Minimal Brain Damage?


I’m thinking about brain injuries today. On Sunday one of my son’s teammates got carted off the diamond after falling on his head while trying to make a play. Though scary, it seems he did not sustain an injury other than a headache. At least that what the initial scans suggest. Then today I heard a story on NPR about brain injuries of soldiers experiencing a “concussive” event–those who survived roadside bombs. These soldiers may not have been pierced by shrapnel and may not have had their heads slam into something (two obvious causes of TBI) but may have experienced injury from the impulse of the blast of energy hitting their brain. Pro Publica explains the injury and has the larger story about the many soldiers who fail to be properly diagnosed and treated in military care centers.

It stands to reason why this would happen. Minor brain damage is hard to quantify. Brain scans may not pick up these minor changes. The person isn’t missing a limb which visually reminds others of injuries. Some of the symptoms are similar to other mental health problems and so providers may wonder whether injuries are physiological or psychological.

Some of you have been around long enough to remember MBD or minimal brain dysfunction. This was a term used in the 1960s for a wide variety of problems that now go under the name of ADHD. MBD was a way of signaling that something wasn’t right in the brain even though no one could actually pin point where the problem lay. At this point we may not have ways to identify damage to cells (rather than whole structures) and cell communication and so much use the term concussion or minor TBI (mTBI).

Worse than missing the diagnosis is not having great solutions to deal with the wide variety of symptoms. Our best solution for civilian sports related concussions is to avoid having a second, even minor, head bump. We do so by banning participation in sports for a couple of weeks. It is often these second or third bumps that do the worst of the damage. But I suspect that having a soldier sit in Iraq for a couple of weeks after being dazed by a blast will not be anyone’s desire.

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Filed under counseling science, Psychiatric Medications, Psychology

Being the warden


I was sent a new book to review (which I am not planning to do). Since it has to do with pastoral ministry to couples involved in a particular sexual crisis I thought I’d give it the 5 minute skim. In doing so I got a great image: The warden in the relationship. This is the person who was wronged in some terrible way and is now the warden who determines the accountability of the offending party.

When one has broken trust and is now trying to regain that trust, they must become entirely transparent. Their can be no hint of deceit, no unaccountability in any area of life. Not only must the person allow for accountability but they must show evidence they actually desire it and do not chafe at their limitations in life. But what of the other partner? The author says this:

It is not OK for one, considered to be the initial perpetrator, to live totally accountable in his life of genuine repentance, while the other partner never moves off being the warden of the relationship.

How does one fall into this position? The author says “just going with the flow of feelings about the injustice and harmfulness of things is all that is necessary to become the warden, and to never really forgive.” This, I must say, is in the larger context where he also says forgiveness does not require trusting the other or repatriating the other.

In much of Christian counseling, wardens get a raw deal. It is so obvious that they are demanding of a standard of perfectionism, judgmental, unwilling to be vulnerable, etc. It is easy to see this and to go after the hardness of heart that is evident in the warden while accepting the “repentance” of the offender at face value.

It is true that the warden must relinquish the position of judge if the relationship is going to survive long-term in any healthy manner. This does not mean the person stops taking stock of the offender’s actions and attitudes. Nor does it mean that they can forego self-examination.

Here’s my questions:

  1. How do you know the line between careful evaluation of the fact and warden mentality?
  2. What helps might be most helpful to let go of the warden mentality?
  3. How could the church be more supportive of the warden?

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Filed under adultery, christian counseling, christian psychology, Christianity, counseling, counseling skills

A Parent’s Private Pain


Most of my current counseling work is with adults. Didn’t used to be this way. When I started, I worked mostly with kids and then sometimes with their parents.

What do adults deal with? Some are dealing with personal problems, some are dealing with difficult marriages, work, and the like, some are dealing with parenting young children. All of them hope that counseling will be part of the solution: depression will lift; intimacy will increase, children will be more obedient.

