March 20, 2008 · 4:59 pm

The thirst for leadership…of any kind


Grading papers from class and one student illustrated her point by including this quotation from The American President. Not a movie I’ve seen but like this little piece:

President’s Aid (Michael J. Fox): People want leadership, Mr. President, and in the absence of genuine leadership, they’ll listen to anyone who steps up to the microphone. They want leadership. They’re so thirsty for it they’ll crawl through the desert toward a mirage, and when they discover there’s no water, they’ll drink the sand.

President: …People don’t drink the sand because they’re thirsty. They drink the sand because they don’t know the difference.

Sounds just about right.

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March 19, 2008 · 10:01 am

Integrative Psychotherapy X: Schema interventions for depression


In the last chapter the authors theorized about our propensity to live out of socially constructed schemas. Now in chapter 9 of Integrative Psychotherapy, McMinn and Campbell apply schema-focused interventions (domain 2–dipping beneath symptoms to core issues) to the problem of depression. But before they get to that task, they make these 2 points:

1. It’s “incorrect and potentially dangerous” (p. 278) to assume one does symptom focused interventions with anxiety problems and deeper level interventions for depression. Instead, the therapist ought to move seamlessly between them as needed. They remind the reader that their chapters are illustrations and not manuals.
2. There are useful symptom based interventions for the problem of depression that should not be overlooked: (a) medications (they explore fallacies that keep people of faith from using them and point out that meds are sometimes better than counseling alone), (b) behavioral techniques (keeping an activity schedule, assertiveness training), and (c) cognitive restructuring (keeping a dysfunctional thought and challenge record).

At this point the authors begin to illustrate their version of schema-based interventions. Unlike classic interventions (diagnosing the underlying schema and then correcting it), they describe recursive schema activation which is designed to “give clients many opportunities, session after session, to decenter [see life from another perspective] from the deep, persistent themes of their lives that can never be fully obliterated” (p. 288-9). The main difference between the IP model and the classic model is their humility in seeing schemas as understood and managed rather than corrected. Also, they desire to activate and experience schemas as much as talk about them.

The goal of this part of IP is to stand apart from one’s schema so as to see it and choose to deactivate it where it is not helpful. In the case of depression, it means standing back from “depressogenic thoughts” using mindfulness and spiritual disciplines. The client doesn’t challenge thoughts so much as he or she activates the schema in counseling over and over in a manner that allows distance and the possible formation of a new schema or identity.

Just how does this work in therapy? McMinn and Campbell suggest these strategies:

1. Taking a life history to identify re-occurring themes that might signify the presence of maladaptive schematics (e.g., long history of feeling rejected by others). In taking the history, the client not only tells but re-experiences the schema with the counselor
2. Schema inventories. They mention one in particular: www.schematherapy.com. These are used to get the client thinking about schemas that contribute to their problems.
3. Discussion of faith. The therapist explores how the client’s view of God fits in their view of self. The assumption is that a maladaptive schema likely contains distortions of the character of God. The goal is to understand at this point, not correct.
4. Moving from specific to general. Clients often describe recent painful events (and thoughts and feelings). The therapist encourages the client to explore how these thoughts and feelings fit their general conclusions in life (e.g., people always leave me).
5. Looking for themes. The counselor looks to articulate and activate themes and creates space for the client to do the same.
6. Evoking emotions. The counselor needs to move from an intellectual discussion to the emotions attache to the schema. Often-times, this means using the here-and-now to explore emotions. Otherwise clients only report on feelings in a disconnected manner. If so, they remain disconnected from the insights they gather.
7. Guided discovery (vs. just telling the client the interpretations). The authors present a good illustration  of the difference between telling and collaboration on p. 298.
8. Imagery and meditation. The goal here is to use these techniques to activate and deactivate schemas. Why? They suggest these techniques support safety (to limit overwhelming oneself). They do note that while prayer may help in schema alteration its primary purpose is to connect with God and shouldn’t be thought of as some technique apart from its main purpose.

