Tag Archives: counseling

May 19, 2010 · 5:51 am

Suicide assessment mistakes


Yesterday’s post was about suicide. Counselors sometimes fail to adequately evaluate suicidal ideation, plan, or intent in their counselees. Some years ago, I ran across a research study looking at the most common mistakes made by 215 masters level counselors when dealing with suicidal clients. I’ve lost the bibliographic data for the article and couldn’t find it easily in Psychlit…

Here are some of the mistakes (in no particular order):

  • Superficial reassurance (“you have so much to live for”
  • Avoidance of strong emotions (not allowing client to express strong despair–usually with first bullet point)
  • Professionalism (cold and distant, possibly seen as uncaring in assessment)
  • Inadequate assessment (failure to explore fully because of nervousness or fear of asking)
  • Failure to identify precipitating causes (most suicides have both current and historical precipitating events. Counselors may identify historic event (e.g., divorce 4 years ago) but miss the current precipitant.)
  • Passivity; failure to be empathic (25% took this stance)
  • Insufficient directness. No contract to not harm, no next steps
  • Overbearing advice. Counselee needs to be involved in the planning for safety
  • Stereotyping response (“She’s just a borderline!”)
  • Defensiveness (usually about whether hospitalization is necessary)

Every counselor worries about how they will perform when addressing the serious problem of suicide risk assessment. We do well to review (a) our natural inclinations when stressed (e.g., do we tighten up, become over-controlling, too professional?), (b) our standard of practice when confronted with despairing or suicidal clients, and (c) our assessment procedures with all clients. While there is no way to prevent the suicides of highly motivated people, we can increase our capacity to respond well to those the Lord sends our way.

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May 18, 2010 · 11:22 am

Helpful read on the warning signs of suicide


Sunday’s lead story in the Philadelphia Inquirer unfolds the tragic story of two high school girls who committed suicide by stepping in front of a speeding train last winter. The death of a child is always a tragedy. But death by suicide exponentially multiplies the pain. Could anyone see it coming? Could they have prevented it?

The story in the paper details the texts and social networking trail of tears leading up to their final actions. If this event happened when I was a child, the parents might have been left with a note or a journal to pour over looking for clues. But, in this case, there are texts and posts over a long span of time. Even worse, the girls made a number of final texts just before their deaths. It appears that loved ones searched frantically for them while “watching” cyberspace during their final act. I can only imagine that this “real time” aspect multiplies the trauma for the family.

Can we learn anything from this? Yes, I think so.

  1. Pay attention to your child’s (or friend’s) social networking and texts. Clues to their state of mind may well be evident.
  2. Act on concerns; take stock of their actions and attitudes. Per this case, it appears there were efforts to help them. Probably not enough. But let us not judge the family here. It is far too easy to become complacent. A child has strong feelings that they express over a period of time, thus making suicidal expressions normal. After the fact the signs seem so obvious. During the stress, it is hard to discern how bad it really is.
  3. Compounding suffering requires additional interventions, whether the child wants it or not. One girl’s father committed suicide, parents’ divorced requiring a move and change of school, a boyfriend was killed by a car. The more these kinds of experiences happen, the more attention the child needs by mentor or mental health workers.
  4. Even good schools won’t likely pick up on problems. Don’t assume school counselors have enough time to respond. It is not that they are incapable but the sheer number of students to follow makes their capacities limited.

Know that some people commit suicide and no one could have predicted it. Be wary of judging family members. They will live with enough guilt on their own. And yet, look for this recipe of pain and perceptions (summary of Jeff Black’s booklet):

  1. Strong powerful experiences of pain
  2. Perception that the they cannot tolerate the pain
  3. Hopelessness and inability to see alternatives other than relief via suicide
  4. Isolation

Other risk factors to consider: previous attempt? Suicidal ideation/plan? Hospitalization (even for non-psychiatric reasons)? Access to lethal means? Depressive anger coupled with impulsive history. These factors aren’t that helpful by themselves but looking over the total may provide *some* clues.

