Today I will be presenting a one hour breakout at the 2017 AACC World Conference in Nashville, TN. If you are interested in seeing the slides, down them here.
Tag Archives: counseling
I’m reading David Wood’s What Have We Done: The Moral Injury of Our Longest Wars (2016, Little, Brown and Company). David is a journalist and has experiences embedded in military operations in Iraq and Afghanistan. PTSD is well-known and discussed, especially in the context of war. If you have listened to the news, you know that many veterans struggle with it and struggle with return to civilian life. Suicide rates of current and former military members should grab your attention and tell you that we have a serious problem on our hands. If you have read further, you probably have heard about treatments such as Prolonged Exposure and Cognitive Processing Therapy being used by VA mental health practitioners.
This book, however, introduces readers to the concept of moral injury, a cousin to PTSD. While the features may look similar to PTSD, moral injury may better account for some of the experiences, especially where terror (the emotion, not behaviors) may not have been the main experience.
The book opens with a story of a Nik, a Marine whose position came under fire from a small boy with an assault rifle.
“According to the military’s exacting legal principles and rules, it was a justifiable kill, even laudable, an action taken against an enemy combatant in defense of Nik himself and his fellow marines. But now Nik is back home in civilian life, where killing a child violates the bedrock moral ideals we all hold. His action that day, righteous in combat, nonetheless is a bruise on his soul, a painful violation of the simple understanding of right and wrong that he and all of us carry subconsciously through life.
… At home strangers thank him for his service, and politicians celebrate him and other combat veterans as heroes. And Nik carries on his conscience a child’s death.” (8)
The author goes on to argue with illustration after illustration that to go to war is to suffer moral injury, to suffer the disconnect between deeply held values and the experiences during war. While it is easy to see moral injury in the forced choice to kill a child vs. save one’s own life, moral injury can also result from being sent on a fool’s errand–political reasons sent to war vs. need to protect or defend freedoms.
PTSD v. Moral Injury?
Post-traumatic stress disorder is biology. It is the body’s involuntary physical reaction as we relive the intense fear of a life-threatening event and the scalding emotional responses that follow: terror and a debilitating sense of helplessness. (15)
He goes on for paragraphs to depict the experience of PTSD and its cascade of symptoms–“fear-circuitry dysregulation.” But then listen to how he talks about Nik
…Nik doesn’t have PTSD. What Nik struggles with is not the involuntary recurrence of fear. He’s okay with the crowds at Walmart. He doesn’t startle at loud noises. In contrast with veterans who’ve experienced PTSD, Nik didn’t feel the pain of his moral injury at the moment of the incident…. [But] he is bothered by the memory of that Afghan boy and with questions about what he did that day. Like all of us, Nik had always thought of himself as a good person. But does a good person kill a child? …No, a good person doesn’t kill a child, therefore I must be a bad person. …The symptoms can be similar to those of PTSD: anxiety, depression, sleeplessness, anger. But sorrow, remorse, grief, shame, bitterness, and moral confusion–what is right?–signal moral injury while flashbacks, loss of memory, fear, and startle complex seem to characterize PTSD. (17)
PTSD has little to do with sin. It is a psychological wound caused by something done to you. Someone with PTSD is a victim. A moral injury is a self-accusation, prompted by something you did, something you failed to do, as well as something done to you. (18)
Guilt and shame are key characteristics. Not being able to save a buddy, making a quick decision that also included losses of civilian life, betrayal by leaders but being forced to carry out orders, or not being protected by buddies–all can create a moral injury. Add a mega dose of grief/loss from death and loss of companionship after the unit breaks up and you have a serious problem. (Don’t forget once home and safe, the loss of adrenaline, the loss of status, the replacement of dullness and the rebuilding of old relationships without your friends and without purpose will enhance all painful feelings including nagging guilt and shame.)
The lasting psychological, biological, spiritual, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. (250)
Spiritual community interventions?
