April 17, 2009 · 5:28 am

Physiology Phriday: Will I be on meds for the rest of my life?


During the course of discussing a person’s anxiety or depression, the conversation turns to the possibility of using antidepressants. Inevitably, I am asked, will I have to take them forever? Clearly, the questioner does not want to and sees the possibility of taking medication for the rest of their life to be unacceptable. So much so that many resist starting or even going to see a psychiatrist in order to consider whether they might take a medication. Rarely do they ever ask if the medications will help.

Consider for a minute why a person might ask this question. Here’s some of the reasons I think I’m asked this question:

1. Everybody is on them and they never get off (from the viewpoint that too many people take them for every little hangnail and then allow themselves to stay on the crutch forever, never solving their problem)

2. Medicines are for weak people, I’m not weak. (Not sure if the person would have the same response if their medical doctor said their thyroid wasn’t working and so they would need synthroid for the rest of their life)

3. It is only a spiritual problem. Taking the medication will solve the problem but not the spiritual problem. I’ll be avoiding the real issues.

4. I hate medicines of all kind. I hate remembering to take them and I hate their side effects.

5. I don’t think they will really work.

Can you think of other reasons? Now, antidepressants do work from a research vantage point. They are not the silver bullet. They will not make a bitter, angry, depressed person, less bitter. They may help them sleep better, improve their mood, and thus more clearly come to terms with their bitterness. Medications never block the heart from spiritual matters. Only the person who does not want to deal with spiritual matters will use them to avoid looking more deeply inside. God can be found in both suffering and comfort. Whether we will look for him is a bigger question.

So, what if you need them for the rest of your life? What if they really do make it possible to function well? Is our distaste for medicines due to their side effects or due to the fact that we have to accept that we are weak and broken people?

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April 15, 2009 · 5:37 am

Lewis on our choices impact on the self


In my CS Lewis reader, Lewis says that Christians often think about the consequences of choices either bringing reward or punishment from God. He suggests another way to look at our choices (entry for 17 March):

I would much rather say that every time you make a choice you are turning the central part of you, the part of you that chooses, into something a little different from what it was before. And taking your life as a whole, with all your innumerable choices, all your life long you are slowly turning this central thing either into a heavenly creature or into a hellish creature: either into a creature that is in harmony with God, and with other creatures, and with itself, or else into one that is in a state of war and hatred with God, and with its fellow-creatures, and with itself. (From Mere Christianity)

Does this not help us consider which creature we are forming as we make our many mindless choices every day?

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April 14, 2009 · 5:32 am

Apologies revisited: Heard a good one lately?


Public, direct, and heartfelt apologies are difficult…and rare.

I’ve written here numerous times about apologies and repentance. I find public apologies very interesting, especially by those who can afford to pay someone to help them “get it right.” Last week I listened to a public figure hold a press conference after his conviction for DUI. This person has a lot of money and access to all of the best “coaches”. And yet, his apology was all about himself. Asked what he learned? “I learned that life is full of second chances and I got one.” Now, that could mean that he realizes that he was protected from killing someone with his car. He avoided ending his career. Or, it could mean something far less than remorse. Really, his “apology” was all about himself.
 
Here’s my question to readers: Have you witnessed or experienced a “home run” apology? What made it so? What features were present? How did you know it wasn’t merely learning the right words? Did you ever think you received a real heartfelt apology only to discover later it wasn’t?

In “Machete Season” (book about Rwandan “killers”), one victim gives one requirement:

“If killers come to church to pray to God on their knees, to show us their remorse, I cannot pray either with them or against them. Real regrets are said eye to eye, not to statues of God.” (p. 163)

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April 13, 2009 · 11:11 am

Practicum Monday: The secret to a good experience


A new semester begins today and I pick up teaching again after a sabbatical. It feels good to get back in the saddle again. Practicum and Professional Orientation starts today and so my students begin their first fieldwork assignments around the region. If they are at all like I was when I first began counseling work, they will be nervous and worried about doing well and doing the right thing. But I have a secret for them. This nervousness will actually help them do well and, for the most part, mistakes in counseling often turn out to be good for both counselee and client. Counseling is more like art and less like surgery. And since counseling is relational art, the opportunity to “do over” actually provides wonderful realism to the healing.

However, there is another secret to good practicum experiences: good supervision. Good supervision makes or breaks an experience. And good supervision requires the active participation of both supervisor and supervisee.