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May 12, 2010 · 12:24 pm

Professional communications by counselors: What do they reveal?


What we say and how we say it can tell someone quite a bit about our character. We counselors earn our keep with words. And yet, it is our words that may do the most harm to others. As a result, I encourage us to take stock of our words. What do they reveal about us? Oh, and don’t just consider the words you use in a session. How you talk to a colleague, about a colleague, to another professional may reveal your character more than you think. Consider the following communication issues:

1. Client put-downs. In agencies where counselors share clients with other professionals (e.g., psychiatrists, social workers, community workers, etc.), it is common for conversation to descend into put-downs. No doubt these professionals care about their clients. But if they are frustrated with the client, does it result in blaming the client? Making fun of their idiosyncracies? “He’s such a narcissist; She’s so Borderline”. These kind of comments reveal more about the speaker than the one spoken about.

2. Professional Lingo. Every guild has its lingo. Read a psychiatric or psychological evaluation and you will likely come across a number of words that only make sense if you are on the inside. The client probably wouldn’t really know what is being said about them with translation help. What do your progress notes communicate? Who are you writing for? How might our lingo hinder our work. I highly suggest that use the client as a standard to evaluate all our written communications. If the client couldn’t understand or could possibly be harmed by what we write, the think better of it.

3. Professional Territorialness. We communicate with other professionals about our clients. Does our communication reveal any condescending attitudes? Any unnecessary hierarchy? How do you talk about another professional to clients? To other colleagues? Do we withhold data for power reasons? For fear of mis-use by the other. If so, we have serious issues to address. Leaving them unaddressed will only injure the client.

4. Unprepared staffings. Staff communications regarding shared clients often include off-the-cuff comments about clients. These kind of statements can sound as if they are well supported by data. Sadly, we can offer up anecdotes about a client and they are weighted as heavily as objective test data. Can we support our comments and insights with data? Are there other data that might challenge our offered hypotheses?

5. General coarseness. I once had a supervisor who used the “F” word in every sentence (and in every form of speech possible). He relished the power he got from using that word. I’m not opposed to ever using curse words but they usually reveal more about the user than the situation. More recently, I’ve noticed how frequently we use genital imagery to talk about important character traits. “Do you have the stones to do that?” I heard this question asked in prime-time television. Why couldn’t they just talk about the trait of courage? I do think that language has a way of devolving in the heat of battle. Counselors work in the trenches and so it stands to reason that they might slip here some.

6. General grumbling. It is easy to slip into the habit of grumbling. I am tempted to revel (yes revel since I think I enjoy it some) in pointing out the failures of other people. I feel better when I can see their mistakes that I would never commit. We grumble against people, against institutions, against policies; against pretty much anything that irritates us.

Let us be diligent to explore what our communication reveals about our hearts and character and let us resolve, with God’s help, to love others even when they are not watching–and to model that love in our speech.

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May 11, 2010 · 10:12 am

Changing Your Narrative in Counseling?


If you have gone to counseling, then you probably wanted something to change in you or something connected to your life. If you have counseled someone or been their wise friend, you also wanted something to change. There are a variety of ways to try to calculate or observe change. Is there a reduction of unwanted behavior or an increase of hoped for behavior? Is there a change in affective or perceptual change (i.e., do I feel better or have more hope?)? Is there more insight? More acceptance of what cannot be changed? Greater responsibility taking for what can be changed? Is there greater congruence between faith and practice, head and heart?

While everyone (counselor, counselee, insurance company) wants objective evidence of positive change to prove that counseling was worth the cost and effort, the most powerful and most valuable change gets little attention. What is that change? Script or narrative change. We all live by a storyline. We use that story line to make sense of our world and of ourselves. However realistic we think we are, we never really use all the data to determine our reality. Rather, we use scripts to fill in blanks and supply us with the “truth.” Don’t think this is true? Just examine the common fights of a couple. Most likely you can remove the content of the fight and you will find an enduring pattern of feelings and perceptions about self and other in each spouse.