Finally, in the last 13 pages the authors take up how recursive schema activation is a bridge-building exercise. It bridges cognitive processes (logic, analysis) and emotional and relational processes; unconscious and conscious processes; past and present; events and meanings that we give them; schema activation and deactivation. They conclude that not every person has the psychological resources to deactivate schemas once activated and point the reader to the next two chapters where relationship interventions will need to be used.

MY THOUGHTS: This is a good chapter that describes what I think is core to therapy: self-observation in a safe environment that happens as much through experience as it does through logical analysis. The reality is that our schemas shape our sense of self and the world as much as our 5 senses do. We think we merely ascertain what is happening to us but in fact we are prepping our critical thinking with assumptions. Here’s my question. Is the schema something that can be changed. I hear the authors saying that they aren’t all that optimistic about it but just maybe we can control it, decide not to listen to it. In part I agree. And yet I don’t want to underestimate just how much a person can change their outlook on life and self. Where I think the biggest challenge lies is helping clients feel safe enough to accept that they make these assumptions. In couples counseling I find many/most couples unwilling to consider the possibility that their assumptions about their no-good spouse were formed before the ever met their spouse. They come wanting to fix the marriage and part of my job is to help them see that before they can fix the marriage they need to understand how their responses tell a lot about themselves and maybe less about their spouse than they think. This is hard for counselees to accept because it sounds to them that they are responsible for their spouse’s bad behavior. Helping a client not live in all/nothing thinking is my challenge. Further, I must make sure not to fall into “telling” mode when helping someone come to this realization. Sometimes I want to speed up the process and thereby lose the client.

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March 18, 2008 · 1:06 pm

Race matters: Obama’s speech in Philadephia


MSNBC provides this transcript of Obama’s speech today. As you likely know he is under fire for comments his pastor, Jeremiah Wright, made in sermons over the years. This speech is quite masterful as it rejects Wright’s characterizations but recognizes the reality that is behind his angry judgments about American politics, racism, injustice, and place in the world. He shows the parallel with white anger for being held accountable for the sins of our early fathers. In both cases, impolite speech is understandable but not helpful. He says,

Just as black anger often proved counterproductive, so have these white resentments distracted attention from the real culprits of the middle class squeeze

What should we do? He tells us to take responsibility for our lives, reject victim mentalities, insisting on justice for all, acknowledging the legacy of discrimination, rejecting cynicism, working together as opposed to for our own good alone. 

He’s right.  When we see hyperbole, we must acknowledge the truth at the center. Fact: we have been arrogant snobs in dealings with other countries. It shouldn’t surprise us that if we kick the dog, the dog bites back. Fact: The country wants equality as long as it doesn’t cost anything. We keep complaining, but until we all agree that my neighbor’s struggle is my own, we won’t see much change. 

He’s wrong.  Trying harder and being truthful about racial reconciliation progress is good, but it is not enough. Without the work of the Holy Spirit, the breaking of our pride, the demand that our individual identities take precedence over that of God’s humble servants, we’re not likely to make much more progress. Legislation helps curb our sin, but it does not stop the seed of racialization. Only the Cross does that. Isaiah’s prophecy is that God is going to discipline his people so that cannot put their trust in man–whether he is bad (e.g., Ahaz) or good (Hezekiah). He lays us bare then He brings us into Zion so that we know that it is His power and holiness that makes us his people.

One final note from his speech. See how he explains why he doesn’t reject a friend who has said stupid things. In my mind this is how we ought to talk about each other instead of throwing them under the bus in order to get what we want:

I can no more disown him than I can disown the black community. I can no more disown him than I can my white grandmother – a woman who helped raise me, a woman who sacrificed again and again for me, a woman who loves me as much as she loves anything in this world, but a woman who once confessed her fear of black men who passed by her on the street, and who on more than one occasion has uttered racial or ethnic stereotypes that made me cringe.

