Tag Archives: counseling

May 11, 2009 · 1:27 pm

Practicum Monday: Learning counseling skills from videos


Counseling education includes the usual academic exercises as well as hands-on practice. There is no substitute for the practice piece. But, videos can provide students with good illustrations of various counseling activities, styles, processes, etc.

But which videos to watch? The classics (masters in unstaged vignettes)? Training videos (usually staged with actors)? One of the first videos I ever saw was of Salvador Minuchin at the Child Guidance Clinic. There he was in a room, unashamedly smoking a cigarette, and manipulating (in the best sense of the word!) a family with an eating disordered girl. I was taken with his larger-than-life presence in the room and his ability to be irreverent. Needless to say, I could never emulate him. In fact this video that I loved made me wonder if I had what it took to be a therapist.

Last week and this week the practicum class has been viewing Mark McMinn’s christian counseling video produced by APA. One ought not expect the APA to be up on Christian counseling (and its many varieties) but this video is useful for many reasons. First, Mark illustrates a relational style of cognitive therapy and so what he does in this first session is usable in almost any method of counseling. Second, the counselee is not an actress. She is a real person with real concerns (which students relate well to!). Third, Mark doesn’t merely focus on her problems but does a great job highlighting her strengths and resources. Finally, Mark isn’t a big personality–meaning we can all see ourselves doing what he does.

We use mock vignettes as well. I participated in making some mock counseling videos at Regent in Virginia Beach. Mock sessions tend to focus on discrete skills and are better in 2-3 minute vignettes rather than full sessions, and for beginning students rather than those about to graduate.

If you ever took a counseling class that used videos, what counseling videos did you watch and were they helpful?

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May 5, 2009 · 5:54 am

Rwanda!


My on again off again trip is now on. I have tickets and yesterday I got my shots! Our small group of psychologists (4) will be leaving on June 22 and returning July 1. We will be going as the guests of the Right Rev. Alexis Bilindabagbo, Anglican Bishop of the Gahini diocese. You can learn a bit about him here.

We will be meeting with pastors, government officials, victims, and perpetrators of the 1994 genocide. Our goal is to immerse ourselves into the culture to learn how best to provide trauma training and counseling education at the graduate level for pastors and key leaders of the church right in Rwanda. While we know quite a bit about trauma and counseling training, we wish to avoid the mistakes of assuming we know best what this particular people need and what works within their cultural milieu.

I hope to be able to give you more details as the time approaches and to blog from Rwanda when I have Internet access.

FYI, each of us are paying our own way. Some donors at Biblical Seminary gave generously to underwrite a small portion of the trip. Further, the American Association of Christian Counselors is helping to sponsor this trip. So, if someone wants to give to the trip, I’m sure we can find a way to provide you a receipt for tax purposes :). Email me at pmonroe[at] biblical [dot]com and we’ll figure it out.

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May 4, 2009 · 1:26 pm

Practicum Monday: counseling mistakes?


I’d like to compile a list of mistakes mostly likely to be made by novicecounselors. In the past I’ve written on some of the mistakes or foolish behavior of counselors and some of you have helped contribute stories like the counselor who fell asleep during the session, the counselor who ate a meal, who tried to set the counselee up with a son or daughter, the counselor who took phone calls, etc. Most of these mistakes wouldn’t be made by the typical counselor, even one who had never counseled before.

So, what are the most common mistakes of the novice counselor? Not sure, here are some I’ve observed:

1. Failing to collect enough data during the first sessionto assess matters of suicidality or mental status. Novice counselors tend to either drill too deep on one topic (and so miss other important matters) or stay on the surface and fail to ask questions they think might embarrass the client

2. Promising too much. We want the client to have hope and we hope they don’t see us as novice, so we promise the world. Such temptations lead sometimes to offering our phone number to call at all hours, to agreeing to meet outside of sessions, too allowing sessions to go beyond the planned limit.