How did we get these scripts? We have experiences of self in the world? We make interpretations of what we experience. Others communicate interpretations for us. But we are not blank slates, we come to these experiences with a distorted imago dei–a God-given image and agency that is both active and yet distorted due to Sin.

So, how does counseling change a script or life narrative? There are a couple of options. You can begin with behavior change. Changes in behavior may cause someone to re-evaluate view of self and other. For example, a person may move from “I can’t” to “I can” based on the evidence in behavior change. You can begin with insight. What is my dominant life narrative and is that really accurate or is there a better one to live by? You can begin with relationship. This form of intervention is less clear but probably more powerful than the first two. By focusing on the “here and now” you are having an impact on narrative as it plays out in the moment. In opposition to insight which pulls narratives apart, this form of intervention is predominantly an experience that shapes the narrative in a more implicit fashion. In other words, we realize the change sometime after the fact.

What you cannot do is exhort someone into a new script. When we try (and we do sure try: “Don’t be afraid of ____ …It isn’t that bad…”), we fail. Even if the counselee “buys” the new script, they have only listened to you say it. They have not yet written it on their heart. Passive acceptance ought not be mistaken for real change. In fact, sometimes hearing the needed change over and over only makes the person more resistant to it. A change in script must be practiced and owned for it to become real. That is why an addict may well become sober by accepting the limits imposed by others and still yet remain an addict at heart.

Narrative changes usually take time. It is possible for powerful experiences to create instant change in our view of self and other. Certainly conversion experiences are evidence of massive script changes. Many of us have had powerful “a-ha” moments that also change our perception of self and the world. But most of our script changes happen via the drip method–water dripping on rock does indeed make changes when viewed over the long haul. When we look back on our lives, we often note places where we have indeed changed–sometimes for the better, sometimes not.

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For more on intervention points in counseling, check out this post I wrote 2 years ago. I tried my hand at illustrating both the script and the intervention points.

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May 4, 2010 · 10:47 am

Clicking with your counselee


In every first session with a client I tell them that part of their job is evaluate whether I am the right therapist for them. While it is very important that your counselor is well-trained, if you don’t click with your counselor, the work you are trying to do will be much harder. Now, of course it often takes a few sessions to determine whether you can form a trusting, collaborative relationship or not.

I am always thankful when a client is willing to raise the “fit” problem with me. It gives us an opportunity to explore the disconnect, fix it if possible or happily refer to someone else. Too frequently disconnected clients choose to either keep plugging away (but being less and less vulnerable) or just fade away and you never know what went wrong.

But what if the counselor doesn’t connect with the client…and the client doesn’t know it? What should the counselor do?

1. Use supervision or consultation to explore the disconnect. Maybe the disconnect will reveal something useful about the counselee. Maybe it will reveal some pride or prejudice in the counselor. Maybe it will reveal some naiveté or lack of competency or empathy or conflict over goals. Or, maybe it will reveal some cultural differentness that is really hard to overcome.

2. Assess whether or not (again using supervision) whether progress is being made. Is the counselee growing in insight? Gaining control? Showing more fruits of the Spirit? Seeing a decrease in anxiety or depression? The counselor may need to reassess their goals for the client.

3. Consider attempting more “here and now” to explore what is going on in the relationship between counselor and counselee. HOWEVER, do not do this to tell them how you are feeling NOR to be condescending. This action is designed to help both of you to be more present and decrease disconnection.

4. If all else fails, refer. This would be appropriate if (a) you believe you are not competent to help them or impaired in some way (and you should communicate your lack–in a limited way–to the client when discussing referral), or (b) you believe the problem is that counseling is harmful (and again you should discuss why you think this way and what the options might look like for them. Remember to avoid abandoning them. Referrals are specific, take time, and are for their best interest, not yours.