Despite their attractiveness, short-term interventions like CISD aren’t effective (chapter 6 details this). In addition, straight up attempts to challenge distorted thoughts are likely to fail. So, what might work? The book details some listening and validating activities by chaplains, including the burning of cards listing their “sins” as they leave the battlefront symbolizing their remorse and reception of God’s forgiveness. Talking about guilt, confessing failures and shame seem central. Note that confessing and validating do not necessarily mean that others agree that sins have been committed or that perceptions of self are accurate. They merely acknowledge the burden the veteran carries. Even the secular therapy models validate feelings of guilt while finding acceptance and forgiveness. Saying, “don’t blame yourself, you couldn’t help it” to Nik aren’t helpful. Finding a path that doesn’t blame or excuse (237) allows for a different path between all or nothing shame responses.
It seems that what spiritual mentors and Christian practitioners have to offer in light of these themes are central to recovery from moral injury.
The reality, says the author, our current therapies are only marginally helpful and sometimes harmful. Near the end of the book he concludes with this conviction,
True healing of veterans with war-related moral injuries will only come from community, however we and they define community–peers, neighborhoods, faith congregations, service organizations, individuals. That means it is up to us. (260)
And thus, YOU have a job to do.
Listen. I highly recommend you read his last chapter (“Listen” begins on page 261). He will tell you how to engage a conversation in order to learn. No matter your personal beliefs about war, this is something you can do. Don’t look for the government to do the job, be the one to listen and learn yourself. Be the one to bear witness, as silently as you can. Your presence (more than your words) will convey compassion, understanding, and God’s presence.
Dissociating during trauma makes PTSD worse by increasing negative narratives about the self? Connecting recovery with rejecting these narratives
It is somewhat common for individuals to experiences a period of dissociation and/or perception of being frozen and unable to move during a traumatic experience. Dissociation is a catch-all word to describe experiences where a person is somehow disconnected from a portion of their senses making what is happening feel somehow unreal. Experiences can include emotional numbness, feeling events are not real, not feeling in one’s own body, or not remembering what just happened.
In the April issue of the Journal of Trauma Stress researchers discuss possible connections between experiencing dissociation during a trauma and increased negative beliefs about the self. Dissociation during a trauma is called “peri-traumatic dissociation.” It is already understood that peri-traumatic dissociation is a strong predictor of subsequent PTSD diagnosis.
This short study suggests that those who have dissociative experiences during trauma may be more likely to think negatively about themselves, both about their trauma experiences (e.g., I should have been able to stop it) and their present feelings about themselves (e.g., I’m unreliable). The researchers suggest that therapists ask clients about both forms of negative views of self if the client describes dissociative like symptoms during the trauma experience.
It would have been helpful if the researchers connected their work with that of shame experiences. We continue to try to understand why some people find some experiences more traumatizing and thus have greater difficulty finding recovery. It seems that shame is distinctly tied to chronic trauma and being stuck in negative self-talk narratives. It may be that those who struggle the most with negative self-talk (I should have been able to stop my abuser) experience the most shame. But I have yet to see anyone try to parse that out.
In my experience, negative attributions about the self are just about the hardest things for us to change. We may have developed these well-formed beliefs from failure experiences or we may have had them formed for us by our families. But whatever the cause, they are so very hard to let go. In fact, when others show kindness to our perceived uglyness, we tend to pull back, refusing to allow these parts to be acceptable.
What is it about letting go of our shame and accepting ourselves as normal, as valuable? How would you articulate the problem?
*Thompson-Hollands, J., Jun, J.J. & Sloan, D.M. (2017). The Association Between Peritraumatic Dissociation and PTSD Symptoms: The Mediating Role of Negative Beliefs About the Self. JTS, 30, 190-194.
