Tag Archives: counseling

Complex Trauma: Going Deeper, By Diane Langberg


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.

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Diane Langberg: Living with ongoing trauma


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?

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What does resilience look like in the face of traumatic experiences?


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.

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PTSD: A New Theory? An Old Treatment


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.

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Over-confidence? Under-confidence? Assessing counselor tendencies


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.

Erosion happens.

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?)

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Does your counselor have these two important skills? 


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.

Conceptualization

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

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? 

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Entering into the Emotions of Others: Thoughts by Winston Smith


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

  1. 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.
  2. 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.
  3. 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. 

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Ruminating: The Mental Health Killer


I teach a course on psychopathology. Each week we consider a different family of problems. We explore anxiety disorders, mood disorders (depression, mania), and anger/explosive disorders in the first few weeks in the class. Later on, we look at eating disorders, addictions, trauma, and psychosis.

While each of the presentations of problems vary widely from each other, there is ONE symptom that almost every person with a mental health problem experiences–repetitive, negative thought patterns. Rumination.

The content of the repetitive thoughts may change depending on the type of problem (i.e., anxious fears, depressive negative thoughts, illicit urges, fears of weight gain, hypervigilance, irritability, etc.) but the heart of the problem in most mental health challenges are negative thought patterns leading to an experience of either impulsivity or paralysis. These patterns can look like obsessional worries about germs (triggering ruminative “why” questions as to the root causes of the obsessions). The pattern can look like repeated negative self-attributions for perceived mistakes. Whatever the pattern, the person finds it difficult to break out of the negative thoughts and attempts at distractions seem futile since the thought or feeling returns in seconds to minutes.

Is there anything that helps?

Yes, there are things that you can do to reduce the “noise” level of these repetitive thoughts. It is important, however, to remember two important factors

  • patterns in place for years or decades are harder to change. Give yourself the grace to fail as you work to change them.
  • As with pain management, the goal should not be the complete elimination of negative thoughts and feelings. Realistically, anxious people will have some anxiety. Depressed people will feel darker thoughts. Addicts will have greater temptations. But lest you give up before you start, this does not mean that you must always suffer as you do now.

Consider the following three steps as a plan of action to address the problem of rumination.

  1. Build a solid foundation of health. Every house needs a foundation if it is going to  last. Your mental health foundation starts with your physical body: Exercise, diet, and sleep. Did you know that daily exercise, getting a good 8 hours of sleep each night, and eating a diet rich in protein supports good mental health and may even prevent re-occurrence of prior problems? Will this solve all your problems. No! But failing to get good sleep and eat a balanced diet of proteins will exacerbate your problems. Sleep is especially needed. The lack of it will multiply your problem. Of course, getting sleep is difficult when you are worrying or depressed. Thus, work to develop a different bed-time routine. Shut off your electronics, do mindless activities like Sudoku, develop rituals that help promote sleep. If you are having trouble with this or your diet or exercise, find a trusted person to review your situation. And avoid all/nothing thinking that often leaves us paralyzed when we can’t reach our goals. On this point, read the next step.
  2. Prepare for change by accepting your struggle. What, I thought this was helping me out of my struggle? Acceptance is the beginning of change. Consider this examples. You struggle with intrusive negative thoughts about your belly. You don’t like how it looks. You’ve tried dieting and exercise, but still it is flabby. Every time you look at yourself, every time your hand rests on your belly, you hear (and feel) that negative narrative. The first step in change is to accept the body you have and to find ways to like it, even love it. Sounds impossible but it is necessary to accept all your parts. This does not mean that you won’t continue to exercise and eat well. Marsha Linehan suggests that one part of change is to accept the problem as it is. In her Dialectical Behavior Therapy model she speaks of choosing willingness over willfulness. Willingness opposes the response “I can’t stand this belly” by saying, “my belly is not as I would like but it is not all of who I am.” “I can’t stand it…” becomes a willful and yet paralyzing response. Whereas acceptance acknowledges the reality and chooses goals that are within one’s power to achieve (e.g., healthy eating choices). Acceptance is not giving up but preparing for realistic change.
  3.  Start to move. Consider these action steps as the beginning movements you undertake in a long process towards the goal:
    1. “So what?” Our ruminations are often filled with interpretations and assumptions. There are times we can challenge them by attacking the veracity of the assumptions. But we can also ask, “so what?” So what if I have OCD? So what if have to fight every day to stay sober? So what if I have to manage my schedule so as to not trigger a bipolar episode? Challenge the worst thing that you are afraid of.
    2. Develop a counter narrative. Rumination is a narrative. Begin by writing and rehearsing a counter narrative. It won’t have much power at first compared to your internalized rumination but it will gain power over time. Work to refine it. Choose to repeat it as often as you see the trigger for the rumination. Make sure your counter narrative doesn’t include self-debasing or invalidating comments. If you have trouble writing one, use Scripture passages that speak of God’s narrative, through Christ, for you. Be encouraged that developing alternative storylines has shown capacity to alter chronic nightmares. If nightmares can be changed, then even more thoughts and feelings during the day.
    3. Practice being present. Much of our lives are run on auto-pilot. When we are in that mode, it is easy to fall into rumination. Work to stay present, to be mindful and attuned to your surroundings. Notice ruminations but let them slide on out of view and bring yourself back to the present. Use your senses that God gave you to enjoy the world he made. Smells, sounds, sights, taste, and touch all give you means to enjoy that world. Start practicing staying in tune with it, a few minutes at a time and build your capacity as you go.