The bottom line is that the onus is on the counselor to work through the disconnect and to do all that he or she can to fix the problem or to tolerate it if the client is making good progress. This is what it means to “love one another.” We fail to do so if we either ignore the problem or use the disconnect to get rid of counselees that do not feed our egos.

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April 26, 2010 · 7:46 pm

First session requirements?


Today marks the third week of my Practicum and Professional Orientation class. This is the first opportunity for many of my students to begin live counseling experiences in their Practicum settings. Most seem to be settling in nicely.

If you have been a green counselor in your first session then you know the terror of: “What will they say???? What will I say????” It doesn’t matter if you have a 10 year file on the client or a 1 sentence “presenting problem”, the green counselor cannot predict the outcome of the session–hence the fear.

To alleviate some of the fear, let’s review what makes for a good first session.

1. Introductions. Make sure they know who you are and who is supervising you. Give them a chance to tell you why they are coming for counseling. Sometimes what they say differs from what they wrote on the forms.

2. Help the client tell their story without too much interruption. Don’t be too quick to jump in and direct with too many questions.

3. Gathering the following data (again, without too much interruption):

  • content and scope of problem (frequency, duration, intensity)
  • solutions attempted, things that help/harm, prior counseling attempts
  • current family/community make-up
  • other mental illness
  • relevant medical history, current meds, sleep quality
  • substance abuse
  • spiritual dynamics
  • supports, strengths
  • typical mood, suicidality
  • Other important factors (employment, finances, relational conflicts, etc)
  • dreams, hopes, goals

4. Summarize (briefly) and discuss possible initial directions or goals as well as alternatives they may wish to consider

5. Counseling model and nuts and bolts of professional care (confidentiality limits, scheduling, contacting you, payment options, etc.)

That will be more than enough for an hour. Most likely, you get great data in some areas and just a tad in others that will require you to follow-up in the next week. The more talkative the client is, the less data you can gather. The less talkative, the more likely you will get the data but the less likely you’ll form a good connection (Q & A leads to very passive clients more often than not).

It is good to have these very general categories in mind as you start that first session. Be wary of either forgetting the categories or obsessively forcing the client to answer all the history questions. You may end up with a wonderful piece of history for a client who never returns.

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April 9, 2010 · 9:58 am

Seeing clients outside the office


Much of what we do in counseling or therapy is enculturated. Confidentiality, the 50 minute session, avoiding dual relationships…these things developed out of the culture of psychoanalysis. Now, that is not a criticism. I personally agree that good therapy requires privacy and the assurance of confidentiality. Who would talk about the deepest matters of the heart if they thought it would be broadcast to the world? And it isn’t as if this is a modern invention. Pastors have been practicing this since the early church.

One of those culture founded practices is seeing patients only in the office setting. Supposedly, this would maintain the “frame” of the counseling hour so as to avoid unnecessary outward intrusions. Further, it maintains one picture of the therapist. Having coffee with your therapist at the local diner would completely change that frame–and reduce confidentiality when your neighbor comes up and says, “Oh, I saw you go into the diner with Dr. Monroe. How do you know him?”

But there are some reasons why a counselor might intentionally see a client outside the office. Here are some reasons I have:

  1. Observation of a child in a school or home setting as part of an assessment
  2. Visiting a client in the hospital (either as a courtesy call or as part of a treatment continuity plan)
  3. Joint meeting with other providers (therapists, pastors, care team) at another location
  4. Part of a treatment plan (e.g., to practice walking over a bridge, get on an elevator, etc.

I have been asked to have coffee by current clients. I have been invited to house-warming parties. I have been asked to attend other celebrations. I’m more inclined to attend celebrations for kids or if the relationship is quite limited (wedding of a pre-marital client seen for 6 sessions only). I have taken clients outside my office for one reason or another (a brief walk, thrown a ball with a kid, etc.).