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March 17, 2008 · 4:11 pm

Signs of Spring at my House


One year ago, we had an ice storm that crushed my greenhouse. I’m itching to rebuild it (already made the skeleton of it out of PVC with my father). But I’m going to wait up bit longer. Until then, I’m looking for the signs of Spring, such as…

crocus.jpg

Meanwhile, my parents still have this (or most of this…) to contend with:

 maine-snow1a.jpg

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March 17, 2008 · 1:02 pm

Science Monday: Perpetrators have PTSD? New connections between attachment and PTSD


Unfortunately, many people experience violent or near death experiences. Some of those folks go on to have symptoms fitting the diagnosis of Posttraumatic Stress Disorder (PTSD): intrusive memories/flashbacks cause them to reexperience the event coupled with attempts to numb themselves in some way and yet still finding themselves in a heightened state of vigilance all of the time.

Since the Vietnam War, we’ve learned a lot about this set of problems. The primary forms of treatment touted now are controlled and imaginal exposure to the traumatic event(s) coupled with relaxation, distraction, and cognitive reframes. And we continue to learn about the presence of PTSD in violent family dynamics as mentioned last Monday (3/10/08).

But here are two articles pointing to somethings I hadn’t thought much about:

1. Perpetrators of violent crimes sometimes experience PTSD from their crimes. A group of English researchers did a study of 105 prisoners who had committed intentional violent crimes. 46% experienced distressing intrusive memories (one aspect of PTSD) and 6% met criteria for PTSD. The more antisocial the criminal before the crime, the less likely they would actually experience distressing intrusive memories. So, those who are most uncaring don’t really struggle with these problems. Here’s a question: should you try to help perpetrators with their distressing, intrusive memories? Does having them lead them to be less likely to re-victimize? Or do they make them more distressed, more hypervigilant and therefore more likely to attack?

Biblio: Evans et al. (2007). Intrusive memories in perpetrators of violent crimes: Emotions and cognitions. Journal of Consulting and Clinical Psychology, 75, 134-144.  

2.  Why is it that attachment literature and adult PTSD from child abuse literatures have been separate? Stovall-McClough & Cloitre of NYU ask this very question and review the literatures from each area. Attachment literatures come out of developmental theories while PTSD research tends to be CBT based. But the two are quite connected. Consider the authors points:

  • “As many as 48-85% of survivors of childhood abuse show a lifetime prevalence of PTSD…”
  • “As many as 80% of maltreated children [are] classified as [having a disorganized attachment pattern]…”
  • “…the theoretical mechanisms underlying the expression of both PTSD and [attachment problems], although developed separately, are notably similar.” How so? Both see powerful events stored in the mind that shape one’s sense of self and the world. Powerful and negative events are avoided in an “effort to contain the intensity of emotions triggered by attachment injuries or traumatic events
  • “When traumatic events are kept locked away or otherwise chronically avoided, the result is often long-term struggles with PTSD symptoms and ongoing fragmentation of memory and fear-related belief systems.” 
  • Both unresolved attachment problems and PTSD lead to dissociative and intrusive self-focused thought patterns
  • Unresolved childhood attachment problems (as opposed to secure or dismissing attachment styles) may predict PTSD in adults
  • Avoidance strategies which help the individual manage distress from the abuse may, in fact, increase emotional distress and cognitive disorganization. This is sad in that those best able to divorce themselves from those early experiences (which may protect them as a child) may set themselves up for the most pervasive PTSD. I suspect that avoidance strategies hinder the person from being able to carefully evaluate themselves in a clear and helpful manner. Thus at a later point when they can no longer avoid, they have little sense of self to use to understand their place in the world.

Biblio: Stovall-McClough & Cloitre (2006). Unresolved attachment, PTSD, and dissociation in women with childhood abuse histories. Journal of Consulting Psychology, 74, 219-228.

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March 14, 2008 · 12:15 pm

John Freeman’s story of God’s mercy


Several of the folks at HarvestUSA (see my sidebar for their site) have written pieces for the Philadelphia Daily News. My friend John’s piece was published most recently so click the link and read and rejoice in God’s redemptive power.

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March 14, 2008 · 12:06 pm

Note-taking in sessions?


Counselors have vastly differing styles of counseling. Some choose to be directive, others are remain passive even when the client wants them to give advice. We are different because of our varying theories and personalities. But I always assumed that most counselors do not take notes during sessions unless needing to record very specific details (say taking a family genogram or collecting details for a psychological report). But after having conversations in several different locations I learn that many write during the session. They write down key client phrases and other things that they wish to come back to and explore at a later date.