But what of the parent of an adult child who seems to be going off course? Their beloved offspring refuses to address an addiction; rejects their faith; rejects values from faith or culture. Where do they find help and solace? Given the little power parents have over adult children no longer under their roof, these parents rarely choose counseling as an option. Seems too expensive for something that can’t change the situation.

Surely these parents hurt. Their assumptions or dreams seem dashed. They question what they did wrong. Others offer unsolicited advice as to what to do or why their child has departed from their family values. Surely these parents face confusing decisions. Do they cut off from the child? Cajole? Pretend nothing is wrong?

Where best might they turn?

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Filed under christian counseling, Christianity, counseling, parenting

Criticizing Christian Counseling Models


Critical thinking and evaluation of what goes for “Christian” has always been a part of the Christian faith. This past Sunday my pastor preached on Colossians 2:13-19 and in the midst of the sermon he made this brief remark about Paul’s list of characteristics of those who have “false ideas about ‘righteousness’ and salvation”–in other words, those who use their critical evaluation skills to destroy others (rather than build up) or to build their own kingdoms.

Based on Paul’s list, he said these leaders tend to (a) be quick to pass judgment about the views of others, (b) equally quick to dismiss their opponents, (c) and likely to claim a vision or something special on which to base their own beliefs. He added that these leaders commonly hide their views under a veneer of humility.

In the counseling world, we have had many of these thought “leaders.” These are those who have a grain of truth as they point out the flaws in the views of others, who refuse to accept any critique of their own position and claim to have a purer view of the Bible (though never once really articulating it as a positive position).

But is there a place for critiquing others’ models? If so, how do you tell the difference between a false critique and a necessary critique? Try some of these questions:

  1. Are the critique overly personal? Does the writer give the benefit of the doubt or choose to read the one being critiqued in the worst possible light? If you finish a critique and it seems like the author was making fun of their opponent or making outlandish statements about the intentions or consequences of ideas–then they probably fail the test of constructive criticism and love for all.
  2. Does the one doing the critique identify where the author has spoken truthfully? If not, then the critique is not balanced.
  3. Does the critic offer an alternative after making statements of judgment? If not, then it is likely that the critic isn’t really looking for solutions but merely wants to be destructive.

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Filed under biblical counseling, Biblical Reflection, christian counseling, Christianity, counseling, Psychology

Maintaining progress in counseling with short sessions


Ever felt that a 10 minute session every day might be more beneficial than a 1 hour session once a week? While a short session cannot dig very deep, it can keep a person on track. One of the frustrating things about counseling is the fact that a client may leave with direction and clarity only to return 7 to 21 days later with confusion. What seems clear in the office becomes foggy in real life. It isn’t that much different from learning a language or algebraic formulations. You think you have it then you try to apply it to a novel situation and you realize you don’t have it quite down.

The phone call session should be short, directed at problem-solving, remembering a previously learned solution, or improving hope and motivation to continue some difficult task. Consider this for marital discord. So easily conflicted couples stay cold and distant between episodes of conflict. Short sessions may help them remember to soften each day and be more inviting of non-conflict interactions.

There is some support for this kind of interaction, though not in therapy literature. The support comes from addiction quitlines. Those who call in and gain support are more likely to remain abstinent than those who try to do it on their own. Sadly, insurance companies do not support this kind of interaction (they do not cover phone sessions). They should, it would likely save money in the long run.

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Filed under christian counseling, christian psychology, counseling, counseling science, counseling skills, Psychology, Uncategorized

insomnia and suicidality


Counselors need to keep regular watch over the insomnia of their clients. Untreated or unresolved insomnia predicts poor recovery and lesser benefit from therapy. It ought not be treated as a secondary problem. But a recent abstract sent to me via email suggests that insomnia may also be a significant factor in suicidal ideation and action. Some researchers at Wake Forest followed 60 adults with both insomnia and major depression for 9 weeks. All received antidepressants but some received a sleep aid as well. Both were assessed by using the Hamilton Depression Scale and an insomnia severity scale.