The Supervisor: Supervisors come with a variety of skills, personality, and style. Some are quite directive and keep a tight rein on your practice attempts. Others are very hands-off, wanting you to try stuff yourself and so they respond to your questions and concerns rather than seek you out. Others are very process oriented and focus on your experience more than what you actually do.

The Supervisee: Some students come with hundreds of questions (some out of curiosity but most out of anxiety). Others want very specific directions and then try to act them out as was given. Others still want to talk about their own experiences and have a harder time recalling client responses.

Practicum students do well to prepare for supervision:

1. Before you begin, have some discussion about how the supervisor likes supervision to go? Do they have an idea about how they want you to function in it? Do they want it to happen just after your counseling experiences for the week so you can debrief? Just before so you can best remember what was decided?

2. When you bring your cases to supervision, come prepared to concisely summarize history, presenting problems, attempts to solve prior to counseling, family systems, current crises if present, work thus far in your counseling. Also, come prepared with a specific objective question you would  like to have answered. The more specific your question, the more likely you will come away with an answer.

3. Be sure to ask the supervisor to help you refine your hypotheses. This is a good opportunity to consider alternative ideas.

4. Schedule time when the supervisor can either watch you live or listen to a taping. There is NO better supervision possible. Scary? Yes. But essential if you do intend to become a good counselor

5. Be willing to ask (nicely) the why question when your supervisor gives you directives that don’t make sense. More than doing the right thing, you want to understand the critical thinking behind the right response.

6. Use your relationship with the supervisor to grow as a professional. This is one of your future colleagues. If there are conflicts between you, practice the good art of resolution. Don’t avoid and don’t attack.

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April 10, 2009 · 8:25 am

Must read: “The Other Cup” by Ray Dillard


Folks, it is “Good Friday” and if you are wondering why it is called good, you ought to read this sermonby the late Ray Dillard. CCEF offers it up for free on their homepage. If someone knows how to get a recording of it, that would be the only better option. I was present when he preached this quite a number of years ago. It is, by far, the best “Good Friday” sermon I ever heard. The cup of wrath is well-known to Christians everywhere. But there is another cup…

Ray Dillard was professor of OT at Westminster during my tenure and one of my favorites.

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April 10, 2009 · 5:49 am

Psychiatric vs. Psychological evaluations: What is the difference?


In place of my usual physiology Phriday post, I give you this…

“I think I need a psychiatric evaluation? Can you test me?” These are some of the questions I get from time to time. And they reveal an ongoing confusion about testings, assessment, evaluations, the world of psychiatry, psychology, and neurology. Interestingly, if you type in “psychiatric evaluation” into wikipedia, you actually get redirected to an entry on psychological evaluations and testing. So, let me try to differentiate a bit here:

What is a psychiatric evaluation? It is done by a psychiatrist who is a physician with special psychiatry training (courses and residencies). This evaluation is comprehensive but medical in nature. Expect the person to ask for your physical, behavioral, and cognitive histories, order blood tests or other medical exams, evaluate (by observation and interview) your mood, your reality testing, and mental status etc. Ultimately, after an extensive (and usually expensive) interview, the doctor will arrive at a psychiatric diagnosis (if appropriate) and may also recommend medicines to help with the problem–which they can prescribe. A few also provide ongoing talk therapy but most do not. Rather, they recommend you find a therapist for that part. They will follow up with med checks as needed to titrate or refine your medicines. When a person has a very difficult, complex, or lengthy history of mental health, or, when the person is needing a diagnosis for legal reasons, a psychiatrist is a good choice. They are usually gifted at extracting subtle physical and behavioral matters that may help correctly pinpoint the problem. While a person might well get anti-depressants from their regular doctor, a good psychiatrist is better able to deal with complex matters and follow you more closely to get the right compound and dosage.

Neurological Evaluation. Stating the obvious, a physician with neurological specialties and qualifications does a neurological evaluation. Neurologists specialize in…wait for it…the nervous system (brain, spinal cord, and 12 cranial nerves). A neurological evaluation includes many of the things evaluated by psychiatrists but with special attention to your motor and sensory systems, your reflexes, and similar kinds of things. You might more likely see a neurologist when you obviously have a neurological issue. Neurologists are more likely to specialize in ADHD, brain injuries, and psychiatric problems that result from dementias or other known physical problems. They are often better able to give and interpret MRIs and other imaging that might be appropriate. They will also prescribe and follow medications.

