Tag Archives: counseling

May 16, 2014 · 8:41 am

Traumatic Nightmares? Two Treatment Possibilities


Many who suffer from PTSD or other traumatic reactions also experience chronic nightmares. It is bad enough to have to deal with intrusive memories and triggers during the day but being robbed of peaceful sleep can send you over the edge, both in terms of physical and emotional health. Christian counselors may be tempted to ignore these nightmares (how can you stop something you have little control over?) or overly spiritualize the content of the dream.

But we ought not neglect the problem of nightmares. It is well-known that reductions in quality of sleep make all mental illnesses worse. Nightmare sufferers understandably avoid sleep but of course this creates a vicious cycle of insomnia, anxiety, and increased avoidance strategies.

There are two intervention options (among many) that appear to have fairly robust positive data indicating helpfulness. (For detailed descriptions of these two and others including the analyses of value, see this pdf): Prazosin (medication) and Imagery Rehearsal Therapy (IRT).

Prazosin is an anti-hypertensive (alpha blocker) that may work on the problem of too much norepinephrine in PTSD patients. It seems to improve sleep length and REM time. Interestingly, beta blockers have been found to increase nightmares rather than reduce them. I am no physician and so cannot evaluate the value of this medication for clients but would encourage clients with chronic, severe and re-occurring nightmares to talk with their doctor about whether Prazosin might work for them. The studies I have reviewed primarily examined the value of this medication for veterans with extreme nightmare problems. The most significant downside to medication treatment is that it only works when the medication is taken. Stop the medication, the nightmares may come back. However, some relief may be beneficial and thus the medication then has value.

Imagery Rehearsal Therapy (IRT) is a short-term therapy that does not work on the actual content of the traumatic experience or attempt to treat PTSD. Instead, it treats nightmares as a primary sleep disorder problem. There are variations on IRT but most versions last between 4 and 6 sessions and may be delivered in individual or group formats. Sessions include education about the nature of nightmares, sleep hygiene protocols, and the imagery replacement protocol. While some of the IR protocols are done imaginally, others ask nightmare sufferers to (a) write down the details of the distressing nightmare, and (b) write a new ending to the nightmare. As Bret Moore and Barry Krakow describe, the therapist does not dictate the new outcome of the revised dream but encourage the sufferer to “change the nightmare anyway you wish” (Psychological Trauma, v. 2, 2010). The nightmare sufferer then rehearses (multiple times) the new ending and is instructed to ignore the old nightmare.

Sound goofy? How is it that a person can just decide to have a different dream? However, the evidence that this therapy works is quite robust. Numerous studies with veterans and civilians indicates it is effective in reducing unwanted nightmares. Most treatment protocols suggest starting with nightmares with content unrelated to actual traumatic events.

Thus, Christian counselors ought to review these two treatments and consider learning the IRT protocol to bring relief to chronic nightmare sufferers.

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May 12, 2014 · 12:58 pm

Counselors talking about themselves? Additional thoughts


Last week I described some research supporting counselor self-disclosures, research that suggests clients appreciate disclosures revealing (a) similarities between counselor and client, and (b) vulnerabilities or personal emotions. While this research flies in the face of conventional wisdom in most counselor training programs, I cautioned counselors to ask some questions first before talking too much about self. With this post, I would like to press the caution just a bit more.

Why do counselors talk about themselves?

Why do counselors talk about their personal life with clients? Read the following numbered list to see some of the main reasons (and the sub-points in italics as illustrations of that reason). Then, consider the bracketed sub point as an alternative to self-disclosure.

  1. We want to put clients at ease and we think knowing something about ourselves might help
    • I can see you are anxious about whether taking antidepressants is appropriate for faithful Christians. I take them and it has only helped my faith.
      • [You’re not alone with that question so let’s explore the pros and cons to taking an antidepressant. Why don’t you start by telling me the reasons you’ve heard or thought about for not taking Prozac?]
  2. We believe our personal history will help a client understand, accept, or challenge something about their struggle
    • I know this treatment for panic disorder is difficult for you but I can tell you it works. It worked for me.
  3. We want to please an inquiring client
    • Yes, I am married and I have 2 children.
      • [Sure, I don’t mind telling you who is in my family, but could you first tell me why that is an important question for you?]
  4. We want to earn their respect and believe that our history will help
    • Well, for starters, I want you to read my book. It is now in its second edition and has been translated into 4 languages. I think you will find it very helpful for your problem.
      • [I’d like for you to start reading about your problem. There are a couple of books out there that I think you might find helpful, including one I wrote. But, feel free to look these over on Amazon and choose the one that seems right for you.]
  5. We like talking about ourselves; our personal stories seem difficult to avoid
    • You and I have a lot in common. My wife has the same problems as your husband. So, I know how lonely you must feel. We’ve tried…
      • [Though you are not saying so, I wonder if you feel lonely in your marriage.]
  6. We see the relationship more like a friendship with mutual sharing
    • I’m so glad to see you today. You are a bright light in a dull day. I look forward to our stimulating conversations. Just yesterday I was thinking about you and wishing to have coffee with you to discuss your career future. 
  7. We want to be seen as human rather than just professional
    • Yes, it has been a stressful day. I could use a back rub after all these sessions today.
      • [You know, some days are harder than others, but I’m curious why you asked this today?]
  8. We want the client to help us in some way
    • I was thinking about your need to work and my need to have someone edit my website. Or, I’m headed out on a mission trip next month. Well, I am if I can get enough donations. I’m about $1000 short thus far but I know God will come through.
      • [neither of these need to be said!]

