operating system (e.g., what is the source of power to change?)

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November 29, 2016 · 6:30 am

Finding hope in a hopeless world


The world has always been falling apart. Well, at least since Genesis 3. But there are times when we are far more aware of just how busted up we are in this world. This is one of those times. Those of us who work in the social services get a front-row seat at seeing individual, family, community, and society level brokenness.

Frankly, this vantage point tempts me to become cynical, skeptical, and in despair. Listen in on some of the thoughts we Christian counselors might have: people don’t change; leaders serve themselves; God doesn’t care… Out of this experiences, counselors may find themselves becoming complacent, settling for palliative care only (vs. recovery), or worse, using clients to sate their own appetites.

So, where do you find hope in an otherwise hopeless world?

Cynicism and skepticism illustrate conclusions we have made about our world. file-nov-28-5-16-13-pmThey illustrate that we have stopped looking for other data. Consider instead these three activities as a reminder and cultivator of the hope available to us:

  1. Waiting and lamenting. I’ve written on this quite a bit over the years. This post was my most recent, but this one and this one may be of use as well. You might wonder whether lamenting leads to more cynicism. But notice that the goal is to actively wait on God for an answer. When we lament in front of God we talk to him about the state of our soul or the state of the world. Waiting requires that we prepare to listen to God’s heart on these same things.
  2. Waiting and looking. This is the season of Advent, of remembering the birth of Jesus, the messiah. †Zechariah, the father of John the Baptist had stopped looking for God to show up. Who can blame him, God hadn’t seemed to show up for a mere 400 years or so. It took being struck silent by an angelic messenger to wake him from his disbelief. Where are you no longer looking for God’s hand in your life? In the world? Look to your present. Ask your friends to tell you where they notice God’s activity. Look to your future, imagine yourself as a child waiting eagerly for Christmas morning. Be like that child and keep talking to God, “Is it Christmas yet?” Look even to the past. See what God has done in your life in the past and let that remind you that he is at work in your present and future. Read Hebrews 11 as a reminder of God’s faithfulness to his people.
  3. Waiting and loving. While we wait, we are not passive! We move and act in love, even when it seems the good we do will not change the outcome. That loving may be acts of palliative care, or it may be an act of planting a dormant seed that one day springs to life and full bloom. This act of loving others grows out of Jeremiah’s lament (Lam 3:21f): because of the Lord’s great love we are not consumed. Therefore we recognize that our minuscule capacity to love, to care, even to call others to repentance are all signposts of God’s ongoing love for his people.

Is it crazy to hope in this world? Absolutely. But the signs of birth are around you if you look. Notice in Luke 1 how Zechariah sings of present-tense salvation and redemption, even though Jesus is merely in utero. How much more ought we to be able to hope as we live in the age of the Resurrection.†

†I got these ideas from a sermon preached by Marc Davis on 11/27/16.

 

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November 21, 2016 · 6:00 am

Lament During Thanksgiving?


First published November 2013 at www.biblical.edu, this continues to be my primary experience today and so I offer you it again, slightly revised.

Thanksgiving is that time of year when we get together with family to enjoy good food, maybe a football game, and to be thankful for God’s provision during the past year. Sometimes, though, we don’t feel all that thankful. Yes, we recognize that God indeed has given us many good things, things like food, water, salary, housing, and the like. We acknowledge that we have no rights to demand these things. We acknowledge that there are many who are far worse off. Given recent events, we can imagine how much more blessed we are than those who refugees from civil wars in the Middle East.

And yet, despite our knowledge of grace and mercy, there are times when all we notice are the broken things in our lives—our bodies, our families, our communities.

I confess this is my state this Thanksgiving. I won’t bore you with the details but I struggle to stay focused on the many good things God has given me.

But it might surprise you that though I am noticing a lot of brokenness, I am not embittered or angry with God. I am full of lament. I lament the length of time it is taking God to act in some matters. I lament how much active and passive hatred for the other is present, even in there is in our Christian communities! Have we not lost love for those we consider outsiders? I lament that Jesus has not returned and ended death and suffering.

I am thankful for lament

Here’s what I am thankful for. We serve a God who has encouraged us to lament to him. Laments are cries of our heart where we question God (sometimes even accuse as in Psalmfile-nov-19-7-46-37-am 89), cry out for relief, ask for understanding, and grieve over sins done by self and others. Think about this for a moment: what King in all the earth not only invites such communication but even writes words for his subjects? He is not afraid of our questions or our complaints. Giving him such can be an act of worship.

Enter Isaiah 64. Isaiah is a book of confrontation of sin, call for holiness, prediction of judgment, and vision of restoration. In addition, we find windows of Isaiah’s lament for what is going to unfold for Israel. Listen to portions of his lament and some of my commentary:

Oh, that you would rend the heavens and come down, that the mountains would tremble before you! As when fire sets twigs ablaze and causes water to boil, come down to make your name known to your enemies and cause the nations to quake before you.

