Tag Archives: counseling

December 18, 2019 · 6:30 pm

Counselor failures: Choosing the wrong goals


Many moons ago, when I was a young counselor, documentation of treatment was left up to the therapist. Many kept no records at all. Some had hand written notes but were only for the therapist to remember the content or a insight they wanted to share at a later time. But, whether a therapist kept notes or not, it would be rare for the client to know anything about their documented diagnosis (even if insurance was paying) and even less about treatment goals.

With the advent of managed care, documentation of service rendered became a reality. At first these documents (diagnosis, treatment plan, quarterly summaries, termination note) were completed without client knowledge. Later, best practices required therapists to share, at least verbally, diagnoses and treatment plans with their clients. Hopefully, today’s client is a bit more informed as to this better practice and is in agreement with the goals of therapy.

But even when agreement exists as to the high level goal, counselors can find themselves working towards goals the client does not want, or, can be working a different path to a shared goal that doesn’t seem to fit the client.

Setting client goals is an easy thing?

While documentation of goals and objectives is relatively new in psychotherapy, setting goals is not. Client comes in, discusses presenting problem, therapist and client explore desired outcomes. As therapy progresses, goals may change due to circumstances or new learnings. Easy, right? Not so fast.

Shared goal, disagreement about the path

Let’s say I go to therapy to work on a phobia I have to flying. We agree on the larger goal and begin to work. Along the way the therapist wants me to try exposure to flying by getting on a high speed train to simulate the sensation of movement and loss of control. I resist because I do not feel ready. The therapist wants me to push through. I resist more. The therapist can continue to press, whether gently or forcefully, but this disagreement will hinder therapy if we do not get on the same page.

Disagreement about the way forward is commonplace in therapy. Sometimes, we therapists believe that our wisdom and insight is best. And, it may be due to the many other clients we have treated with the same challenges. But what the counselor does with resistance tells you a lot about that counselor and their capacity for “withness.” Do they,

  • Check in with the client to see what they are feeling when they resist? (Resistance can be about confusion, disagreement, need for encouragement, concern for consequences, etc)
  • Brainstorm about alternative objectives that might be possible? Sometimes small changes in steps make all the difference.
  • Pontificate about how the chosen path is the best? When we therapists feel defensive we can easily fall back on our expertise as a weapon to convince another that we know best.
  • Ask pointed questions that leave the client feeling shamed? “You do want to get better don’t you?”

Shadow goals

From time to time both therapist and client can work toward an unspoken goal, a shadow goal. Since we are focusing here on counselor failures, let’s consider what kind of shadow goals counselors might begin to pursue. Shadow goals are those that are not verbalized and yet have a controlling influence over the therapist’s words and stance in a session. Here are some examples:

  • Client comes for help with grief over a lost relationship but the therapist wants client to see how she is the cause of the lost relationship
  • Client comes for help in leaving an abusive marriage but the therapist is committed to helping the client stay in the marriage
  • Client presents with a mood disorder but therapist wants client to leave his dysfunctional church
  • Client want to become less dependent on others but therapist wants client to continue to need her help
  • Client seeks treatment for PTSD but therapist wants client to stop being needy or to terminate therapy.

Shadow goals are best addressed in supervision where therapists talk about their clients–and yes, talk about how they feel about clients. As therapists explore their feelings, shadow goals come to the surface and can be acknowledged and addressed. Their presence is not a sign of counselor failure or weakness. They are normal and part of what it means to be human. The only danger is these goals remain hidden and active. As long as they stay hidden (for lack of insight or because of shame), shadow goals will exert control and create confusion on the part of the client and the therapist.

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November 29, 2019 · 3:43 pm

Counselor failures: A short series


I recently passed my 29th year anniversary of mental health practice and 18th year as a psychologist. I’m not quite old but also have a few years under my belt. When I first began counseling as a counselor in my very early twenties I was fairly committed to proving my value. I wanted to diagnose problems and offer wise solutions. I’m embarrassed to say that I often thought I could do so in the first 15 minutes of a session. Sometimes I was right, but I can say for sure I hadn’t earned the right to speak. Needless to say, I wasn’t particularly helpful in those early sessions. Thankfully, I learned that if I was going to be helpful I needed to stop worrying about whether I sounded smart and had something valuable to say and instead spend my energy entirely on the work of listening and understanding the person in front of me.

Not listening to clients might be the first and most common failure counselors make. It can happen throughout a session or for just thirty seconds during a momentary lapse of concentration. While beginner counselors may struggle to listen well, seasoned therapists can lose their edge without even recognizing it.

Not listening can happen by means of trying to dictate goals. It can happen when we therapists talk about ourselves. It can happen when we misdiagnose a client. It can happen when we are bored, or irritated, or caught up in our own world of pain.

This little series is dedicated to therapist failures. We’d rather believe that our mistakes are really client resistance or family interference. But as we own our mistakes, we acknowledge that counseling is a human interaction that requires our willingness to evaluate our end of that interaction. While this series is written for mental health practitioners, I suspect clients will also benefit from this look inside, if for no other reason than to identify when they are not feeling heard.

Some related thoughts previously written

I’ve written a couple of blogs recently on related topics. The first is embedded in my last blog,

I’m going to skip over the large problem of counselors pressing for any change whatsoever. (Suffice it to say that pressing a client for forgiveness, confession, reconciliation, or any other action rarely works and more often causes harm. You cannot heal a trauma caused by misuse of power with more force–even if your goal is good.)

https://philipmonroe.com/2019/11/24/some-thoughts-on-when-restoration-hurts/

I will write more on the problem of choosing the wrong goals for counselees–or the problem of choosing goals in the first place. A few months ago I wrote about the problem of choosing reconciliation as a goal.

Some years ago, I wrote this list of common mistakes made by novice counselors.

Come back for the first post exploring the setting of goals in counseling and how not listening leads to the likelihood of failure.

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September 28, 2017 · 7:00 am

Trauma-informed Churches: Clinical, Pastoral, and Theological Support for Victims of Trauma


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.

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July 22, 2017 · 10:50 am

War-related moral injury: what is it? What helps? 


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.)

Definition offered

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.

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June 16, 2017 · 11:10 am

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.  

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April 13, 2017 · 4:13 pm

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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April 10, 2017 · 11:40 am

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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April 8, 2017 · 10:45 am

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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January 12, 2017 · 5:43 am

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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December 16, 2016 · 11:15 pm

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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