Whatever you choose to do. Be sure to evaluate the effect it will have on your relationship with the client. What potential pit-falls exist? Talk to them about it. Afterwards, continue to see if such actions introduce any relationship confusion. Be wary of informality. You don’t have to be stiff but informality breeds complacency and soon you are doing things you never dreamed of doing. Also be especially wary if the client has any history of abuse or boundary violations. Take care to protect those boundaries for their sake.

While psychological ethics are built on “Do no harm,” we know that the bible also supports this. Watch out for your weaker brother or sister!

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April 8, 2010 · 9:51 am

Counseling Ethics and Electronic media


Once before I wrote a bit on this topic. Just how much should we use electronic media to work with clients? While most counseling takes place face to face, counselors speak with their clients using the phone, e-mail, texts, live chat, video conferencing, even through “second life” formats using avatars.

In the latest edition of the Pennsylvania Psychologist, I saw another little article reminding us counselors how to manage these electronic methods. Rachael Baturin suggests the following tips:

  1. Always clarify what kind electronic connectivity you will have and the nature of those interactions. For example, use of email to receive documents and make scheduling changes but wary of too long or too informal style emails. If you look like a friend (sharing personal stuff back to the client), it blurs boundaries
  2. Anticipate and respond to abuses of your policy (e.g., frequent texting, demanding emails)
  3. Avoiding the use of e-mails and texts for emergency contacts from clients. Use the phone or answering service for that
  4. Establish a general turnaround policy (how long you will likely take to respond to emails)
  5. Inform clients about privacy issues. Such as, use of work email to contact them, possibility of a shared email.
  6. Maintain a copy of every email or electronic contact. Or summarize them in the next case note.
  7. Use the standard text at end of email msgs to remind them of confidentiality and the possibility of errors in sending.
  8. Remember, tone of voice is missing in emails. Be sure to be extra careful about this

A couple of additional matters not mentioned:

Be clear on whether you bill for time on emails BEFORE you start emailing back and forth. Recognize that SKYPE or other kinds of video conferencing to other countries may not be as private as you might think. Other countries may do more to monitor NGOs and others serving abroad. If you get emailed journals, ask the person to use an agreed upon password for their Word documents. That way, if the email goes awry, no-one else can view the contents but you and your client.

Bottom line? Don’t be lulled into unprofessional activities on-line. Assume everything you send (chat, texts, email) may be printed out or shared with someone else. How would what you are saying or doing look to a court of law determining whether you acted in the best interests of your client and whether or not you held yourself to a high standard of care?

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April 6, 2010 · 11:13 am

The burden of a secret


I once ran across a website posting short video clips of individuals revealing some deep secret. Some of these secrets were funny (developing a fake friend on a social networking site to make an ex girlfriend jealous), some were eye-brow raising (eating contents of nose), and some were downright painful (revealing affairs, addictions, sexual abuse and the like).

Keeping a secret (your own or someone else’s) requires that you carry a burden. You know something and can’t share it. You can’t talk about it. You might like to, but the consequences seem dire if you share it. You might lose a friend. You might lose your reputation. You might lose your security.

As someone who listens to secrets for a living I’ve a few observations about the secrets people hold:

1. Even in the confidential setting of counseling, it is near impossible to lay down the burden of some secrets. These secrets are covered in shame. Sexual abuse; Unwanted sexual thoughts and feelings; addictions.

2. Secrets shape our identity in some powerful ways–maybe even more than known truths.

3. The longer a secret is kept, the harder it is to tell, or the harder it is to tell truthfully. Time has a way of distorting facts and feelings in some cases. Similarly, we make lots of excuses for why we keep secrets. Some excuses are cover for shame (e.g., “It would hurt her to know that I…”).

4. When someone has a guilty secret (e.g., an affair), they often tell it to finally throw off the burden of guilt. So, when they tell their spouse, they often feel better right away. Unfortunately, the spouse does NOT feel better. In these cases I find the guilty spouse has a hard time relating to the new burden they’ve just loaded on to their mate. They feel free and wish their spouse would now also feel free too. It is always good for the guilty spouse to question why they wish to confess. Is it to promote truth and long-term possibility of healing? Then, they should tell (carefully). If it is to just be relieved of their guilt, then such a confession may not lead to repentance and healing.