Ok Lord, act already. Do it! What are you waiting for?

But when we continued to sin against them [the vulnerable, the righteous], you were angry…all of us have become like one who is unclean, and all our righteous acts are like filthy rags…no one calls on your name…you have hidden your face from us and made us waste away because of our sins.

We so deserve your wrath Lord, but we are wasting away here Lord, if you don’t help us!

Yet, O Lord, you are our Father, we are the clay, you are the potter; we are all the work of your hand. Do not be angry beyond measure O Lord…Oh, look upon us, we pray, for we are your people.

Lord, we know you are our creator. We deserve no special recognition. Yet, remember we are your image bearers. Oh Lord, shape us, don’t destroy us.

Thankful I can vacillate?

Notice how Isaiah 64 and other laments (e.g., Psalm 42-43; Habakkuk, the book of Lamentations) bounce between recalling God’s goodness, questioning his plans, grieving own sin, yet imploring God to vindicate. Are these writers wishy-washy?

I don’t think so. Too often we think the best theology is all neat and tidy:

Problem + Victorious God = No Problem

While this will be true one day, it isn’t yet. And so we lament in vacillating and non-linear ways. Even as we proclaim God’s sovereign power, we also acknowledge that we are in great turmoil. These laments give us examples of how to hold on to our faith even as we have no answer for the moment. We are not required to end on a happy note. Look back at Psalms 42-3. See how the Psalmist cries out in despair, recalls better times, enjoins himself to hope in God, but then again remembers that he is great pain. Notice that neither Lamentations nor Habakkuk end in victory for the “good guys.” Lamentations, like Isaiah 64, ends with a question mark—“if you haven’t forgotten us already?” Habakkuk acknowledges the victory of being able to praise God in a terrible famine, but that doesn’t remove suffering or the reason for the lament in the first place (ongoing sin by Israel and her destruction by a pagan nation).

So, I’m thankful this season that we worship a great God capable of holding our laments and recording our tears. I am thankful that I do not have to pretend all is well for fear God will strike me down. He knows my pain. He has suffered in every way and so is a High Priest who can relate to my feelings of abandonment. And he is working for our future Good. But for now, I can lament that it (victory) hasn’t arrived in its fullest form and take comfort in a more realistic equation:

Problem + Presence of God = I Lament and am Not Alone

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November 16, 2016 · 10:00 am

What is more important to your church when it fails abuse victims? Gospel-driven behavior or reducing liability


Over the years I have had the opportunity to walk with church leaders through the difficult waters of abuse, whether done by leaders or done by congregants. One of the first conversations I try to have with those tasked with responding to the situation is this: What core values do you want to shape your response? Another way of saying this could be, “At the end of the day, who do you want to be, who do you think Christ calls you to be?

These values do not tell you what to do. They do not give you steps. But, they will help evaluate if a particular response is moving towards or away from those values.

If we don’t start at this point, then a couple of other values will control the conversation and control the decision-making: limiting legal liability, damage control, reputation management, and the like. These are understandable but do not comport with Gospel-driven responses to abuse.

Consider this fictional case.

A decade earlier a youth pastor is caught engaging in sexual activity with a teen. The church does not name it at sexual abuse and allows the youth pastor to leave and does not tell the congregation why he left. All this was done for complex reasons: lack of understanding of the gravity of the situation, desires to protect the victim (requested by the parents), and desires to protect their own identity. Years later, it is discovered the youth pastor has gone on to abuse more children in two other settings. Through a variety of reasons, the church is confronted for its failure to handle the situation properly. They are publicly accused of misconduct. The leadership of the church calls their attorney and their insurance company and get the strong advice to not admit any wrongdoing. Instead they are to make a bland statement and initiate an internal investigation (some of the leaders now were not there ten years ago). The report is issued some time later with policy changes made public. While it reveals “mistakes were made” by one of the leaders no longer present, it offers regret but falls short of an apology or indication that the church bore any responsibility for the subsequent abuse experiences.

What core values shaped the church’s response?

What would a church response look like if shaped by deep apology and behavioral repentance? What would it look like if the church considered the plight of the victims and their needs? Would they feel a responsibility to support their recovery? What if they cared more for kingdom values more than worrying whether they would be sued?

Sometimes, times of trouble reveal which god we really serve the most. And sometimes it is not very pretty.

It doesn’t always go badly. I do know a number of churches who opened themselves up to increased liability in order to speak truth about their failures. Take heart. It is possible!

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November 7, 2016 · 6:56 pm

Election Anxiety after November 8?


In a little more than 24 hours we should learn the identity of our next President of the United States (We hope; recall the hanging chads and drama of the 2000 election). And we hope we will be able to take a collective sigh and return to daily life without being bombarded by attack ads and new revelations about the character (or lack thereof) of the candidates.