Psychological Evaluation, AKA testing, psych assessment. These are offered, mostly, by doctoral level psychologists. These evaluations will cover much of the same history, mental status, and provide diagnoses when appropriate. Interviews, just like the previous two options, are essential. However, what sets psychological evaluation apart is its use of standardized tests. These may be paper and pencil or electronic. They may be filled out by the client or by family members. The results provide a snapshot of behavior, or cognitive functioning, or mood by contrasting the individual results against a peer group. For example, a child may complete a computerized test to assess attention span. The results are compared to thousands of children taking this test who either are “non ADHD” and or ADHD. A good psychologist collects data from multiple data points (test data, interviews by client and maybe family, observations, etc.) and uses that data to make interpretations and recommendations for ongoing care. Usually, the best psychological evaluations begin with a very objective, specific question. Just throwing a bunch of tests at a person to “see what comes up” isn’t all that helpful. Just because something pops up doesn’t mean it is meaningful.

It is true that masters level therapists (licensed or not) give and interpret some tests. But most of the best tests can only be given and interpreted by doctoral level, licensed psychologists.

There are other types of evaluations. Neuropsychologists are doctoral psychologists with specialized training and help pinpoint brain injury, unravel more complex learning disabilities, etc. Neuropsychiatric evaluations are done by another similar but slightly different professional. You can check out their interesting history on this wikipedia page.

So, how do you choose what is best for you? Answer a few questions.

1. What do I really want to know when it is all said and done? What might help me decide how to proceed? The more specific you are, the more likely you can get the answer you want.

2. Do I think I need to focus more on physical options or behavioral options?

3. Do I think I’m likely to need medications? The physician types are better. Psychologists cannot prescribe meds (unless you live in Hawaii or are in the military).

4. If I am given a diagnosis, what do I need it for? Both doctoral level psychologists and psychiatrists are capable of giving you diagnoses. However, some people or systems value one opinion over another. Figure out if it matters for your purposes.

5. Am I looking for specific behavioral/relational suggestions? Then psychological evaluations are more appropriate.

6. Am I looking to form an ongoing therapeutic talk based relationship? See the psychologist.

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April 9, 2009 · 5:30 am

Final thoughts on roots of evil


Well not really. Just that I posted on Tuesday that I would add a few more thoughts on this topic. On Sunday, Terry Traylor preached on the last verse of Judges and the first part of Matthew 21. You can hear it here. In his sermon he gave a nice summary of the book of Judges and the cycle we find in it:

1. The people stop dealing with sin, begin to flirt with it
2. God gives them over to their desires. He lets them have what they demand.
3. The people slowly recognize the problem, take a long time to do something about it, but finally call to the Lord for help.
4. God raises up a protector/deliverer.
5. God provides a period or rest and safety

Unfortunately, the cycle repeats itself. Except for one small problem: the cycle is broken when the people fail to cry out to God for help but keep going on their way. We could call it the “butterfly effect.” When the people fail to get rid of the idols but accept forms of syncretism, then it allows temple workers (Levites) to make it okay to have a concubine in the first place. He doesn’t protect her when some rapists come his way. He shows her no concern after her rape. She dies and he doesn’t give her the decency of a burial but sends her body parts to the 12 tribes and tells only the part that makes others look bad. And ultimately this butterfly effect ends with thousands dead in a civil war and innocent women stolen and subjected to forced marriages. All because everyone did right in their own eyes.

It would seem that this is part of the problem in Rwanda. You have a rather religious/Christian population that flirts with hatred and jealousy of the other, turns a blind eye to neighbors doing violence to others and ends up with civil strife and genocide.

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April 8, 2009 · 5:16 am

Ramp up your helping skills!


Biblical Seminary is offering community education (non-degree) for those not able or not eligible for graduate education. It is a way to get a taste of what we do here. Starting next Monday night, Jenn Zuck (one of our counseling adjuncts) will be teaching an introductory counseling skills class for 6 weeks. If you’ve wanted to ramp up your listening and helping skills, wanted to see what we teach counseling students, or just wanted to improve your family relationships, you should enroll in this course.

By the way, the course isn’t just for your head. You will practice some new skills and you will find that your spiritual life will also be enriched.

Here’s the link for more info (flyer and syllabus): http://www.biblical.edu/pages/embark/about-us-upcoming-eventstest.htm

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April 7, 2009 · 5:50 am

Some more thoughts on the roots of evil


Continuing my reading about the tragedies in Rwanda, I’m now following the writer Jean Hatzfeld–thanks to my colleague Carol King. He has written a few books on the genocide in an attempt to give voice to both surviving victim and killer. “Machete Season: The Killers in Rwanda Speak” is a chilling mix of interview of 10 “killers” from the district south of the capital and background information

[FYI, for those following this blog for some time, my trip to Rwanda has been delayed until at least July. Pray that it happens then!].