3. Encouraging. Beginning Christian counselors sometimes fail to let the counselee sit with their pain. Instead, they trot out verses to comfort and encourage. Often, these passages fall flat without their intended result.  

4. Writing too much. Progress notes may look like novellas. When you don’t know what is important, everything is documented.

5. Going along with the parents. Novice counselors often seen kids and their parents. It is easy to become railroaded into allowing the parents to use the session to gang up on the kids. Novice counselors have a hard time managing the parents and the kids in the same session.

What mistakes did you make? Did you experience at the hands of a novice?

When I started, I hated the question about my age (I was 24 but looked younger). I tried all sorts of creative ways to illustrate my experience and to be vague about my actual age. I’m sure I never convinced anyone. They stayed because they didn’t want to start over. I should have just said (nicely), “your right, I’m young. We can either find you another client now or we can try the following intervention and if you don’t like what I’m doing, we can find you someone else then. What would you like to do?”

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May 1, 2009 · 5:42 am

Physiology Phriday: Dieting starves your brain?


I heard a psychiatrist recently tell her depressed client that she should not go on a diet to lose weight. The client was confused. She thought that losing weight would help her with her self-esteem. She had not been exercising and had put on 15 pounds over the past 3 years. So, she asked her doctor why not. This was the explanation (paraphrased):

Exercise does provide a natural antidepressant and so I heartily encourage you to start an exercise program. However, many diets consist of decreasing foods rich in carbohydrates. Getting more protein is good but your brain needs glucose to produce neurotransmitters (e.g., serotonin) and foods rich in carbs are more easily turned into glucose. When you starve your body of glucose, your brain is the first place that starves.

Maybe this explains a bit of yo-yo dieting. The person is feeling poorly about weight, reduces foods that provide simple sugars in order to lose weight, starves their brain of serotonin (thereby creating a greater feeling of depression), and then caves to a binge in order to feel better. 

Don’t know if this supposition is true, but it might be important for those on antidepressants to make sure that they are keeping a balanced diet and exercising frequently.

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April 20, 2009 · 11:03 am

Practicum Monday: The green counselor


No one wants to be a green counselor. “Hi, I’m an intern and you are my first counselee.” Who wants to say that? Also, no one wants to entrust their most significant problems to a green counselor. “I see you haven’t any experience, so let me expose my most tender parts to you and see what you can do.”

Houston, we have a problem.

Every counselor has to get their start somewhere just as every surgeon cuts a live human being for the first time. Young single folk counsel conflict-riddled married individuals or offer parenting advice while not yet a parent. Individuals with no history of addictions sit with folks in their 10th inpatient stay in a treatment center.

Is there any way this goes well? YES! Let me tell you why going to an intern with a good supervisor is good, even sometimes better than getting a seasoned counselor by them self.

1. You get two heads instead of one. Even if the supervisor is not in the room, you get a young, determined-to-do-it-right counselor and a supervisor on his or her toes (who loves to teach and wants nothing bad to happen) thinking about you and planning carefully. They talk about the intricacies of your situation at great depth, they consider the options, and carefully review the outcome. If you only have a seasoned counselor, they may perform better (relationship wise) in sessions, but they probably aren’t thinking as critically as they could. I can attest that I am thinking much more carefully about clients during supervision (as supervisee or supervisor) than when I am not there.

2. Book knowledge actually does help. The further a person gets away from textbooks, articles, etc. the more they rely on old knowledge. Teaching counselors and green counselors are fresh from their reading and thinking about key problems. For example, the student having just completed an ethics course will be more sensitive to boundary violations than the one who has grown accustomed to thinking they will always do the right thing. Sometimes resident doctors are more aware of subtle health issues because they are running down every article to learn and running down every symptom.  

