March 10, 2008 · 10:06 am

Science Monday: Child PTSD


Today’s psychopathology class focuses on child related problems. Given the societal focus on ADHD and Asperger’s, our class will hang out there. However, I want to bring to your attention some work in the area of family violence and childhood trauma reactions. Gayla Margolin and Katrina Vickerman (of USC) published 2 articles in a 2007 (38:6) issue of Professional Psychology: Research and Practiceon the topic of PTSD in children exposed to family violence.

Article one (pp 613-619) provides an overview. First, they recognize that some kids have PTSD without a single discrete precipitating and/or life-threatening event. It appears that prolonged exposure to violence (e.g., domestic violence, physical abuse, sexual abuse, community violence) likely has a deleterious impact on children. Some 30% of kids living with both parents experience domestic violence. Some 5-10% of kids experience severe physical abuse. One article summarizing a number of studies suggested that somewhere between 13 and 50% of kids exposed to family violence qualify for a PTSD diagnosis. In foster home and clinic studies, the number with PTSD seems higher, especially in girls. Not every child who experiences violence shows signs of PTSD. Severity and frequency of exposure to violence probably matters most. What makes family violence so troubling is that the child is faced with the constant threat of additional episodes.

What are the common domains of impairment related to complex trauma exposure? Affect regulation (inability to modulate anger, chronic flooding of negative affect), information processing (concentration, learning difficulties, missing subtle environmental nuances, overestimation of danger, preoccupied with worry about safety), self-concept (shame, guilt), behavioral control (aggression, proactive defenses, and substance abuse), interpersonal relationships (trust), and biological processes(delayed sensorimotor development (p. 615).

The authors repeat a previous suggestion of a new diagnosis: Developmental Trauma Disorder(DTD) to adequately capture the picture of youth trauma reactions to family violence. Criteria include: repeated exposure to adverse interpersonal trauma, triggered pattern of repeated dysregulation of affect, persistently altered attributions and expectancies about self and other, and evidence of functional impairment.

In their second article (pp. 620-628), the authors summarize typical treatments for children: reexposure interventions(to help the child understand and gain mastery over their past experiences that intrude. This is done primarily by a trauma interview where therapists work directively to bring fragments of the story together into a coherent whole and meaning and safety are explored), cognitive restructuring and education about violence exposure (goal to undo lessons learned, practice thought stopping, and to normalize reactions), emotional recognition and expression (to attend to and understand connections between emotions, thoughts, and behaviors), social problems solving, safety planning for those not able to be out of potentially violent environments, and parenting interventions.

Do any of these treatments work? It appears several do. I’ll mention just one here:Trauma-focused CBT for child abuse victims (by Cohen, Mannarino, and Deblinger. That intervention is published in their 2006 Guilford Press book, Treating trauma and traumatic grief in child and adolescents.   

We should not underestimate the impact of family and community violence on children. There are many kids labeled bi-polar, ADHD, personality disordered, oppositional (and worse) who carry within their body the impact of violence. They might look like a gang-banger or a thug who’d kill you because you scuffed his shoes, but they likely are hypervigilant and only read part of the environmental cues to determine if they are in danger.

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March 7, 2008 · 11:44 am

On-line Models of Counseling Course


Biblical Seminary offers several completely on-line courses these days. Check out our homepage for short videos on each course: www.biblical.edu. Let me highlight one in particular. My colleague Bryan Maier is offering one this Spring entitled, Models of Counseling. Here’s his syllabus: http://www.biblical.edu/pages/equip/classes-course-syllabi-spring.htm

If you ever wanted to explore the key secular and Christian models of counseling from a Christian/biblical perspective, this course is for you. The good part is you don’t have to travel to Biblical to take it. Bryan is a great teacher with a good sense of humor. I think you would enjoy it.

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March 7, 2008 · 10:07 am

The morality of changing political parties


For years I have felt like halfway between a Republican and a Democrat. Frankly, I don’t like much of the mainstay arguments in either party. I don’t like the scare tactics and self-focus of many Republicans and I don’t like the relativism and throw money at problems part of the Democratic party. When we lived in NH, I registered as an Independent and when I voted in the primary, I could vote either way and keep my status. Here in PA I have to choose. So, today I changed my status to Democrat so I could vote in the upcoming primary. I’d like to have a say and being a Republican means having no vote now that McCain has wrapped up his nomination.