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Filed under addiction, christian counseling, christian psychology, Cognitive biases, counseling skills, mental health, Mindfulness, Uncategorized

Reliving memories long after trauma. Why does it happen?


I just returned from a week’s trip to Lebanon to train participants in a Scripture-Engaged mental health-informed trauma healing program. It was a wonderful experience. I made new friends, heard important stories of hardship and God’s faithfulness. I ate good (no, great!) food, and saw some beautiful scenery. Now, as I try to get my body clock back on home time zone, I’m waking early. In those wee hours of the morning, many of these memories come without any seeming effort on my part. There are great ones–laughter, sweet times, a poignant story of pain and heartache, a story of courage–and the brief moments of terror in several taxi rides. Since we survived the taxi rides, these latter memories are no longer negative as much as they invoke a chuckle or two.

In a small way, I’m reliving and recalling memories. I can smell the smells. I can feel the tension of riding in the front seat of a taxi going 60 miles an hour on a city street or the driver’s attempt to squeeze between a barrier and a large truck at a high rate of speed with only inches to spare. I can feel it and see it. And I didn’t even try to recall either the good or the bad. They just appeared.

This is how traumatic memory works. You experience a trauma and later flashes of memory–painful, shocking, unwanted–appear after the subtlest of triggers. You do not merely remember it, you feel it. You taste it, as if it were happening again. They come in bits and pieces, flashes and images; rarely in a linear sequential fashion.

While most good and bad memories fade and are replaced by new and more salient experiences, some memories stay powerfully strong and consistently intrude into the present. Even when we tell ourselves, “We’re safe now. We are no longer in danger” or “You’re not a child anymore, you are grown up and don’t have to be afraid of being hit,” the memories and associated feelings keep coming. It is as if your logic and perceptions aren’t able to moderate the response.

Let me give you a little silly example. I once became violently ill  for 4 days after eating deli turkey. To this day I cringe and feel stomach pain when presented with deli turkey. That experience was more than 12 years ago. Yet still I react. I know that what is in front of me is not tainted but it doesn’t seem to matter to my stomach.  Sure, the reaction I have is minimal and faded compared to immediately after my illness. But it is not gone.

Why does this happen? What are the processes in play that keep us experiencing and reliving what may be old and distant–as if it were still present? What follows is brief and a relatively simplistic summary of two very complex processes. Use them to help you understand yourself or a friend and to increase your empathy for those trapped in such processes.

Memory and the Connected Self

Psychology focuses much of its work on the individual person–the self. However, the self never exists outside of social connections (or disconnections) with others. Our understanding of our self begins at birth with billions of interactions (smiles, frowns, words, touch, etc.) with others. As we develop and become aware of ourselves, we often have key experiences of success or failure that continue to shape our sense of self long into the future. Find someone with a powerful sense of failure and you will find someone who will struggle to interpret present success as indicative of who they are. Whether success or failure oriented, both outlooks form on the basis of how we perceive that others see us. It seems that shame and humiliation act as intensifiers making it hard to alter our sense of self even after corrective experiences. They turn me from “bad things happened to me” into “I am bad.”