Now surely a seasoned counselor provides many good benefits. Working with an intern or medical resident often takes longer to get to a good outcome. They just aren’t as fluid. They are still learning–learning on you. A seasoned counselor will make fewer mistakes. But if they are a humble learner, the green counselor will catch on quickly and repair any damage. Whether green or seasoned, the most dangerous character problem in counselors is arrogance and listening only to him or herself.

But the intern can manage some of this by dealing with his or her own anxiety. Confidence does actually help. It enables you to think clearly, consider options, be honest about your own weaknesses, offer the client help in finding someone else if you aren’t the right fit. It is like baseball. If you are afraid of getting hit, you’ll likely not catch or hit the ball. If you have confidence, you’ve got a better shot of catching it and/or at least making contact when hitting.

 

All that said, I have to tell you a story about my “first time.” I had just completed a 13 week internship where I counseled 2 separate clients with my supervisor in session and by myself. I could be given good grades for trying hard, but probably was too impatient to get to the good stuff of people’s problems–the stuff of repentance. In a moment of insanity my supervisor set me up as a staff counselor in a satellite center. On my first night I saw a person who said the Lord had told her I was the counselor for her but now was rethinking she had misheard. How could an 18 year old be right for her (ahem, I was all of 24!)? After trying to find out the issues, she said if I couldn’t figure it out, she definitely had misheard God. The next client was a couple. In the course of the session, the husband actually stood up and started choking his wife. I stood up–not knowing what else to do–and he fled the building.

There’s nothing like baptism by fire 🙂

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April 13, 2009 · 11:11 am

Practicum Monday: The secret to a good experience


A new semester begins today and I pick up teaching again after a sabbatical. It feels good to get back in the saddle again. Practicum and Professional Orientation starts today and so my students begin their first fieldwork assignments around the region. If they are at all like I was when I first began counseling work, they will be nervous and worried about doing well and doing the right thing. But I have a secret for them. This nervousness will actually help them do well and, for the most part, mistakes in counseling often turn out to be good for both counselee and client. Counseling is more like art and less like surgery. And since counseling is relational art, the opportunity to “do over” actually provides wonderful realism to the healing.

However, there is another secret to good practicum experiences: good supervision. Good supervision makes or breaks an experience. And good supervision requires the active participation of both supervisor and supervisee.

The Supervisor: Supervisors come with a variety of skills, personality, and style. Some are quite directive and keep a tight rein on your practice attempts. Others are very hands-off, wanting you to try stuff yourself and so they respond to your questions and concerns rather than seek you out. Others are very process oriented and focus on your experience more than what you actually do.

The Supervisee: Some students come with hundreds of questions (some out of curiosity but most out of anxiety). Others want very specific directions and then try to act them out as was given. Others still want to talk about their own experiences and have a harder time recalling client responses.

Practicum students do well to prepare for supervision:

1. Before you begin, have some discussion about how the supervisor likes supervision to go? Do they have an idea about how they want you to function in it? Do they want it to happen just after your counseling experiences for the week so you can debrief? Just before so you can best remember what was decided?

2. When you bring your cases to supervision, come prepared to concisely summarize history, presenting problems, attempts to solve prior to counseling, family systems, current crises if present, work thus far in your counseling. Also, come prepared with a specific objective question you would  like to have answered. The more specific your question, the more likely you will come away with an answer.

3. Be sure to ask the supervisor to help you refine your hypotheses. This is a good opportunity to consider alternative ideas.

4. Schedule time when the supervisor can either watch you live or listen to a taping. There is NO better supervision possible. Scary? Yes. But essential if you do intend to become a good counselor

5. Be willing to ask (nicely) the why question when your supervisor gives you directives that don’t make sense. More than doing the right thing, you want to understand the critical thinking behind the right response.

6. Use your relationship with the supervisor to grow as a professional. This is one of your future colleagues. If there are conflicts between you, practice the good art of resolution. Don’t avoid and don’t attack.