As part of our staff meeting today we watched this video by Diane Langberg. It reviews the 3 stages of typical trauma recovery process plus focuses on the impact of the work on the counselor. Self-care is a common conversation these days. However, a few lines stuck out to me:
Unless we take care of ourselves, we will not be able to bear witness…. Vicarious trauma is not something done to us but a consequence of having empathy…. Evil and suffering also provide an opportunity to expose the weak places in [the counselor]…. Seek out the antidotes to the poison that you sit with…[these antidotes] are not just good coping mechanisms but part and parcel to living the life obedient to God.
A few years ago, Dr. Diane Langberg gave a talk about ongoing trauma experiences, when there is no “post” in the posttraumatic stress disorder. When there is no after trauma yet (e.g., ongoing domestic violence, living in a war zone, etc.), what kinds of help and hope might a survivor hold on to? Is there anything that can be done?
Does a resilient individual appear as if stress and trauma has not lasting impact? Does it mean we bounce back as if it never happened? Are there better ways to think about resilience in real life?
In 2014 I gave a presentation reviewing the topic of resilience (definition, examples, threats to, and helps) at our annual Trauma Healing Community of Practice hosted by the American Bible Society.
Sometimes we consider only resilience as an individual trait. I spend a bit of time talking about community resilience. Video is 25 minutes and associated slides (not embedded in the video) can be found here: 2014 COP Resilience.
Researchers Liberzon and Abelson at the University of Michigan have published an essay articulating a new way of conceptualizing what is happening in the brains of those with Posttraumatic Stress Disorder. While you can’t read their essay for free, you can read this good summary here.
What is their new theory? the neurobiological problem of PTSD is “disrupted context processing.” In simple terms, I fail to respond to the “stimulus” in its proper context when I am triggered by old experiences in a new setting. Even more simply, when I wake up on full alert in the middle of the night after smelling wood-smoke in my sleep I initially fail to recognize the context (my neighbor burns wood) and immediately think my house is on fire (as it once was). Thankfully, the alertness is less than it used to be and I don’t always get up to check on my house.
The authors suggest that 3 separate and current brain models are inadequate in their scope of understanding the brain’s activities in PTSD. From their perspective the “fear model” (Fight/flight learning), the “overactive threat detection model” and the “executive functioning model” work best when integrated into one unified theory with their new label. And, in true humble researcher fashion, they request help in testing this model to see if indeed it can carry the freight.
An Old But Essential Treatment?
It is good to have a better handle on what is happening in the brain when someone experiences PTSD. Neurobiological research is growing by leaps and bounds. It is hard, frankly, to keep up. And yet, let us not forget an old but essential part of PTSD treatment, the person of the therapist. Humans are designed to be in relationship. PTSD has a way of shattering connections with others and thus the treatment must reverse the disconnect. Being present and bearing witness to trauma will always be the first and primary intervention every therapist must learn. Our temptation is that we want to move beyond the bearing witness phase into change phases. While this is understandable (we want others to get better as fast as possible), we sometimes want this for our own reasons–to avoid the pain we experience in sitting with traumatic experiences of others.
Let us remember that we therapists (and pastors, friends, etc.) are the primary intervention when we are present with those who suffer, when we become a student of their suffering. All other treatment activities stem from this foundation. To use a different analogy, consider Dr. Diane Langberg’s meditation, “Translators for God” (Day 26 of In our Lives First). In this meditation she describes the experience of being translated in a seminar. The translator must fully understand both languages in order to accurately communicate the speaker’s words into the heart language of the hearers. Counselors are translators for God and for healing. And yet, if they do not deeply learn the heart language (pain and trauma experience) of the client, they will not be able to connect the client to healing and to the God who heals.
Every counselor desires to be effective, to handle client concerns and problems with competency. We do this work because we long to see others recover quickly and we do not want to get in the way of needed and desired growth. Early career counselors often feel out of their league and so seek out all the help they can get: supervision, books, essays, and peer-consultation. This is the proper way to learn and become better at our craft.