I’m curious about your experiences–either as a counselor or counselee. Was there note-taking going on during the session and was it helpful (for both)? Did it cause problems?

I don’t take notes in session so that I can stay engaged in good dialogue with my clientele. I don’t want to miss subtle details and I don’t want to break up the work by taking a note. It seems to me that if I take a note during the session, the client waits for me to do so and then they move out of an experience to only describing an experience–and so distance themselves from their feelings and thus any insight or intervention is also distant.

What do you think?

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March 13, 2008 · 5:21 am

Feeling judgmental about Eliot Spitzer?


Its easy to do…here’s a man who knows all the ins and outs of money laundering tactics since he used them to prosecute many criminals in his previous job. He’s also taken down several prostitution rings. He has daughters and ought to think about how he would feel if they engaged in this behavior. He has a long marriage and ought to think about she has been so violated.

He knows better and yet he spent thousands of dollars over a long period of time pursuing sex with prostitutes. And we are tempted to think judgmental thoughts. How could he… Serves him right…

But Jesus says that if you have engaged in desiring and lusting after someone not your spouse, you are just as guilty as Spitzer. That’s a hard teaching. We know secret thoughts don’t have the same consequences as actions and yet everyone starts down the path from the same place.

What his tragic story should encourage us to do is to be sober about our own deceptive thoughts and desires, pray for his family, thank God for the cross and the offer of forgiveness, and endeavor to say no to sin and yes to love of others.

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March 12, 2008 · 1:39 pm

Integrative Psychotherpay IX: Schema Focused Interventions


McMinn and Campbell go into detail regarding the 2nd domain of their 3 tiered model of persons/change in chapter 8 of Integrative Psychotherapy. While the first domain addresses symptoms, this domain (schema) looks beneath to deeper roots than habit and thought. “Schema-based interventions dig deeper than symptom-based interventions, looking to general core beliefs rather than specific automatic thoughts” (p. 243). Schema interventions address the heart of soul and deeply held beliefs (perceptions) about the self and the world that persist beyond specific situations.

So, they open their chapter with this assertion: “…it is often the currents beneath the surface of consciousness that have the most power and bring the most troubles in personal adjustment and interpersonal relationship.” (p. 240). They point to perceived parallels in Romans 7 (Sin causing me to do what I do not want to do) and Freudian theory regarding unmet needs to be both talking about underlying–yet controlling–currents in our lives. A wide view of sin (both active choice and result of living in a fallen world) incorporates both views without making one attack the other.

On page 242 they revisit a vignette of a unhappily married, 24 year old woman. She was afraid she didn’t love her husband and was afraid of being “doomed to misery if they stayed together.” In the vignette, “Denise” is told by her elder that she was facing a spiritual problem that required more prayer and bible reading. The authors fault the elder for having bad psychology (premature advice, no rapport) AND bad theology (that spiritual disciplines can always solve the problem of sin). They faulted the elder for not recommending a fuller orbed treatment of therapy or meds and for not considering a wider variety of underlying issues (her family of origin, communication issues, interpersonal anxiety, hidden secrets, biological predisposition, etc.)

So, is a better answer to Denise’s problem to trace her automatic thoughts back to her core belief? Not so fast say McMinn and Campbell. Linearity is nice but too simple. So, they turn to a discussion of schema.

Schema is not synonymous with core belief despite the fact that it is used that way (mea culpa in this post). Defined by the authors, “a schema is simply a structure that contains a representation of reality” (p. 247). They remind us that since we are actively interpreting our world, we shape our schemas and we shape our lives to fit our schemas. They further describe schemas with these statements (fleshed out in the book)
1. Schemas affect how we interpret and construct the world
2. Schemas are adaptive and maladaptive
3. Schemas can be activated and deactivated
4. Schemas are connect to modes (while schemas are cognitive they lead to a way of being, a personality, a motivational bent, an emotional and physiological bent)
5. Schemas can be categorized in how they interpret self, world, and future (p. 260 has a list of 18 schemas with accompanying core beliefs)
6. Schemas have a historical dimension (they point to literature describing 4 different early life experiences as key historical causes: toxic frustration, trauma, overindulged, and identifying with the pathology of a parent)
7. Schemas have an interpersonal dimension (they are not developed in a vacuum)
8. Schemas are influenced by original sin (faulty thinking doesn’t just come from bad environments. Those raised in great homes also struggle with faulty thinking because they are tainted from the Fall.)
9. Schemas have a cultural dimension (some schemas are culture-based and the authors warn against trying to change these)
10. Schemas have a faith dimension (schemas may shape perception of God; One’s theology shapes schemas)

