February 10, 2010 · 5:38 am

Delusions and hallucinations: What are they?


Most of us trust our thoughts, feelings, and perceptions. If we hear something, we assume it to be real. Imagine someone telling you that what you feel or heard wasn’t real. Would you be inclined to believe them? Probably not. And the more they tried to convince you that you were crazy, the more you might see them as trying to deceive you.

That is a little piece of the world of those who experience psychotic symptoms–where they believe, feel, hear, experience things that others deny are real.

So, what is happening when someone comes to believe they are Jesus Christ in the flesh? What is happening when someone hears a voice telling them that they should die?

Possible explanations:

1. Misinterpretation of feelings and perceptions. I walk into a room and the hair of my neck rises. Does it mean that there is a lot of static electricity in the room? That I’m nervous in crowds? Or that someone is beaming thoughts at me? One explanation is that I’m mis-reading the data.

2. Mis-firing of neurons in the perception areas of the brain. I know that isn’t exactly the scientific language we ought to use but it is true that certain electrical stimulation of the brain leads to perceiving smells and sights that are not real. Elevations of dopamine and other neurotransmitters are possible causes of psychosis.

3. Real supernatural experiences. It is possible that spiritual forces are at play and the person is hearing what is being sent to them. Now, whether those forces are telling the truth or not may be the question the person ought to entertain. Further, labeling these symptoms as supernatural does not necessitate a supernatural response (e.g., casting out demons). Deception may be broken by basic Christian responses (e.g., prayer, submission to the Word) and by medications.

As a Christian psychologist I believe all three are at play in any disease. We are individuals with broken bodies that do not work right. We are mis-perceiving and vulnerable to deception. I cannot say for sure that someone who believes themselves to be a prophet is lying. However, if they are not evidencing the fruit of the Spirit in their lives then I do question the validity of their identity.

Counselees experiencing intruding sensations and perceptions can break their influence when they are able to attend to other “data”. For example, “I feel others are out to get me but I will live as one who trusts in the Lord rather than in my ability to prove to others that I am in danger.” “I will not use violence or rage to be heard.” “I will not isolate in order to be safe.” “I feel like God has me here for a special reason but I will not neglect caring for my children nor abuse those who do not think I have a special calling.”

Counselors will find more success joining counselees, accepting their reality, rather than merely attacking their beliefs. It is possible that my counselee is a prophet but I can still encourage them to faithful work, love, and honor of those around them.

[Note: I’m not covering the issues of medications, hospitalization, and other psychiatric treatments in this post. These are important and not merely ancillary to the care of those struggling against psychotic symptoms. I am only musing on the possible causes of delusions and hallucinations.]

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February 9, 2010 · 8:50 am

Follow up to yesterday’s post on harmful counseling


Yesterday I posted on the need for Christian psychology to advance its ability to avoid harmful practices. Back in 2008, I posted something similar and referred to the same Lilienfeld article as yesterday. See it here. I looked at his article again this week. Here is his list of potentially harmful therapies:

1. Critical Incident Stress Debriefing (CISD). This one isn’t always harmful but it may be most harmful to those who are mostly likely to experience PTSD. He raises the interest point: most report it being helpful even if their PTSD symptoms are made worse by it.

2. Scared Straight Programs. Apparently, those who are taken to jail for a day to scare them out of criminal activity are more likely to re0ffend. He also addresses boot camp interventions for kids with conduct problems. These too have issues

3. Facilitated Communication. FC views autism as a motor not a cognitive problem. Thus, counselors help children communicate via a keyboard and pressure by the therapist’s hands. Appears the “communications” from the child are likely the therapist’s impressions rather than the child’s actions.

4. Rebirthing/attachment therapy. No studies indicate positive data and actual evidence of death by smothering.

5. Recovered memory techniques. While individuals do indeed recover lost memories of abuse, techniques designed to help one recover memories has been shown to lead to false memory creation. The potential for harm is great and calls into serious question whether a counselor should ever try to help a client “recover” a memory they currently do not have. Along with this treatment are a number of other suggestive treatments (where therapists may create problems by suggesting to vulnerable clients on a variety of topics): “finding” of altars in DID, expressive therapies (designed to release pent up emotions). These have significant opportunity for damage.

6. Grief counseling for normal grief. Apparently, many in the “treatment” groups got much worse than those who did nothing.

7. DARE. You know, that educational program designed to prevent substance abuse? No evidence that it does work to reduce drug use. He didn’t mention it but same has been true for “good touch, bad touch” programs.

8. Peer groups for incarcerated children. These may turn out to help them become more deviant.

9. Relaxation training for some panicked individuals. Some individuals have a paradoxical response (more anxiety). We need more data on who it helps and who may not be helped.

Interesting list. Any here that bother you? That you would want to defend?

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February 8, 2010 · 8:29 am

Do no harm?


[This is the second guest post I am making over on the www.christianpsych.org. You’ll have to click the link to read the whole post…]

Every counseling ethics code in existence includes this principle: Do no harm. This maxim is drilled into the heads of counseling students (and any other medical professional as well). Our work should help, not hurt. Who could disagree?