So, is it okay to change for this reason? I think so. I don’t like it when folks change so they can vote against someone or vote for someone they think won’t be able to beat their true candidate. But it seems different if I change to vote and haven’t yet made up my mind.

What do you think?

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March 6, 2008 · 5:57 am

The danger of apologizing too soon


Can an apology come too soon? I was listening to an NPR show discussing a national apology for slavery in the US (and reparations). One guest on the show stated that if a government or organization apologizes before there is adequate dialogue about the real effects of that entity’s misdeeds (i.e., support of slavery), it kills further dialogue.

Really? Why is it that if we apologize for hurting someone that we think the conversation is over?

Point of fact: true apologies invite further discussion, including exploration of the effects of the “crime.” When discussion ends because of an apology, we discover that the apology was really cover for, “Will you let me out of jail for what I did to you? Will you forget my bad behavior?”

True apologies are not formed as questions or requests–either explicitly or implicitly. It is offerings of forgiveness that end or at least change discussion regarding criminal activity. When we demand instant forgiveness or apology acceptance we inappropriately tie apologies with conversation endings.

Do you agree with this next statement? The truly repentant do not mind apologizing as many times as necessary nor engaging in conversation about the effects of their misdeeds.

In relationship to slavery, the matter is complicated in that the conversation is happening between those who either indirectly benefit or suffer from slavery. Because of our overemphasis on individualism, we often fail to acknowledge corporate sins and that some of us benefit from those corporate sins. Read Ezra and Nehemiah and you see a different picture. A people repenting for sins done by the previous generation. Now there’s a novel idea.

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March 5, 2008 · 5:35 am

Integrative Psychotherapy VIII: Symptom reduction of anxiety


If you recall from prior chapters, McMinn and Campbell propose a 3 tiered model (IP) to address symptom, schema, and relationship issues. In chapter 7, they explore symptom focused interventions for anxiety (while not denying or addressing relational or schema matters of anxiety disorders). The authors provide a description of 5 types of anxiety problems (panic, phobias, OCD, PTSD, and GAD) and typical Cognitive Therapy interventions for each. For example, they describe panic as a “fear of fear” and explore interventions designed to interrupt the cycle of “internal physiological events” and “fearful appraisal of physiological sensations.” Such interventions include cognitive challenges or reframes, breathing and relaxation, and exposure (in vivo or imaginal) coupled with relaxation training. 

After providing this review of anxiety and common interventions, they move to a very brief discussion of fear from a spiritual perspective. The opposite of fear is love (not courage). They conclude that fear is, “a great spiritual problem” (p. 236). But, they quickly say, “we should not attribute anxiety problems to spiritual weakness.” They argue that doing that sets up an inappropriate simplistic model (you are anxious because you are immature) and ignores the complexities of fear. They fear it may also send the message that only people with anxiety cause their problems, when in fact we all live “outside of Eden.” So, our bodies, our communities, our wills are all tainted with sin. But, they say, “it is damaging and unrealistic to assume direct and immediate connections between a particular problem and spiritual maturity.” What should we do? “Our best response is to recognize our own brokenness so that we can, in humility, become people of compassion and understanding, willing to walk alongside others through the difficult passages of life.” (p. 236)

My thoughts? This is a classic CT review of anxiety. I’m not sure I saw much of their theological model of persons in this chapter. However, I have to remember this is a chapter designed only to address the symptom reduction aspects of therapy. The authors did not intend to look at relationships and schemas. In the real world, we can’t separate out schema and symptoms and deal with only one and not the other. I understand why they do highlight interventions in each domain in the book, but it comes at a cost (realism). I do wish they would have included a chapter on putting it all together by following a particular case. I also wish they would keep following anxiety problems through the other 2 domains of the model, but they didn’t.