But what happens when we begin to feel competent and confident? Do we stop feeling needy? Stop seeking input? If we do stop pursuing growth and increased competency, skills and capacities will erode. We might think all is well, we’ve got this under control, but in reality we would enter dangerous territory. Imagine wanting to be an Olympic athlete and yet forgoing training.
So, should we want to feel less competent? No. The goal is not to feel ineffective nor to lack confidence in what we do. I would not want a second-guessing surgeon to operate on me. Rather, it is important to maintain regular (not obsessive!) self-examination and invitation to others to give you input and feedback.
For the possibly under-confident counselor:
Where do you feel you need help, are less competent than you would like? What are your common responses to that feeling? Who have you talked to about this problem? Where have you sought help? What continuing education have you completed? While it is good to get help to “know what to do” don’t forget that a large portion of therapeutic success is attributed to who you are in the session. Be sure to focus on your listening, and “bearing-witness” skills. Remember to be a student of the client.
For the possibly over-confident counselor:
Do you still have supervision? If not, why not? Look over your caseload. Who are you working with who you have not reviewed assessment, diagnosis and treatment plans with another (note: peer supervision can be done without revealing confidential or private information)? When was the last time you verbalized your case conceptualizations with a critical eye to the potential myopia that plagues us all? What continuing education have you completed that can revise and improve your skills? While relationship-building skills are the most important, do not stop learning and growing in knowledge and understanding.
It is good to remember that our skills WILL erode without attention, just like muscles with grow flabby without exercise. One such muscle for the Christian counselor is that of prayer. Consider your recent counseling activities and ask how prayer has fit into your work. Is it a perfunctory or an afterthought? Does is change depending on how you feel about your competency? What does it reveal about your therapeutic operating system (e.g., what is the source of power to change?)
I love working with counselors-in-training. We get to discuss everything from diagnoses to interventions, ethics to theology, character development to politics. I know I’m biased but along with the population of Lake Wobegon, our students “are all above average.”
That said, there are two extremely difficult counseling skills every student needs to learn–frequently the hard way. To be an effective counselor, you have to be able to conceptualize a person and their presenting problems well (e.g., wrong assessment leads to wrong treatment) and you have to maintain a clinical alliance throughout the course of treatment. Of course, a counselor needs to be of good and mature character. She needs to have a bank of excellent questions to ask, a knowledge of common intervention strategies, and a good ear to hear what the client is trying to express. These things are necessary foundations for the skill of conceptualization and alliance.
When you come to counseling to discuss a challenge in your life you want the counselor to be able to understand and put your situation into proper perspective. You expect them to have some expertise beyond your own–otherwise why go? As you tell your story, it always has missing and disjointed parts. There are dead ends and mysteries that may start out feeling important that in time become less a focus than other issues. Your counselor needs to put the problems you raise into some context. What lens to view the problems should be used?
- Is the conflict between a mother and teen best understood by the lens of enmeshment, Attention-Deficit, autism, sinful pride, depression, anxiety, rebellion or…?
- Is the conflict between a husband and wife best understood as lack of knowledge, demandingness, personality disorder, emotional abuse, etc.
An effective counselor uses multiple lenses to view his counselee and holds those lenses loosely in recognition that first impressions need refinement.
Do you feel heard or pigeon-holed by your therapist? Does your therapist discuss possible ways to look at the problem you have and thus different ways to approach solutions?
Alliance is a hard thing to describe but it encompasses a trust relationship where therapist and client work in concert to explore and resolve a problem. There is agreement on the problem definition and the process of therapy. There are several things that seem to be part of this concept but fall in two key categories: techniques and stance. A good therapist asks great questions that enable a person to feel heard as they tell their story. A good therapist validates the person even if they do not agree with interpretations of the client. A good therapist makes sure that the client knows they are more than the sum total of their problems. Finally, a good therapist checks in with a client to find out how they are experiencing the therapy session and approach. But good questions and feedback are not the full picture of alliance. The therapist needs a stance that reflects being a student of the person; of collaboration over action. It reflects an understanding of pacing and the client’s capacity to process information.