But pause for a minute and consider how you might evaluate whether an intervention helps or harms. What criteria will you use? From what vantage point will you evaluate the criteria you choose? If a medical treatment extends life for an ill patient that would seem good—unless it keeps them alive and in a vegetative state with no possibility of recovery. Some would then wonder if the treatment was indeed best. Or, is it harmful if marriage counseling encourages truthfulness between spouses leading to the revelation of a terrible betrayal leading on to divorce and financial ruin? If honesty is your criteria for helpfulness, then the intervention is sad but helpful. If stability is your criteria, then such counseling is harmful. We could go on and on. Do we use client interpretation of whether treatment is helpful or counselor observation? Do we consider the difference between short and long term evaluation? And importantly for Christians, do we consider only statistical analyses or do we also consider biblical categories (e.g., intervention “A” leads to increased positive affect but encourages clients to pray to another deity).

Despite the muddy water I just churned up, I want to argue that Christian psychology is well poised to help Christian counselors provide treatment that does not harm. This society includes some of the best philosophers, theologians, sociologists, clinicians, and researchers of our day. These members are interested in looking at how people grow and change, how the bible connects with everyday life, common human struggles and effective interventions, etc.

How then do we go about refining our practices and avoiding harm? Let me suggest some steps we might take:

[rest of post on www.christianpsych.org.]

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February 5, 2010 · 1:28 pm

Mental Retardation passe?


Did you see the news stories about Rahm Emanuel’s use of the word, “retarded” as a slur against his political opponents? It has spawned a number of conversations about the term mental retardation. Some are arguing for the removal of this term in legal and medical arenas. It is too closely connected to the abusive use of the word. Others, probably a small minority, even suggest not using the word retarded in other contexts unrelated to intellectual capacity (e.g., retarded growth, retarding energy consumption).

I’m not much of a fan of this latter idea. I remember when a DC official was castigated for using the term “niggardly” (having absolutely nothing to do with race) just because it sounded like the other “n” word. However, maybe we do need another term. Some are suggesting, “intellectual disabilities” “neurodevelopmental disorder” as options.

I’m for terms that are very descriptive and less pejorative. However, I will also say that stigma and the use of terms to harm will not change as the human heart that does such activity has not changed.

What do you think?

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February 3, 2010 · 9:56 am

Trusting in your own wisdom


I recently had the need to consult a couple of experts on a medical question. In doing so I re-discovered a maxim:

we trust in our own expertise to solve problem.

Or, more colloquially, if what we have is a hammer, everything looks like a nail. The psychiatrist puts her trust in her common tools. The neurosurgeon puts his trust in his scalpel. The neuropsychologist puts trust in the common diagnostic tools she uses.

Hmmm. I think I’m no different. I’d like to think that I’ll give my clients the right recommendation for treatment but when someone comes to me with a run-of-the-mill problem I must admit that I usually think I and my skills are up to the task.

Good care requires that I inform clients of other options. For example, if someone is depressed, I can provide counsel but they may wish to choose to see a psychiatrist for medication options. If a couple comes for therapy, I should inform them of the various kinds of therapy that might work equally well: EFT by a certified specialist, intensive Gottman style interventions (3 hour sessions every 3 weeks with lots of homework). Or, if a parent brings a child with ADHD like symptoms, do I suggest my style of intervention or do I recommend more careful diagnostics of a neuropsychologist’s exam? But even when we counselors tell clients of other options, they probably can tell we think fairly highly of our own counseling methods.

Don’t be surprised when surgeons want to use their knives, when oncologists want to ply their trade, or when nutritionists emphasize their health improving interventions. If you are seeking care, keep this human frailty in mind. And do be sure to ask more questions when you are seeking the best path for solving your problem.

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February 2, 2010 · 2:27 pm

The unpardonable sin


Ed Welch has a good post at www.ccef.org on the “unpardonable sin” passage found in Matthew 12. This is a worrisome passage for many–especially those with scrupulosity (aka Obsessive Compulsive Disorder). He hits the nail on the head that the flip answer, “if you are worried about this, you haven’t committed it” is both likely true but also insufficient for the true worriers among us. So, his post goes in great detail about the passage, its context and good conclusions to draw from it. Well worth your read!

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February 1, 2010 · 5:49 am

Blogging this month for the Society of Christian Psychology


This month (really, the 4 Mondays of February), I’ll be the guest blogger at the Society for Christian Psychology’s site. You can find it at www.christianpsych.org or from my links on this page. Here’s a tease from my first post:

Should Christian Psychology become a Profession?

Right now, in the Commonwealth of Pennsylvania, lawmakers are considering a bill that would place more restrictions on who can provide counsel. Currently, the state has a number of mental health credentials. Among those is the Licensed Professional Counselor credential for those with a requisite master’s degree and post graduate supervised practice. If passed, the new bill will not only protect the title of “Professional Counselor” but also the practice of professional counseling. Per the law, one may not “style” themselves as a counselor unless they are licensed as such.