My bigger concern is the thin discussion on spiritual aspects of fear symptoms. Now, maybe they will pick up more when we get to schemas since schemas look at worldview and beliefs. But, while I agree completely with the last quote above, I think they make an all-or-nothing proposal. They are right that judgmentalism and simplistic understandings of fear are inappropriate. However, avoidance tactics found with panic symptoms do reveal implicit demands for control beyond what God intends. Symptoms both happen and are chosen. These demands that we make may be unconscious and may be completely understandable. And yet, I believe we can explore symptom maintenance and reduction AND talk about spiritual matters without equating spiritual maturity with the elimination of all problems.   For example, OCD symptoms such as worry that one has caused harm to another (e.g., hit someone while driving to work) can be best treated by cognitive challenges, imaginal exposure and response prevention. But as one attempts these interventions it is likely that conversations arise about the desire to avoid causing anyone harm. Now that is a deeply spiritual conversation–and I suspect the authors agree. Hopefully we’ll see some discussion of this in the next two chapters as they look at schema issues.  

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March 4, 2008 · 5:46 am

ER: Is it easier to feel guilt than forgiveness?


Someone sent me a link to a recent ER show where a dying man is talking to a chaplain about his guilt and whether or not he can be forgiven for his taking innocent life. While some of the chaplain’s comments are relativistic mumbo-jumbo, she has one very insightful comment.  The dying man says something to suggest he can’t make up for his sins. The chaplain says,

“[Sometimes I think] it’s easier to feel guilt than forgiven….that your guilt is your reason for living…but maybe you need something else to live for.”

I may not have gotten that quote just right at the end as I was scribbling it down. But, this line is very powerful. In fact, some make a living out of guilt, depression, hopelessness, etc. They can’t imagine life any different. Pride makes it hard to give up what feels to have become a central feature to their identity. While her counsel was terrible, she was right on the money about the nature of guilt and the difficulty in giving it up. He would have to accept that he received something he did not deserve and could never pay back.  

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March 3, 2008 · 11:58 am

Science Monday: The Epidemic of Insomnia


Americans appear to be quite sleep deprived, so says the latest National Sleep Foundation Survey of working adults (2008). Sleep deprivation seems to be linked to obesity as well as driving and work accidents. We’re insomniacs for many reasons. One key reason is our electronic appetite. With 24/7 electronics we stay up later and then stay up longer when we do get up in the night because of insomnia.

Sadly, once we retire and have the freedom to sleep longer, we can’t. Some 30-60% of older persons have sleep complaints. Does anything help? Commonly, doctors prescribe sleep aids, exercise, Cognitive Behavioral Therapy, and sleep hygiene education. While sleep aids are quite attractive they often have significant side effects and tend to be less effective if used regularly. Susan McCurry and her colleagues at University of Washington reviewed 20 key studies published between 1990 and 2006 to determine if any psychological treatments (they eliminated drugs, massage, etc.) would meet standards for evidenced-based treatment. They determined that two treatments have strong evidence of success among the older population:

1. Sleep Restriction/Sleep Compression. This treatment “is based on the principle that curtailing time spent in bed helps solidify sleep.” (p. 20). So, if you are in bed for 8 hours but only sleep 5, then restrict your time in bed to only 5 hours. The idea is that if you do so, you will sleep more soundly for those 5 hours and likely begin to sleep longer until you read your optimal (not necessarily desired) sleep time.

2. Mulitcomponent CBT. This interventions combines sleep hygiene education (information about how to schedule sleep, dietary matters, activity recommendations, etc.), stimulus control(strengthening the association that bed is for sleep and avoiding napping and lying down awake), sleep restriction, and relaxation training (relaxation to induce drowsiness).

Stimulus control may in fact be beneficial by itself but more study is necessary.

It has been generally accepted that most individuals with secondary sleep problems need sleep hygiene education. In other words, they make matters worse by how they deal with their insomnia (staying in bed awake too long, napping, drinking alcohol, not enough exercise or too late in the evening, etc.). As of yet, we do not have actual research (meeting evidenced-based criteria) to prove that education helps in the elderly population–though some exists for the 40-50s crowd. There also may be some benefit to bright light exposure, exercise, and massage but these authors didn’t explore these nonpsychological interventions.

Bibliography: McCurry, Logsdon, Teri, & Vitiello (2007). Evidence-Based Psychological Treatments for Insomnia in Older Adults. Psychology and Aging, 22, 18-27.