To make this real, they refer back to “Denise.” Since Denise’s schema contains distrust of the world, she quickly interprets her husband’s cooking her favorite meal as an attempt to make up for his dis-trustfulness and so is defensive and irritable. Of course, this schema “predicts” distrust and then finds evidence of it when Don is hurt and doesn’t try to be nice after her attack of him.

So how does Integrative Psychotherapyaddress maladaptive schemas? They suggest “Recursive Schema Activation” (p. 270) over against class CT tactics that challenge core beliefs with logic. Merely engaging in logic battles minimizes, in their view, that core beliefs, “are embedded in a complex array of motivations, behaviors, emotions, and physiological responses” (p. 217). By “recursive” they mean to emphasize that we change through experience, dialog, repetitive activation and deactivation of the schema.

This means the client’s troubling schemas are activated and deactivated in the context of the therapeutic relationship, over and over again, all the time helping to foster the client’s ability to stand apart from the core beliefs and reconstruct a new, healthier identity–an outcome know as decentering. In decentering the clients begins to understand the nature, power and origins of the maladaptive core beliefs while simultaneously developing more conscious control over the schema deactivation process. (p. 272)

What is really different here from classic CT? McMinn and Campbell don’t want to talk only about a client’s schema, but to activate and experience the schema, and then decenter from it in order to understand and control it. They do not believe they can eliminate a damaged schema. Classic CT wants to correct maladaptive thoughts. IP wants attempts to recognize the impossibility of that and yet gain control and reduce the power of these maladaptive thoughts via therapeutic relationships.

My thoughts? Okay, lots to munch on here. I like how they recognize the limitations and arrogance of classic CT in correcting our struggle with deception and sin. Just as we don’t try to stop sexual temptation but fight to kill those things that lead us further along, we can’t stop initial fearful thoughts but work to stop our acting on them. What we do with our thoughts (take them captive) matters. And the authors here recognize that such efforts are not merely logical but experiential. I generally agree with their thoughts regarding how schemas color our world. We are active in shaping our interpretations of self and other and our world is active in shaping us. We are neither completely responsible for the content of our perceptions or completely victim of our perceptions. However, we are responsible for our actions and attitudes per the Scriptures. The Scriptures do not excuse us because we were mistreated. But there is grace.

I have two pet peeves. First, the example of bad pastoral care is not followed by bad example of stereotyped christian psychological care. Both are problems. I wish they did more to call out their own kind. Second, they continue to see sin primarily as only original sin. This, I think, does much to minimize active will, motivation and choices in everyday living. By listing the faith dimension of schemas last, they may unintentionally give it only a small slice of the pie when in fact it is a part of every other part of a schema. Each of the other 9 statements about schemas are clearly shaped by our spiritual beliefs and actions.  

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March 11, 2008 · 1:15 pm

Poking fun at yuppies and people trying to be hip


There is a very popular website on WordPress that pokes fun at the things yuppies like (e.g., bottled water, coffee, Whole Foods, graduate education in the humanities, etc). The site is mistitled: Stuff White People Like. It would be better to see it as poking fun at suburban/urban people trying to be upper-middle class and hip. One of the best posts is a sarcastic view of graduate education in the humanities to make us feel smarter than others (second best, in my opinion, is a tie between the post on drinking bottled water and the post on worshipping at Whole Foods). 

Be warned that while the posts do not have offensive language, the comments attached seem to contain much meanness and coarse language. Skip that part.     

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