5. Even little secrets kept from a loved one can hurt when revealed. If you lie to me about how many Easter eggs you ate on Sunday, maybe you are lying to me about more weighty matters.

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March 30, 2010 · 11:22 am

Book Note: Linkages between stress, inflammation, and mental illness


I am in the process of clearing my desk of semester debris. Well, truth be told, I am in the process of clearing a portion of my desk from said debris. The rest will have to wait. In the process, I came across a book I’ve been meaning to read since the dept. purchased it for me: The Psychoneuroimmunology of Chronic Disease: Exploring the Links Between Inflammation, Stress, and Illness (APA, 2010).

Before you all stop reading, it really is an important work! You should care if you are someone experiencing high levels of stress or if you counsel those who do. AND, there IS an answer (you won’t like it!) that can help given at the end of this post.

Yes, it is very technical. You can’t skim this book easily unless you read only the chapter summaries (not a bad idea!). However, I find it very interesting to read about how well-connected (too well!) our minds are with our bodies. Here are a couple of book highlights

1. Chapter one: Stress activates primary and secondary responses that may actually increase our vulnerability to disease. Secondary? Examples given include alcohol abuse, poor diet, non-compliance with treatments. Primary? Your body does a couple of things in reaction to stress. First, your sympathetic system starts looking for inflammation. Immune cells look for an injury. You have more glucose available to burn and cortisol increases which also works to activate anti-inflammatory responses. Inflammation is the problem (a “rapid and nonspecific response to danger”). Too much inflammation? damaged tissue. Too much anti-inflammatory response? Damaged tissue. Those with depression may have become less sensitive to cortisol and so end up with lots of non-specific inflammation. Maybe this is why depression hurts so much!

2. Chapter 3: Poor sleep has serious health consequences, especially concerning chronic diseases. One study indicates that disordered sleep has a direct link to type 2 diabetes, independent of age and body size. Individuals with sleep apneas have a greater production of inflammatory bio-markers. Women may be at greater risk for cardiovascular diseases due to sleep problems than men. One problem (sleep problems) begets the other (inflammation) which creates a vicious cycle.

3. Chapter 4: “Western diets typically contain an abundance of proinflammatory omega-6 fatty acids and are low in anti-inflammatory omega-3s.” (p. 96). In other words, dietary fish oil helps promote healing and may lower symptoms due to inflammatory diseases. More fish oil, less vegetable oil.

4. Chapter 5: Links between stress, depression, PTSD, hostility and inflammation. Each of these things increases inflammation, increases sleep disorders which in turn…(you get the picture).

Okay, does anything help l0wer stress and increase healthy immune system functioning? This is the answer I promised at the top of this post. Are you ready? It is so simple you will hate it!* (that will be something to explore at a later date–why do we resist the things we CAN do to help our situation?)

1. Diet. Having a better (lower) ratio of Omega-6s to Omega-3s (more cold water fatty fish) seem to lower rates of depression. Higher Omega-3 consumption predicts lower suicidality, lower depression, and bipolar disease. It appears these amino acids help stop the overactive inflammatory response caused by repeated stress.

2. Exercise. It will initially raise inflammation markers (hence why many with RA feel that any exercise creates more pain), but later lower it if continued on a regular basis.

3. Counseling. Cognitive-Behavioral social support interventions have shown to reduce the inflammation effect by lowering stress. be effective in doing just that.

So, encourage your stressed clients or friends (even better, do it with them) to eat well, exercise (just walk!) and seek social support. In doing so, they will find relief from inflammation and the effects on the mind and body. I guess it is time for me to get up from this desk, skip the doughnut, and walk up to the library for a bit of exercise. On the way, I should stop by a colleague’s desk and get him to come with.

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*Simple? Yes. Quick fix? No. Sure bet to solve all our problems? Absolutely no.

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