Tag Archives: counseling

October 17, 2009 · 12:23 pm

The most important counselor capacity


Okay, so really there are a number of important counselor qualities and skills. You have to be able to be quiet and listen, to have good questions, and comments, to be able to follow a line of thinking, to have some idea of a goal, etc. But, maybe the most important quality is the ability to be self-reflective. Reflexive responses may be useful (these come from the gut) but they can be dangerous in that we have little thought and review of these kinds of responses.

At the retreat today I suggested that the unexamined life may create more opportunity for damage in counseling than the lack of knowledge of how to help a person. We may assume that our “truth-telling” capacity is good when it is really merely harsh. We may assume our “listening” skills are good when really, we are hiding from dealing with the big pink elephant in the room. We may think our advice and information is very important when really it merely exists to show off what we know.

We looked at Galatians 6:1f where we are called to help others by restoring gently, carrying burdens, and watching our own lives closely. (I got this from Paul Tripp some years ago). This passage shows where we may fail to care well for others.

Of course, there is also the danger of the over-examined life. Such a life leads to rumination, anxious second-guessing, and paralysis by analysis.

Retreat is going well, but wet and cold…

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October 13, 2009 · 5:21 am

Fear and trust hand in hand?


This week I’ll be speaking to a group of counselors about complex PTSD. One of the hallmarks of C-PTSD is the combination of chronic relational fear AND chronic shame/guilt over having said fear. It manifests itself as, “I’m afraid of you but I know it’s my fault for being afraid.” (NOTE: the reverse is not necessarily true: that those who have chronic fears, trust problems, and self-condemnation have PTSD or C-PTSD.) My focus at that training will be on this question: How do you lead someone (in therapy) in the repetitive work of “Do not give in to fear”?

On Sunday, Tim Lane of CCEF preached a sermon about fear and disappointment. In that sermon he mentioned our propensity to “flail ourselves”–assuming that we must be doing something wrong–if we experience fear. Instead of focusing on the experience, we ought to examine our responses to fear. Do we shut down? Do we believe that we are alone and isolated? Do we turn inward and act only in self-interest?

He gave us this quote from CS Lewis (Screwtape Letters): “The act of cowardice is all that matters, the emotion of fear is, in itself, no sin.”

Here’s my question: Is it possible to be afraid and to trust nonetheless without much reduction in the level of fear? Don’t we assume that if we act in a trusting way that our fears should abate? Especially in light of trusting God? Is it possible to trust God fully and yet fear? What might such fear and trust together look like? If we could do both at the same time, would it reduce inappropriate self-condemnation?

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Filed under Abuse, Anxiety, biblical counseling, Biblical Reflection, christian psychology, Christianity, counseling, Post-Traumatic Stress Disorder

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October 2, 2009 · 5:32 am

Workers’ Comp for Pastors?


The concept behind workers’ compensation (WC) insurance is that employees have coverage for injuries sustained on the job (and secondarily that if they get the compensation that they won’t sue their employer). Nowadays all US states have WC laws.

But, what if churches provided or paid into a fund to provide spiritual workers’ comp? While I suppose pastors could fall out of the pulpit on the job, strain their vocal chords, get a typing injury, most won’t. But, I would contend that most pastors suffer under the weight of the pastoral care needs of their congregation. Being exposed repeatedly to crises, conflict, attack, and other weighty matters, pastors may become broken themselves. Imagine if churches or denominations provided recovery care for these matters. Just as in worker’s comp, there might be requirements that the pastor go to a specific specialist.

Wouldn’t this be novel? Of course WC doesn’t do prevention work–which is what pastors need. But, it might get a congregation to admit that exposing a pastor to endless supplies of brokenness is going to create brokenness in the pastor.

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Filed under christian counseling, christian psychology, Christianity: Leaders and Leadership, church and culture, pastoral renewal, pastors and pastoring

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September 21, 2009 · 12:02 pm

AACC revisited


Not much time today for any significant posting on psychological assessment and/or the AACC world conference I’ve just returned from. 5 Days away from home leaves way too much other stuff to do!

However, here’s one small reaction question I pondered on the plane ride home: Which is better: a conference where I agree with most speakers, OR, one where there is wide diversity and quality of work (and some work that is downright bogus)?

I attend two different counseling conferences. One really scrutinizes speakers and makes sure they are in agreement with the organizing agency. The other seems to let any counselor teach if they can write a decent proposal and outcomes statement. The first one protects from outrageous presentations but most likely limits new voices and/or progressive ideas. The second one gives many ideas an opportunity but the listener bears the responsibility to figure out whether the speaker has any basis for their opinion.

Now, I don’t know this for sure, but I’m guessing the first one suffers from highly critical followers who make sure that no speaker ventures too far from home. And I also guessing that the second group has a large following that does not discern truth from simplistic pop psychology.

So, which is better? The first one rarely ruffles my feathers. The second one has speakers that make me want to scream but also  exposes me to new ideas and research.

As I said, I’m not sure which I prefer. Both tempt me to have arrogant thoughts…which reveals more about me I suppose.