For most of the world, Rwanda was a quiet, tiny country that exploded into Tutsi genocide in 1994 after their Hutu president was assassinated. One day it is calm, the next an entire population of Hutus begin systematically destroying their Tutsi neighbors. Even soccer teammates killed each other, with no remorse.  

But dig a little and you find out that this is not so. Despite living and working together, Hutus (the majority) felt the minority Tutsis (treated as the upperclass by Europeans in the formation of Rwanda) had too much power. Much radio and media did comic portrayals about the killing of cockroaches (the Tutsis). Apparently, they were so funny that even the Tutsis listened and laughed.

It looks like this is what happened:

1. Conflict between groups, fanned by leadership (read pp 52-58 for how it happened).
2. Use of both comic discussions of killings plus occasional actual killings going unpunished
3. Lots of free beer, food (many ate meat every day when normally they only ate it at weddings), and promises of rewards
4. Threats of violence to Hutus if they do not follow outsiders orders. These outsiders “apprenticed” farmers into killers.
5. A large group involved (100% involvement) with lots of camraderie so as to defuse guilty feelings.
6. A simple task ordered: kill.
7. The abandonment by the white individuals in the country and so gave the sense that the world didn’t care and wouldn’t hold them accountable.

This is quite a chilling book (because thus far there is no apology or blameshifting in the book by those being interviewed). Here’s one especially difficult passage:

For my part, I offer you an explanation: it is as if I had let another individual take on my own living appearance, and the habits of my heart, without a single pang in my soul. This killer was indeed me, as to the offense he committed and the blood he shed, but he is a stranger to me in his ferocity. I admit and recognize my obedience at that time, my victims, my fault, but I fail to recognize the wickedness of the one who raced through the marshes on my legs, carrying my machete. That wickedness seems to belong to another self with a heavy heart. The most serious changes in my body were my invisible parts, such as the soul or the feelings that go with it. Therefore I alone do not recognize mysefl in that man. (p. 48)

Tomorrow I will post one more on this topic: the pattern of running away from and then back to the Lord as seen in Judges. Or, how we stop seeing our sin and forget to cry out to God.

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April 6, 2009 · 5:03 am

Connecting the dots: porn and rape


A few days ago a young woman/teen was found partially clothed and semi-conscious under a Philadelphia bridge. At the time I am writing this post, it is assumed (nothing too outlandish here) that she was assaulted and raped and left for dead. Whether or not this turns out to be the exact situation for this injured woman matters not for the rest of the post. What does matter is that we know that rape happens.

How does one get to the place of treating another human being like an object and caring nothing for that person’s feelings, interests? We’d like to believe that rape, murder, slavery, trafficking, and the sort are different sorts of animals than the wee little sins we commit. But such heinous acts have exactly the same roots as “normal” objectification.

Take porn for example. On first blush, there is not any interpersonal crime in looking at a pornographic image. The assumption goes that the individuals in the pictures have voluntarily allowed themselves to be photographed and are happy with what they are doing. Of course, we know that these two assumptions are not always true. But even IF we accept the assumption, we must also accept that the viewer of the pictures cares nothing about the person in the picture. They exist for one reason only–to provide pleasure for the viewer. They have no feelings, they are only objects on a page.

The one dimensional image allows the viewer to begin the process of not seeing the other and not seeing their abuse of the other. And we are well aware of the common path of porn use. Start with a scantily clad image, move to complete nude, then to more and more dramatic pictures of sex acts which often include bondage, pain, or other grotesque acts.

Most people would have trouble watching a friend or a loved one engage in such an act, much less act out such activity on someone in pain. Most of us couldn’t just rape a stranger–at least at this point. But the root is the same: ignoring the personhood of the person in front of us. The person who is able to rape, traffick, or enslave has just been more successful in protecting themself from empathy, putting themself in the shoes of another, etc. We haven’t yet gone that far but notice that we begin such activities by our ability to objectify people on television or even in our everyday life. We murder (in our hearts) the incompetent bagger at the grocery store. We care little about his or her life. I’m not putting a passing hateful thought on par with rape but when we fail to recognize the person on the other side we begin to make it possible to deny the humanness of the other, whether a victim of a crime or the perpetrator.

Reminds me of Miroslav Volf’s quote in Exclusion and Embrace (p. 124): 

“Forgiveness flounders because I exclude the enemy from the community of humans even as I exclude myself from the community of sinners.”

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