February 12, 2010 · 5:36 am

The good and bad of new diagnoses


A draft of the next edition of the Diagnostic & Statistical Manual (DSM-V) has been posted to their website and open for comments by users. The website breaks out the changes being considered in categories so it is easy to find your area of interest.  The final edition isn’t expected until 2013.

Diagnostic changes can be a help and a problem at the same time. When DSM IV removed Multiple Personality Disorder in favor of multiple diagnoses for clarifying dissociative symptoms, that helped clinicians be more descriptive of their client’s struggles. In this new proposal, they plan on eliminating Asperger’s Disorder and subsuming a number of diagnoses (Retts, PDD, etc.) into one diagnosis: Autistic Disorder. I would think this would not be helpful as it reduces specificity.

How about this new entry: Temper Dysregulation Disorder with Dysphoria? A new diagnosis for children? I think it may help in that it might hinder the ever popular “bi-polar” label given too quickly to children (and accompanied with serious meds). On the other hand, it probably will make quite a few roll their eyes. The label doesn’t have that ringing medical sound to it. Not that I’m disparaging the symptoms it tends to cover. There are children who mood is so easily dysregulated, whose reaction to frustrations are way over the top. These children tend to be impulsive to boot. Something isn’t right, but what best identifies their struggles; the etiology of their problems?

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February 11, 2010 · 2:32 pm

Winter personality test


Try on this question to determine your snow related personality:

Do you shovel once at the end of the storm or do you shovel multiple times to reduce the amount of snow you move at a given time?
This only works for those of us who still shovel…

I’m a multiple shovel kind of guy.

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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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