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April 3, 2009 · 5:53 am

Physiology Phriday: Your brain and your food


We all love certain kinds of foods and when we eat them, our pleasure quotients increase dramatically. Some recent work in brain imaging suggests that women with propensity for bulimia show “greater activation of key reward regions of the brain” after tasting a chocolate milkshake. These same individuals may also experience decreased activity in parts of the brain that control self-regulation and impulse control (as reported in the April 2009 Monitor on Psychology, pp. 48-49).

This area of research is new and so the results need replication plus interpretation. Does the brain function this way after years of bulimic behavior. Or, does the brain instigate or tempt such behavior (strong reward response plus increased impulsivity) with it’s prior functioning?

Of course, the individual struggling with bulimia cares only a little about the why. They really concern themselves with the what. How do I eat with moderation? How do I not eat for emotional reasons? Unlike alcoholics who can always avoid alcohol, everyone has to eat, and eat everyday.  So, what to do when your brain responds the way it does to food? Here’s a couple of practical ideas to start you down the right path:

1. Get a “coach” or counselor who you will be completely honest with. This coach will help you construct an eating schedule and an array of responses to eating or purging temptations.

2. Construct a realistic eating schedule that avoids avoiding food. Keep a food journal. Be honest. Keep troubleshooting with your coach until you find something that works best for you. Remember to check out your schedule (times and foods allowed) with a nutritionist.

3. Construct and use an array of behavioral responses to eating temptations. These include distractions, connections with others, ways to make the moment better, crisis call opportunities.

4. Develop mindful techniques to focus on eating, on stopping eating, on other forms of pleasure God has given you–even on the difficult emotions that you feel.

5. Identify controlling automatic thoughts and lies in your “script” that drive you in particular emotional and behavioral directions. These can be about your body image, about your relationships, etc. Begin responding to them with truth from God’s point of view. Make sure your coach and others know what truthes you are trying hard to believe.

6. As you recognize triggers, temptations, etc., also identify “ways of escape” offered you by God.

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March 13, 2009 · 3:38 am

Physiology Phriday: Anticipation and Anxiety


Anticipation and its relationship to anxiety.

This week we have been thinking about how we evaluate our world. Evaluations or judgements come from a variety of locations. Our expectations and desires prep us to look for certain kinds of “data.” Our histories and past perceptions prep us as well. Finally, what is actually happening is part of the data we use to evaluate ourselves and our world. Notice that we aren’t as logical and objective as we’d like to think. Instead, we ANTICIPATE life and then respond to data that fits into that anticipation.

The primary feature of chronic anxiety is that anticipation of negative, dangerous outcomes. The anxious person views ambiguous data (e.g., a boss who is grumpy, a funny feeling in the chest, etc.) and reads that data in the worst possible light (I’m going to get fired, I’m having a heart attack).

If the problem is bad habits in thought patterns, it would make sense that the treatment ought to be to challenge these logical fallacies with the truth. And while cognitive counseling does indeed work (clear data that one can challenge and reject anxious, ruminative thinking) most find that counseling stops anxiety from growing but doesn’t often stop it from starting in the first place. This struggle to fight anxiety leaves many Christians feeling quite guilty for not trusting God more. 

But what about the amygdala? There is significant research that anxious people have very activated flight/fight activity in the amygdala. In fact, brain scans of this area show greater activity in anxious people than non-anxious people even when they are responding to neutral events. Thus, the anxious person’s brain is in a chronic state of hypervigilance even when nothing is going on. Hypervigilance maintains higher levels of norepinephrine the body, which in turn keeps the adrenal system in high alert. Medications (of the SSRI and NSRI type) have the capacity to positively impact serotonin and Norepinephrine and thereby allow individuals to decrease the negative hormonal activity in the brain.

Which comes first?

So, does biological hyperactivity in the amygdala result from either bad experiences or bad thinking? Or does a predisposition towards overactivity of this part of the brain encourage negative and anxious thinking, forming a vicious cycle? 