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February 28, 2008 · 5:23 am

Integrative Psychotherapy VII: Functional Domain Interventions


McMinn and Campbell start out chapter six (a deeper review of the 1st domain of interventions, that of addressing symptoms) with this helpful insight: “Many of our graduate students select psychology as a profession after deciding against one of two alternative career paths.” Some are tempted to pastoral ministry and so see psychology as a way to care for human souls. Others are tempted to medical practice and so see psychology as a way to, “help people find relief from their troubles” (p. 177). This distinction is helpful in explaining why some of us hang out in one type of intervention over another.

But whatever one’s interests, everyone must address presenting problems and not bypass symptoms as these are what bring people in to therapy in the first place. So, the authors use this chapter to outline, in general, symptom-focused interventions, The next chapter will apply these interventions specifically to anxiety.

Right off the bat, the authors bring up emotions. They want to dispel the myth that cognitive therapist care little for feelings. They want to define negative emotions as either a sign of cognitive distortions and/or a warning sign that something is off in one’s life. [Hopefully, they do not fully believe that negative emotions means that something is wrong in one’s life. It may be something is wrong in the world…]. To achieve successful interventions in this domain, one must have good relational skills to listen well to both explicit and implicit feelings.

It comes as no surprise that domain 1 interventions include behavioral skills. The authors summarize classical and operant conditioning in a few short paragraphs and suggest that these techniques may help clients have dominion (through reinforcement strategies?) over their own behaviors and responses to life. Their lack of attention to behavioral mod. sends a message.

The bulk of the chapter then focuses on the basic of cognitive restructuring. They divide this task into two parts: sorting an experience into its component parts AND challenging distorted thinking. The authors describe the technique of the thought record and walk through several vignettes to show how it might be used. The record separates situations, thoughts, and feelings (and rates intensity of feelings/experiences on 1 to 10 scale). As the client gains insight, then the work is to counter the automatic thoughts with a rational response. The authors want to remind the counselor to avoid a disputing mindset when countering a client’s distorted thought patterns. Instead, they suggest a more collaborative approach or “Socratic method” using questions and reflections to lead the client to insight rather than drag them to it. 

Beyond the thought record, they describe other methods of changing one’s thinking: scaling (moving away from all/nothing thinking to put stressors in proper perspective), probability estimates (used when someone is worried about an unlikely event), decatastrophizing (helping to move away from “extremist thinking”), humorous counters (identifying silly thinking without making fun of), role-playing (reversing roles and having the client become the counselor), paradox (overstating the client’s fears to see the logical outcome), and cognitive rehearsal (repeated challenge to automatic thoughts).

Finally, they attempt to provide a Christian appraisal of these interventions. First, they tackle the problem of relativism that may underly CT by the biblical concept of testing and trying every “truth.” Instead of rejecting all client automatic thoughts by some sort of Stuart Smalley self-talk mantra, test their thoughts with Scripture, tradition, experience, and reason—aka Wesleyan quadrilateral. Then they give some examples of how a Christian collaborative response to a client with a difficult marriage might look different from a relativistic (be happy) response. The client and the counselor work together to explore what Scripture, tradition, experience and reason might bring to the table (these are not considered equally weighted of course) in discerning the truth about our selves and our thoughts about ourselves.

My thoughts? This chapter is solidly within the CT frame with the recognition that truth has a capital T. Our job as counselors isn’t to tell the clients the truth but to walk with them in a collaborative manner. It is good to see lots of humility in the chapter. We can abuse Scripture, overplay tradition or reason, become disputational, etc. What is missing from this chapter (maybe in comes later) is that while it is helpful to recognize logical errors, it is also true that logic does not always (often?) lead to better thinking. We have some pretty embedded views of ourselves that continue even in the face of our logic. How will they deal with this issue?

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February 27, 2008 · 12:56 pm

Do we really learn from instruction?


[Note: those looking for my blog summary of Integrative Psychotherapy, ch. 6 will need to come back tomorrow. Running behind :(]

How much do we really benefit from instruction? Yes, instruction increases our knowledge base. That is certainly true. But do we benefit–does our behavior really change from it? Do we learn and does it show? Allow me the freedom of hyperbole here…

This question about instruction was raised in my Sunday School class on Isaiah by our teacher John Timlin. Consider the following examples:

1. The first Fall (instruction was given and rejected) happens. God remakes creation through the flood. What happens next? Noah’s son mucks it up.