Their findings suggest that insomnia is a factor in suicidal ideation independent of depression or lack of pleasure. Insomnia leads to more intense suicidal thoughts. Thus, counselors ought to redouble their efforts to ask about insomnia, to track it and to especially follow-up with questions about suicidal ideation or plans when complaints of insomnia increase.

Interested readers may find the abstract of the research here.

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Filed under christian counseling, counseling, counseling science, counseling skills, Depression, Uncategorized

Buy scarves and support breast cancer research


Most breast cancer chemo patients lose their hair. Kim is not the exception. She’s done well in accessorizing her head with hats, wigs, halos (a ring of hair that would show under a hat or scarf), and other forms of head covering. They are so great I’ve lobbied for her to keep wearing some of them after her own hair returns.

But let me point those of you who wear scarves to one particular company: Good Wishes, which provides a free silken (very soft!) head wrap for any breast cancer patient. Kim’s came in the mail today and is absolutely

gorgeous. You can see lots of options on the site of “Its a wrap” scarves.

While they are not cheap, the company donates 20% of your purchase to the Triple Negative Breast Cancer Foundation which funds research. This is Kim’s kind of cancer.

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Intractable conflict in marriage


The latest American Psychologist (65:4, 2010) has an interesting article on the topic of intractable conflicts. These can be seen in families, communities or whole country disputes like found recently in Rwanda and the Congo.

The authors make this point at the outset of the article,

Conflict resolution should be easy. Conventional wisdom…has it that conflict arises when people feel their respective interests or needs are incompatible….A conflict that has become intractable should be especially easy to resolve….After all, a conflict with no ed in sight serves the interests of very few people, drains both parties’ resources, wastes energy, and diminishes human capital in service of a futile endeavor. Even a compromise solution that only partially addresses the salient needs and interests of the parties should be embraced when they realize that such a compromise represents a far better deal than pursuing a self-defeating pattern of behavior that offers them nothing but aversive outcomes with a highly uncertain prospect of goal attainment.  (p. 262)

True, but since when does logic ever beat conflict? It doesn’t and these authors know it.

As a conflict becomes a primary focus of each party’s thoughts, feelings, and actions, even factors that are irrelevant to the conflict become framed in a way that intensifies or maintains the conflict. It is as though the conflict acts like a gravity well into which the surrounding mental, behavioral, and social-structural landscape begins to slide. Once parties are trapped in such a well, escape requires tremendous will and energy and thus feels impossible. (ibid, my emphasis)

This is EXACTLY why marriage counseling is so difficult. Everything is read through the lens of “He is so controlling,” or “She won’t respect me.”

Why does this happen? On the surface, an intractable conflict might seem to be about land (e.g., Palestinians vs. Israelis) or about ideological solidarity (republicans vs. democrats) or about bald desire for power. In marriage conflict may appear to be about respect, money, or power. But these authors suggest that conflict becomes intractable because the larger system is supported by the conflict and would more or less collapse if peace were to overtake it. Attractors, they say help maintain a coherent view of the world, a way of promoting unequivocal action without hesitation. Truth be told. We like living in a black/white world where our actions are always clear to us and the bad guys are always bad. A word about power. In conflict, we use power to get what we want (via direct use or manipulation). But there are always power differences between parties. Someone always has more power. In couples, one spouse will always want more sex than the other. This isn’t a bad thing. It only becomes bad when either party refuses to accept the differences or show any capacity to be influenced by the other.

When peaceful resolutions take place, it is because a new system has been developed; a new set of values and definers of reality.

How do you implement such a change? You cannot go directly after the thing that maintains the conflict. In other words, don’t say, “You, wife, stop believing your husband doesn’t love you”; or “You, husband, start loving your wife by…” Built into the maintainers of conflict is a strain of resistance. “I know you just did something nice for me but you really are just trying to get on my good side so you can [fill in the blank], but I’m on to you!”

The authors say, and I agree, that, “Attempts to challenge directly the validity or practicality of an attractor for intractable conflict are therefore often doomed to fail and in fact are likely to intensify people’s beliefs and energize their response tendencies.” (p. 273)

Again, how do we deal with these longstanding conflicts? How do we stop seeing the problem as a simple equation (you stink and I’m great) to something more complex (we’re both broken and here’s what I can do to make things better)?