Memory and the (dis)Connected Brain

In simplistic language, the brain is an amazingly connected and efficient organ firing constantly day and night. Memories are stored and accessed, intensified or eroded, and often altered through the firing of neurons. The efficient brain “learns” to access information quickly. Just as you no longer have to think to insert your key into a lock the right side up, you also no longer have to consciously recall a memory–it just happens. Because multiple hormones and structures in the brain are involved in memory formation, it stands to reason that ignoring a life-altering memory (and the full-bodied experience of it) is next to impossible. Structures like the brainstem, amygdala, hypothalamus, hippocampus are evaluating and communicating (or not) with high-level processing within the cortex even before you know it. Thus, a memory and its reaction is already well-underway before a person can think and critique such a memory.

So, are we doomed to be controlled by our past?

No. There is ample evidence that we can form new connections and minimize intrusive and unwanted memories. The brain is plastic. It is adaptable and changeable. And yet, we are not in the age of the MiB neuralyzer. God does not usually remove us from our histories or make them so distant they have no effect on us. Adaptation takes time and energy and rarely is so complete that the person no longer feels nothing when they recall a painful event (in fact, feeling nothing might be rather dangerous as it would be a denial of reality).

So, the next time you are beating yourself up for still struggling with the past (or are questioning why a loved one can’t move beyond a trauma), be gentle. Consider instead how you might develop a corrective response that accepts what has happened and gives opportunity for a new second response after the first automatic reaction.

 

 

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Counseling Advice From Lady Gaga?


Lady Gaga has a new song about the aftermath of sexual assault. Unless you’ve been living in a cave, you likely have heard of Lady Gaga who is known for crazy getups and stunts. Known in my household as the lady who wore the meat dress, she sings these words (I’ve included just a few lines) in the song “Til it happens to you.”

You tell me it gets better, it gets better in time
You say I’ll pull myself together, pull it together, you’ll be fine
Tell me, what the hell do you know? What do you know?
Tell me how the hell could you know? How could you know?

Till it happens to you, you don’t know how it feels, how it feels
Till it happens to you, you won’t know, it won’t be real
(How could you know?)
No it won’t be real
(How could you know?)
Won’t know how I feel

Her message is clear: If you haven’t been raped or assaulted (or experienced any other sort of trauma) you can’t possibly know what it is like. And since you can’t know what it is like, stop giving superficial comfort and advice.

Is Lady Gaga right? Does she offer sound counseling advice?

Yes and no. Yes, we are far too willing to offer platitudes to people in pain and wonder why they get angry and hurt and avoid us altogether. Lady Gaga captures the sentiment of the doubly hurt–first by the initial trauma and second by foolish words. The ancient Greek Aeschylus aptly puts it this way

It is an easy thing for one whose foot is on the outside of calamity to give advice and to rebuke the sufferer

Our quips roll easily off the tongue, but they injure the already wounded. Before you speak to someone and offer your ideas, do your friend a favor and be quiet. Ask them again (and again) to tell you what they experienced (past or present tense). But I don’t think Gaga goes far enough. I would argue that EVEN IF you have experienced the same trauma as the person in front of you, stop thinking that you know what they are feeling and struggling with. You may, but you may not as well. Do not assume your experience is theirs. Listen. More than you think you need to. Assumptions of “getting it” communicate that their pain doesn’t really matter to anyone.

But also, Lady Gaga is wrong (and I get it, this is art not counseling skills training!). It is possible to help others even when you have not had their experience. As long as you approach your work with humility and the heart of a student, you can do much good. You bear witness to their experience through your reflections and observations. You can ask good questions and paint word pictures of trajectories of growth. Do not think that just because you did not have the trauma, you have nothing to offer. Offer yourself (more than your words). If you fail to offer yourself out of fear of not being adequate, you also harm by not giving the present of being understood.

But let Gaga’s anthem be a challenge to those of us, myself included, who speak before listening and who assume rather than learn. We won’t get it. But we can bear witness.

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