2.  Israel is warned against falling away from God by Moses as they enter the promised land. He not only tells them what to avoid but that they will likely do it anyway. What happens? Israel turns away from God to pride and idolatry.

3. The Prophets warn both the Northern and Southern Kingdoms that unless they turn from their idols, God will punish them via Assyria. First the Northern Kingdom falls. Does Judah learn from this? No. Read the passage of Ezekial 23 adn the two sisters for a graphic image of this not learning from instruction.

Fast forward to today. Does information about the risks of drug use, unprotected sex help? Some, I’m sure. But not as much as we’d like to think…

So, what does God do? he blinds the people (Isaiah 6:9ff; parables in the Gospels) so that we are left without any doubt that our salvation comes only from him. In Isaiah 6 at the end, there is only a stump left. We the vine are a mere stump. And out of that stump, the root of Jesse grows and we are grafted back in as branches.

Yes, we learn from instruction, but not enough to save ourselves. Thanks be to God for his rescue plan!

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February 26, 2008 · 10:53 am

Characteristics of an on-line predator and victim


The February edition of the American Psychologist (63:2) has an article surveying the literature regarding, “Online ‘Predators’ and Their Victims.” The authors start by making this assertion, “The publicity about online “predators” who prey on naive children using trickery and violence is largely inaccurate.” (p. 111). So, what is the truth as we know it now?

1. “…Internet-initiated sex crimes–those in which sex offenders meet juvenile victims on-line–is different, more complex, and serious but less archetypically frightening than the publicity about these crimes suggests.” (p. 111-2) The on-line predators are not usually pedophiles and are rarely violent (unless you would believe that convincing a minor to have sex is by very nature a violation and therefore violent.) And yet, child porn is often found with these offenders (maybe more teen version than pre-pubescent).

2. After surveying current literature, crime stats, and law enforcement agencies, they find that most crimes, “involve men who use the Internet to meet and seduce underage adolescents into sexual encounters.” (p. 112). Generally, these men do not deceive the minors about their age. Only 5% pretended to be teens. The deceptions that are present are promises of love and romance. So, the authors suggest these crimes usually fit statutory rape (non-forced sexual contact of an adult with a minor) rather than child abuse or pedophilia. (This assumes that the latter is not as bad as the former???)

3. At the present time, it appears that Internet-initiated statutory rape accounts for 7% of all statutory rape cases. Sex crimes against youth are not increasing (based on a decrease in substantiated child sexual abuse cases and reports of sexual assaults by teens). So, the evidence of marked increase is not yet found per these authors. Of course, this does not account for the marked increase in sex exposure that is very definitely happening. Nor does it account for the increase in children being spoken to in sexual terms by other folks on-line. I would want to assume this is an offense.

4. The victims are rarely young children. Instead, they are teens (and more likely the 15-17 year olds) taking risks with personal information. What actions make these teens vulnerable? Its not so much that they post identifying information about themselves (since a very large proportion do this). Rather, they send personal information to an unknown person, chat with an unknown person (only 5% do this), have unknown persons in their “buddy” lists, use the Internet to look for sexual material, spend time on file-sharing sites, have off-line sexual abuse histories, have same-sex attraction, and/or use the Internet to make threatening comments to others (this is interesting, those willing to attack others on-line are themselves more at risk for being sexualized).

The point the authors are making is that media accounts may focus too much on the younger child victim image and miss the typical offender in his late twenties that is immature and unable to relate well to peers so he pursues younger teens to make him feel more manly. If this is the case, then they argue that our prevention plans should be to increase education regarding the nature and consequences of statutory rape, to focus more on adolescents rather than their parents. This is probably a good idea. However, having parents actually know and track their kids on-line behavior is still the best bet. There is no reason a child needs to be in a chat room. period. And just because it isn’t so much about pedophiles, lets not let our guard down. Statutory rape isn’t any better just because the victim thinks they are consenting.

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