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September 14, 2009 · 11:17 am

Psych assessment and the new semester


And so we begin the new semester today. I’m teaching Psychological Assessment tonight to our advanced professional counseling students (recent grads looking to complete licensure courses). Psych assessment covers a wide variety of formal and informal assessment techniques for counselors. Among them are the use and interpretation of psychological tests. It is my experience that most people with superficial exposure to psychological tests have one of two responses

1. Inordinate value of testing and what it can do

2. Inordinate suspicion of testing and what it can do

Most of these responses come from quick reactions to some personal exposure to tests. Those who give too much value to tests may have taken a test and had it “nail” them. For instance, someone takes the Myers-Briggs (MBTI), finds out they are an INTJ and that it explains why they nearly lose their mind around their boss who is an ESFP. Those who are suspicious of testing often have had a bad experience of testing (test mis-use, a negative evaluation or they have had a course that exposes them to the weaknesses of some test construction and research.

The truth is that tests do have both limits (some way more than others) and value. Never underestimate the power to abuse a test or the data that comes from one. A relative of mine once was turned down from a job because some wacko decided he had repressed issues from a simple drawing.

However, those who say that they can get all they need from a clinical interview fail to recognize the value of learning how one functions in comparison to a large sample of peers. And several data points like that can really flesh out a personality or learning profile.

I’d be curious to hear reader’s experiences with testing (their administration and/or interpretation). Did you have a positive or negative experience and why?

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September 9, 2009 · 11:45 am

ICAT as a new therapy model?


Take any psychotherapies class and you will get your usual dose of the classic models built on grand schemes attempting to explain the meaning of life and human behavior: psychoanalysis (and later versions of object relations), humanist/client-centered, behaviorism, cognitive (and later combinations of the two), and various forms of family systems models. Students in advanced courses may learn a bit about various combinations of these models but usually such classes leave learners picking and choosing a theoretical home–or becoming eclectic by trying to take parts of each model.

But nowadays, models are built not to explain the meaning of life but to show “what works” in therapy. Sometimes model builders stumble onto a technique and then attempt to provide evidence how and why such interventions work. For example, I would classify Les Greenberg’s EFT, Francine Shapiro’s EMDR and Marsha Linehan’s DBT (though DBT has much more robust evidence supporting and has validity whereas Shapiro’s techniques have reliability but lack validity in my mind) as these kinds of models.

Now comes another model to try to capitalize on a number of proven techniques: Integrative Cognitive Affective Therapy. Right now, it seems to be used and studied for the treatment of Bulimia. But, I expect to see it grow over the years to any number of problems (just as DBT is not just used for Borderline Personality Disorder anymore).

What is ICAT? It is an attempt to improve upon the weaknesses of Cognitive-Behavioral Therapy (CBT) while maintaining the robust empirical power of the model. What are CBT’s weaknesses? Stephen Wonderlich says they are “1) a limited view of emotional responding; 2) inadequate consideration of interpersonal factors; 3) insufficient attention to therapist-client relationship; and 4) overemphasis on conscious-controlled cognitive processing.”*

ICAT attempts to improve on CBT by paying very careful attention to emotion, mindfulness, and other aspects of a person’s experience of self and world. Again, Wonderlich describes ICAT as “a collection of interventions drawn from an array of cognitive behavioral and emotion-focused therapies and based on a testable theoretical model…”

ICAT for Bulimia exists in a 21 session form as of now. It focuses on experiencing and identifying key emotions involved in the Bulimic process, making initial changes to eating habits, developing alternative coping mechanisms to deal with distressing emotions, dealing properly with desires, practicing self-regulation and challenging discrepancies between ideal and actual self. What makes it different from CBT is its focus on emotion and collaborative work between patient and counselor.

In many ways, it seems to adapt other model’s focus on validation, affect, mindfulness, and distress tolerance. Over and over it appears that understanding and addressing subtle emotional interpretations of life are the building blocks to changing pathological behaviors.This is not the first attempt to build an affective version of CBT. Some attempted to talk about constructivist CBT but that did not take hold. I suspect this model has a better chance at catching on.

*Wonderlich, Stephen (Summer, 2009). “An introduction to Integrative Cognitive Affective Therapy for Bulimia Nervosa” Perspectives: A Professional Journal of the Renfrew Center Foundation, pp 1-5.

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August 31, 2009 · 5:44 am

Disorders of Extreme Stress Not Otherwise Specified (DESNOS)


I recently scanned a book, Healing Trauma(published by Norton in 2003), and ran across a new name (for me) for the problem of complex PTSD–Disorders of Extreme Stress NOS or DESNOS.  Because many christian counselors are only marginally aware of the research on complex PTSD I’ve decided to give a brief summary here.