1. Force self to step back to see the complexity of the situation. This sometimes happens when something blows our mind (we act in a way we THOUGHT we never would). To do this we have to believe that the simple answer is easy but ALWAYS wrong and desire to have a more nuanced view of self and other

2. Go back to see previous unity. So, a couple might go back to remember their first love. What affinities did they once have? Can they recover them? Some couples can. From here, they may find the power to fix problems that seem just a wee bit smaller because of a more powerful unifying narrative that was forgotten.

3. Focus on who we want to be in the midst of trials and tribulations. What kind of person do I want to be (that God empowers me to be) come what may?

Notice that only #2 has to work towards maintaining the marriage and living in close quarters. One can develop a more complex and realistic view of the problem (#1) or focus on character development (#3) and still choose to end a violent or destructive relationship. Both also require that we value something greater than self-interest. From a Christian point of view, love must be the reason for all three options–a love given to us by God alone.

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Filed under christian counseling, Cognitive biases, conflicts, counseling skills, Desires, marriage, Psychology, Relationships, Uncategorized

Frontline on PTSD in soldiers


Caught a portion of the PBS Frontline show, The Wounded Platoon, documenting the extensive combat trauma in the 3rd Platoon, Charlie Company, 1st Battalion, 506th Infantry stationed in Fort Carson, CO. Click the above link to watch it on-line if you missed it.

It is heartbreaking and mind-boggling to consider that so many of these young men are now in jail or dead due to suicide. The PTSD is evident to all. The men admit to massive drug and alcohol addiction, trauma, domestic violence, etc. What is even more mind-boggling is the interviews with some of the platoon leaders–some of whom are quite matter of fact. Yes, they say, it is bad. But it is part of what we get. Too much demand for soldiers, too few to meet the demand. This equals spending longer rotations in theatre thus more PTSD.

They discuss the amount of psychiatric meds prescribed for these soldiers while in Iraq. While this means they are getting some treatment, others see this as merely allowing them to suffer more damage while still being able to fight the next day.

I’m thankful for my freedom in the US. But never forget the cost. And do remember that few of these men get any decent treatment once they return.

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Suicide assessment mistakes


Yesterday’s post was about suicide. Counselors sometimes fail to adequately evaluate suicidal ideation, plan, or intent in their counselees. Some years ago, I ran across a research study looking at the most common mistakes made by 215 masters level counselors when dealing with suicidal clients. I’ve lost the bibliographic data for the article and couldn’t find it easily in Psychlit…

Here are some of the mistakes (in no particular order):

  • Superficial reassurance (“you have so much to live for”
  • Avoidance of strong emotions (not allowing client to express strong despair–usually with first bullet point)
  • Professionalism (cold and distant, possibly seen as uncaring in assessment)
  • Inadequate assessment (failure to explore fully because of nervousness or fear of asking)
  • Failure to identify precipitating causes (most suicides have both current and historical precipitating events. Counselors may identify historic event (e.g., divorce 4 years ago) but miss the current precipitant.)
  • Passivity; failure to be empathic (25% took this stance)
  • Insufficient directness. No contract to not harm, no next steps
  • Overbearing advice. Counselee needs to be involved in the planning for safety
  • Stereotyping response (“She’s just a borderline!”)
  • Defensiveness (usually about whether hospitalization is necessary)

Every counselor worries about how they will perform when addressing the serious problem of suicide risk assessment. We do well to review (a) our natural inclinations when stressed (e.g., do we tighten up, become over-controlling, too professional?), (b) our standard of practice when confronted with despairing or suicidal clients, and (c) our assessment procedures with all clients. While there is no way to prevent the suicides of highly motivated people, we can increase our capacity to respond well to those the Lord sends our way.

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Filed under christian counseling, christian psychology, counseling, counseling science, counseling skills, Depression, Despair, ethics, Psychology, Uncategorized