It has, by every account, been an especially long and  difficult election season. We are tired. We want it over. But will the angst really disappear on Wednesday?

Probably not. But maybe you can do something about your own anxiety and distress.

  1. Detach from social media.
  2. Engage in a face-to-face conversation with a person about their history and future. Find out what excites or energizes them.
  3. Detach from the faux breaking news sites. If you want to look, look to stories that have depth of reporting and which avoid clickbait titles.
  4. Engage other important stories of our day, both here and beyond our borders.

Remember, your true safety does not come from a president or a king. Your future is truly in God’s hands. Do talk to him about your angst. Do ask him to intervene. But also listen and look for evidence that God’s kingdom is expanding. Look for where he has placed you “for such a time as this.”

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November 2, 2016 · 12:18 pm

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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October 28, 2016 · 1:28 pm

Does your counselor have these two important skills? 


I love working with counselors-in-training. We get to discuss everything from diagnoses to interventions, ethics to theology, character development to politics. I know I’m biased but along with the population of Lake Wobegon, our students “are all above average.” 

That said, there are two extremely difficult counseling skills every student needs to learn–frequently the hard way. To be an effective counselor, you have to be able to conceptualize a person and their presenting problems well (e.g., wrong assessment leads to wrong treatment) and you have to maintain a clinical alliance throughout the course of treatment. Of course, a counselor needs to be of good and mature character. She needs to have a bank of excellent questions to ask, a knowledge of common intervention strategies, and a good ear to hear what the client is trying to express. These things are necessary foundations for the skill of conceptualization and alliance.

Conceptualization

When you come to counseling to discuss a challenge in your life you want the counselor to be able to understand and put your situation into proper perspective. You expect them to have some expertise beyond your own–otherwise why go? As you tell your story, it always has missing and disjointed parts. There are dead ends and mysteries that may start out feeling important that in time become less a focus than other issues. Your counselor needs to put the problems you raise into some context. What lens to view the problems should be used? 

  • Is the conflict between a mother and teen best understood by the lens of enmeshment, Attention-Deficit, autism, sinful pride, depression, anxiety, rebellion or…?
  • Is the conflict between a husband and wife best understood as lack of knowledge, demandingness, personality disorder, emotional abuse, etc.

An effective counselor uses multiple lenses to view his counselee and holds those lenses loosely in recognition that first impressions need refinement. 

Do you feel heard or pigeon-holed by your therapist? Does your therapist discuss possible ways to look at the problem you have and thus different ways to approach solutions? 

Alliance

Alliance is a hard thing to describe but it encompasses a trust relationship where therapist and client work in concert to explore and resolve a problem. There is agreement on the problem definition and the process of therapy.  There are several things that seem to be part of this concept but fall in two key categories: techniques and stance. A good therapist asks great questions that enable a person to feel heard as they tell their story. A good therapist validates the person even if they do not agree with interpretations of the client. A good therapist makes sure that the client knows they are more than the sum total of their problems. Finally, a good therapist checks in with a client to find out how they are experiencing the therapy session and approach. But good questions and feedback are not the full picture of alliance. The therapist needs a stance that reflects being a student of the person; of collaboration over action. It reflects an understanding of pacing and the client’s capacity to process information.  

A counselor can understand a problem but if they rush ahead or lag behind in pacing, the alliance will fail. Consider this example. Therapist A meets with a client with a domestic violence victimization problem. It is clear to the therapist that the client needs to move out and that the client is resistant to this idea. The clinician presses the client to leave and challenges her to see her husband as an abuser. While the counselor may be correct, the confrontive and authoritative stance is unlikely to bear much fruit and will either create defensiveness or passivity in sessions. One sure sign of poor alliance is when a therapist is constantly thinking about how to get his or her client to do something. 

Meanwhile, Therapist B meets with the same client and explores the ambivalence she has towards her husband and the abuse. Options are discussed, less for movement sake and more for examination of fears and opportunities, hopes and despair. Both therapists have the same sets of good questions, but one is more aware of the pacing of the client and meets her where she is where the other one forces a pace the client is not ready to match. This does not mean a counselor never pushes a client but it does mean they never do that without the understanding and agreement of the client. 

Alliance is not a static feature. It grows and shrinks during the course of a relationship. There are ruptures and hopefully repairs. Sometimes a rupture leads to an even stronger alliance if the repair leaves the client feeling cared for and respected. Ruptures are not always caused by the counselor but it is the counselor’s job to notice and to work to resolve. 

Do you feel like you are on the same page with your therapist? Do you have evidence (not just fears) that your counselor is frustrated by you? When you have a “miss” in a session, does your therapist acknowledge it and talk about how you are feeling about therapy? If you bring up an rupture, are you listened to? 

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