The following symptom presentation may be found in those with prolonged and severe personal abuse (and often starting at an early age): 

  1. alterations in the regulation of affective impulses, including difficulty with modulation of anger and being self-destructive,
  2. alterations in attention and consciousness, leading to amnesias and dissociative and depersonalization episodes,
  3. alterations in self perception, such as a chronic sense of guilt and responsibility, and chronically feeling ashamed,
  4. alterations in relationships with others, such as not being able to trust and not being able to feel intimate with people,
  5. somatizating the problem: feeling symptoms on a somatic level when medical explanations can’t be found, and
  6. alterations in systems of meaning (loss of meaning or distorted beliefs)

Some folks include a 7th characteristic: (alterations of perceptions of perpetrator(s).

Check out the this paper(44 pages long) written on the assessment and treatment of DESNOS.  Though written for psychiatrists, I found the language easy to understand. The authors do a nice job of helping counselors differentiate between Borderline Personality Disorder and DESNOS. While they recognize significant overlap between the two constellation of symptoms, DESNOS folks tend to experience less relational push/pull (less manipulative behavior) and more push behaviors coupled with more intense sadness and grief.

Counseling work falls (per this paper) into 3 categories: stabilization, trauma processing, and re-integration into their world.

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August 28, 2009 · 5:18 am

The danger of “why” questions


Most thoughtful counselees want to ask “why” questions. Why do I do what I do? Why did she do what she did? Why am I the way I am? Why am I so depressed? Why isn’t my life going the way it should or seems to go for others? Counselors too ask “why” questions. Why did you blow up at her? Why is this child afraid of going to school? And closer to home, why did my client drop out of therapy?

On the surface why questions seem to want to get to the bottom of things. We assume that if we understand the nature of the problem, we’ll know how best to respond. And there is much truth in this assumption. 

But consider their danger. Some answers to the “why” are so complex that the answer to the “why” doesn’t really point to any one answer. Further, we frequently prejudge the question with implicit answers (e.g., it is because something is wrong with me…I’m a loser…God doesn’t want me to be happy…I can’t help it that I’m this way…).

Why questions also make us passive. We look for answers; we mull over the “facts.” We are less likely to become active to do something about our situation when we are in a “why…” mode.

Let me suggest a better kind of question: What questions

What is happening? What am I feeling/thinking/doing? What is it that I want? What do others want? What am I doing about my situation? What goals do my behaviors emphasize? (this is a why question that forces us to look at our behaviors and see if they match up with our stated desires) What options are before me? Be descriptive rather than interpretive. Notice that why questions jump to interpretation but seldom activate a person to do what is in their power to do.

Frequently, by asking descriptive “what” questions, we find it easier to activate the will and begin doing something about our situation. In addition, we often come to posthoc understanding of the “why” when we have some distance from the situation.

So, the next time you find yourself stuck in the “why” set of questions, stop and try to ask yourself some what questions instead. Observe the impact of distancing from the passive whys? Does it help?

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August 21, 2009 · 8:46 am

Case consultation by videoconference?


For my counselor readers…how interested would you be in participating in videoconferenced case consultations with an expert in your field for the purpose of discussing client cases with that expert? Bear in mind that this kind of activity would have to meet ethical guidelines (e.g., no identifying information about any clients could be revealed, clear distinction that this is consultation and not supervision, etc.), but would you be interested? Would something like this reduce your sense of isolation?  Consider answering the following questions:

1. Would you be interested in getting consultation for some of your cases via videoconference (private video exchange with an expert, such as skype or other service)?

2. Would you still be interested if the videoconference was a group of no more than 4 (and everyone got to present something)? If it was a group of about 10 and not everyone got to present but all got to participate in the discussion)

3. Would you be willing to pay for such a consultation? 

4. If yes to above questions, how frequently would you think you might use this type of service? Monthly? Quarterly? Other?

5. Finally, what questions or concerns does this idea raise for you?

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August 18, 2009 · 7:35 am

Cultural sensitivity or watered down


Having been in meetings yesterday and today about our next steps regarding counseling training in Rwanda, I’m wrestling with the best way to address cultural differences in whatever training we do. And specifically I’m wrestling with a particular dilemma forming in my mind:

Teach what we know about counseling NOW but be unaware of subtle but important cultural differences vs. listen, learn, and teach LATER what we know (but in culturally relevent terms)

It is not the first time that I have been asked to do something sooner rather than later with these words. “Don’t worry about the cultural relevance. We’ll tell you when something doesn’t work or our students will do the application to their own situations. If you try to be culturally sensitive, it will end up being watered down. We want our students to get the best education, something that the US would recognize.”

Why do I struggle with this request? Well, in my head it sounds like, “hey, come bring your colonialistic methods of evangelism and we’ll handle it.” I struggle with it because I know American counseling culture has significant problems with it. And, I struggle with it because I know that some students (this is a universal truth!) are really good at critical thinking while others blindly ape what we say without much thought at all. AND YET, I know that waiting until I’m culturally aware enough to teach means I wouldn’t do so for a very long time.  

So, part of my struggle is not wanting to look like a culture boob by just assuming that what I teach US students is what Rwandans would need. I suspect the answer is (a) being courageous enough to risk looking like a fool, but (b) flexible enough to change on a dime when I am aware of a disconnect.

Hmmm. I may have a problem with both.

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