Who does this effect? This will especially impact the many Christian counselors who are not licensed but practice a form of counseling (aka biblical counseling, Christian counseling, etc.). While these counselors do not provide diagnoses or bill insurances they do collect fees, keep progress notes, maintain confidentiality, and provide counsel for those struggling with issues such as anxiety, anger, depression, marital conflict and the like. So, the 64 million dollar question: Do these unlicensed Christian counselors “style” themselves as professional counselors? And who decides the line between the two? As an aside, the bill does contain an exemption for pastoral counselors. Pennsylvania does not yet define that title but in other locales that title is reserved for those ordained, trained in a pastoral counseling graduate program, and doing work in church-related institutions.

Here’s where the bill gets interesting. It describes what typifies a profession that might overlap with counseling but have a separate (and thus exempted) identity and practice. Here are some of the criteria they might use to discern a separate profession (note my bolded text to emphasize interesting details):

[For the rest of this post, click here.

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January 28, 2010 · 4:33 pm

Christian peace


What is your definition of peace? Readers of the Bible notice that peace is a comfort in the midst of raging turmoil: at a banquet with one’s enemies drawing their weapons; a still small voice in the midst of a storm; manna and some water in the desert; a house on a highway used by two marauding super powers. On we could go…

I’d like to have peace as something without threat of pain. Not the biblical definition so it seems.

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January 22, 2010 · 11:53 am

Update on PA HB 1250


Posted previously here about the bill proposed to go to the PA legislature that will change the Licensed Professional Counselor credential from a title act to a practice act. This would further restrict non-licensed counselors from “styling” themselves as a licensed counselor, from offering the services of a counselor. Already one cannot call themselves a professional counselor or similar titles. But these changes would eliminate many from practicing. This bill (see here for bill with highlighted changes. Go to page 10 to see most pertinent changes and list of exempted individuals) is being voted on by the committee on 1/27.

Note that the exempted parties include “pastoral counselors”. In PA they are not defined. However, in other states they are defined and licensed. Thus, who will determine who is a pastoral counselor and what to do with the overlap between the two? In other states, a pastoral counselor must be ordained and trained in pastoral counseling. Also, psychologists supervising unlicensed people with counseling degrees may be exempted but there is still fuzziness in the law.

It all comes down to the definition of “styling.” See this quote from page 10:

Only individuals who have received licenses as licensed professional counselors under this act may style themselves as licensed professional counselors and use the letters “L.P.C.” in connection with their names. It shall be unlawful for an individual to style oneself as a licensed professional counselor, advertise or offer to engage in the practice of professional counselor counseling or use any words or symbols indicating or tending to indicate that the individual is a licensed professional counselor without holding a license in good standing under this act.

Section 3.  The act is amended by adding a section to read:

Section 16.4  Unlicensed practice prohibited.

No person shall engage in the practice of as a licensed social work worker, licensed clinical social work worker, licensed marriage and family therapy therapist or licensed professional counseling counselor in this Commonwealth unless the person holds a valid license to do so as provided in this act. The provisions of this section shall not apply to the following persons:

If you are in PA and one of these representatives (scroll down for the list) are from your district, you may wish to register you opinion on the matter.

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January 20, 2010 · 3:09 pm

Harmful counseling?


This month’s edition of American Psychologist has several interesting articles about the negative effects of therapy. The article by David Barlow, “Negative effects from psychological treatments”, provides a good overview of the effectiveness research controversies. But instead of focusing on how best to collect data about the benefits of a treatment, he gives some attention to looking more clearly at who benefits from a treatment and who is made worse (using dismantling type studies).

The next article (by authors Dimidjian and Hollon) gets at the definition of harm. Defining harm is rather complex. That a client may not get better from a treatment or may get worse during a treatment is not necessarily evidence that the treatment caused harm. And true to form, we have to accept that some treatments may both harm and help (they give the illustration of a nursing mother on medications: it may help her and yet harm her baby). Or, a treatment may make someone worse at first but then help them later on. Or, the treatment may be just fine but the practitioner may use it in a way that is good or bad. Finally, a treatment may be thought of as harming a patient when in fact what is seen is the normal trajectory of the disease.

So, how do you get at understanding whether a counseling treatment harms? They offer a number of methods for research which I won’t get into here.

Finally, the last article covers training implications (Castonguay et al). They cite therapists’ frequent underestimation of treatment failure and client deterioration. Looks like about 5-10% of clients get worse in treatment. If one wants to train counselors to avoid more failure how might one do that? Castonguay et al suggest that one do so by beefing up (a) proper therapy skills, and (b) skills to identify potentially harmful treatments. On p. 45 the authors include a table of training recommendations, which include

  • expose trainees to list of potentially harmful treatments
  • help trainees monitor change and deterioration
  • enhance relationship skills
  • learn and practice interventions that are empirically supported
  • prevent and repair a variety of relational pitfalls
  • adjust treatment choice, expectations, etc. based on client characteristics
  • Address trainee’s issues (anxiety, hostility, defensiveness, naiveté, etc.) that may hinder counseling

Every counselor fears harming another; fears not helping enough. And it is often unclear whether our work is having its intended impact in the moment. However, there are things we can do to keep the communication lines open and thus listen to our clients about what is helping or not helping. This is what keeps us on our toes. What works for one person harms another. We must not get wedded to one way of helping.

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