Seems to me good treatment needn’t answer this question. Good treatment would include (a) medications that might make it easier to slow down the anxiety processes (biology and behavior), (b) recognition that vigilance can be directed via counseling work away from the feared object and to a better understanding of the brain, and finally (c) that one changes the goal from cessation from fear to a more godly and humble response to Jesus in their fear.

What I mean by (b) is that the anxious person see themselves as like unto a person with colorblindness or dyslexia. In each case, the brain functions in a way to send the wrong messages. The dyslexic person learns to recognize the problem and designs a means to compensate in order to truly see the right order of letters/words. The anxious person accepts that their brain sends certain messages but that their job is to stay remember that while something real is happening it is not necessarily the way their brain is putting the “facts” together. Thus, the work is not to remove the fear but to practice a better response to it.

Ironically, when the person reinterprets the stimulus differently, they do see a marked reduction in fear triggers.

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March 9, 2009 · 5:04 am

Frustrated goals? Here is one solution…


Let’s admit to ourselves that we carry a large number of goals for other people. We wish and desire for them to change their ways. Life would be so much easier if my son…my wife…my boss…my pastor would only… 

This is especially true in the counseling office. People come to counseling to find a way to fix a problem (person) in their life. They may well recognize their own need for change but commonly find their attention turning to the one person causing them great relational pain. Counselors are no less capable of being frustrated as well. We have goals for our clients–ways we want them to act. When they do not accept our goals or are not able to fulfill them to our egocentric demands, we too can be frustrated.

Here is one solution that may provide you with less frustration:

Make your goals things that you can meet on your own.Okay, maybe this sounds a little crazy, but hear me out. Let’s say your spouse frequently responds to your questions with irritable defensiveness. You know you are nothing but sweetness and light to him/her and that the problem lies solely with your spouse. You are frustrated that they do not get that they need to change. You’ve brought up nicely and you’ve brought it up repeatedly–even seeking help from a counselor. But to no avail.

Consider, then, a goal change. Goal: I want my response to my spouse to be filled with love, truth, and an invitation to warmly try again, even if they do not accept my invitation. You have the power, with God’s help, to meet this goal. You can use this to evaluate how well you are doing?

Does such a goal change make your suffering from your spouse’s crankiness any less? No. But when (a) you accept that you have NO power to make someone else change and (b) accept that you do have power in how you will respond to such things, you receive two benefits

  • You stop distressing over how to fix another person
  • You use different criteria to evaluate yourself and your life (and thus may find that your own irritation is adding to the vicious cycle and your negative evaluations of your life)

Now, I am not saying that if you are suffering at the hands of your spouse or child or boss that you should just smile and take it. It is okay to speak the truth to sin. Maltreatment does do damage and working to stop it is a good thing (if necessary, by removing oneself from the situation). But even then, you can offer an invitation to a new way of relating should the person be open to hearing you.

So, if you are frustrated with others not helping you meet your goals, consider whether or not you can rewrite your goals to be something within your power to do. Warning: it can be a challenge to give up a goal for another. It feels like giving up a dream. It will be easier to give up said goal for other if you recognize that there are a host of goals available for you right at your fingertips.

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February 4, 2009 · 5:37 am

Try your hand at diagnosing clients…


Ever wondered if your counselor really knows what is in the Diagnostic & Statistical Manual (DSM, ver. 4TR)? Or do they just do the flip and dip method (let the large book open to any page and blindly point to a spot on the page)? Let’s hope not. Well, some professors are trying to increase the accuracy of their students via video vignettes.

One such person, Dr. Aaron Rochlen of U. Texas, has a website with 5 video vignettes available on his website (http://www.edb.utexas.edu/psychopathologypractice/index2.html) for students to watch and then try their hand at giving a DSM diagnosis.

Warning. Site is free. There are no answers given so don’t bother submitting your diagnostic considerations as they won’t go anywhere unless you send them to someone. Second warning: At least one of the “clients” uses some curse words.

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