A counselor can understand a problem but if they rush ahead or lag behind in pacing, the alliance will fail. Consider this example. Therapist A meets with a client with a domestic violence victimization problem. It is clear to the therapist that the client needs to move out and that the client is resistant to this idea. The clinician presses the client to leave and challenges her to see her husband as an abuser. While the counselor may be correct, the confrontive and authoritative stance is unlikely to bear much fruit and will either create defensiveness or passivity in sessions. One sure sign of poor alliance is when a therapist is constantly thinking about how to get his or her client to do something.
Meanwhile, Therapist B meets with the same client and explores the ambivalence she has towards her husband and the abuse. Options are discussed, less for movement sake and more for examination of fears and opportunities, hopes and despair. Both therapists have the same sets of good questions, but one is more aware of the pacing of the client and meets her where she is where the other one forces a pace the client is not ready to match. This does not mean a counselor never pushes a client but it does mean they never do that without the understanding and agreement of the client.
Alliance is not a static feature. It grows and shrinks during the course of a relationship. There are ruptures and hopefully repairs. Sometimes a rupture leads to an even stronger alliance if the repair leaves the client feeling cared for and respected. Ruptures are not always caused by the counselor but it is the counselor’s job to notice and to work to resolve.
Do you feel like you are on the same page with your therapist? Do you have evidence (not just fears) that your counselor is frustrated by you? When you have a “miss” in a session, does your therapist acknowledge it and talk about how you are feeling about therapy? If you bring up an rupture, are you listened to?
Winston Smith delivered an extraordinary plenary about how we enter into the pain of others. He began by telling the story from Good Will Hunting, an exchange between the Matt Damon character and his therapist, Robin Williams. The exchange illustrated the difference between having loads of knowledge about love or hurt and a true experience of love (or hurt). Knowledge knows nothing in comparison to experience. Winston then talked about an early counselor experience he had where he listened to a person’s pain but only critiqued it rather than entering in. He acknowledged the danger of biblical counselors to whip out a 3 trees chart and assessing them, thereby invalidating their experiences of pain.
Instead, he suggest a better path
- Enter in. Really listen to them. Don’t imagine how you would feel in that situation as that will cause you to think and respond to yourself, not to the concerns and needs of the one who you want to help.
- Connect to their experience. Don’t go first to fixing or giving perspective. That can be helpful in the right time. When you are trying to connect, that is NOT the right time.
- Care. Let their grief become yours. Caring does not mean agreeing. And when you see strong responses or biases, we start to think that care means to correct. There is something true enough that you can start with their experience.
(By the way, I find most first year counseling students really believe they are ready and willing to do these. But here’s where the challenge lies. You sit with someone and they begin telling you their pain. You convey a few connecting and caring responses and then after 5 minutes, you have nothing else to say. You are already wanting to comfort, give perspective, gently correct. We really do struggle with sitting with another’s pain. It makes us uncomfortable)
There is a cost to entering in. It will cost you your comfort.
These 3 steps are quite hard even as they are simple. They are skills to be learned, but Winston reminds us that it is mostly hard because of something within. Why hard? You have to connect to something inside yourself that enables you to connect with them. You need to connect to fear, to grief, to despair, to rage. It will cost you something to do this well. You have to be willing to be uncomfortable.
So why would we do this? Sincere love calls us to enter in. It isn’t just a motive; love is a person. We can do this because we know and are connected to Jesus. His nature is love, willing to leave his comfort zone and enter into the world of another. He becomes one of us. Want to give the same love to others? Experience God’s entering into your world.
He ended with 1 John 4:12: No one has ever seen God. But if we love each other, God lives in us, and his love is brought to full expression in us. So enter in with boldness.