Is it necessary? Is it helpful?

While self-disclosures may improve client perceptions of counselors, I suspect that empathic, client-centered therapists evoke these same feelings by asking good questions making observant reflections yet still minimizing disclosures, especially those where we initiate them and those that force the conversation to our personal history. There are some disclosures that are in response to client questions (e.g., have you ever struggled with addictions? Are you married? Do you believe in medications? Are you angry with me?) that warrant an answer. When giving this answer, work hard at keeping it brief and returning to the client’s story.

Don’t forget about social media self-disclosures

Clients sometimes “hear” our disclosures through social media. Imagine a client reading, “Well, that was a difficult session, glad I’m done for the day” having been that counselor’s last appointment! Blogs (like this!), Twitter, Facebook, and Instagram can be forms of self-disclosure. Be wary of these. Conventional wisdom says to avoid social media contacts with most clients so as to avoid harm to the counseling relationship. While we need not require an outright ban of these connections, a thoughtful counselor will review connections via social media for potential harm.

Be human

Despite these efforts to avoid letting our selves intrude too far into the session, sometimes life gets in the way. A counselor has a health or a family crisis. Clients have ways of finding this out and often want to ask how things are going. Here it is appropriate to say something brief, thank them for their concern and then start the session. In other situations a client discovers a shared passion for food, a sporting team, a connection through mutual friends. Enjoy these connections, acknowledge them, but be sure not to linger there during the session proper. We are, after all human. Don’t be surprised when counselor and client humanness come into contact.

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May 9, 2014 · 10:36 am

Should therapists talk about themselves to clients? Surprising information


How do you feel when your counselor begins to self-disclose during a session? When they do, is it helpful or a lapse in their judgment?

This is a common conversation in counselor training programs. Generally, most models of counseling and therapy discourage counselor-self-disclosure; some models do so more than others. The reasons for discouraging counselor self-disclosure vary from breaking the unconscious projection (analytic) to just confusing clients because we change the subject from client to counselor.

But a recent article in the April 2014 Journal of Counseling Psychology, suggests that self-disclosure might actually help more than we think. Henretty, Currier, Berman, and Levitt completed a meta-analytic review of 53 studies examining counselor self-disclosure versus non disclosure. And “overall” they found that clients have favorable perceptions of disclosing counselors.

Why? It appears that when a client perceives great affinity/similarity with a counselor, they rate that counselor higher. Also, when a counselor reveals something difficult or painful (a vulnerability?), it makes them more human to their clients. Some examples of this negative valence might include, “when you said that, I felt really sad.” Or, “Let’s talk about your anxiety, having suffering with it some years ago, I suspect you…”

Not so fast!

So revealing similarities with clients and being human make clients feel more similar and possibly more understood. This makes sense. Client/Counselor matching seems to correlate with better outcomes. However, before counselors go talking about themselves they ought to consider a few things.

  1. Why am I doing this? Is what I have to say for them or really for me? (Too often, we speak to talk about self)
  2. Is what I say really going to keep my clients focused on themselves or distract them to my story?
  3. Am I sure that what I say will show similarity? The truth is that we *think* we have a similar story but the times we are sure we know what our clients are feeling we are most likely to stop listening and then miss the client.
  4. How often do I do it?

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April 29, 2014 · 12:39 pm

Urban trauma or bad kids?


Psychiatrist Michael Lyles gives an excellent presentation on the nature of urban trauma at the 2014 ABS Community of Practice. He points out how much of what gets labeled as uncaring violence is better seen through the lens of urban trauma reactions. In addition, he discusses the response of the church. Not to be missed!

Michael Lyles – COP 2014 from American Bible Society on Vimeo.

After his presentation, Police chaplain and urban pastor Rev. Luis Centano gave this response regarding trauma in the city of Philadelphia.

Rev. Luis Centeno – COP 2014 from American Bible Society on Vimeo.

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April 15, 2014 · 5:59 am

Comparing ACA and AACC ethics codes: Multiple Relationships


Continuing our review of the ACA and the AACC codes for counselors, let’s take a look at how both codes address the matter of multiple or dual relationships. (See first and second posts about comparing the ACA and AACC code of ethics for counselors and mental health professionals.)

Multiple or dual relationships between counselor and client (or client’s family) are those that combine the professional relationship with one of another sort. If a counselor of a client is also that client’s pastor, that would be a multiple relationship. Other types could combine counselor and friend, counselor and business partner, counselor and employer, and increasingly possible, counselor and social media “friend.” Both codes are concerned about the formation of dual relationships because they become fertile ground for counselor judgment bias and harm to the client. Both see that once a counseling relationship has been formed, that relationship ought to be clear take priority over all others.

The ACA code of ethics prohibits outright the following dual relationships:

  1. Counselor and sexual partner: Counselors may not have sex with clients or their family members
  2. Counselors may not start counseling work with former sexual partners
  3. Counselors must wait at least 5 years before engaging in sexual activity with former clients (and even then may be prohibited)
  4. Counselors may not provide services to friends and family
  5. Counselors are prohibited from engaging in personal virtual relationships (social media) with current clients

Beyond the sexual arena, the ACA code warns counselors to avoid dual relationships or “extending the boundary” of the counselor or supervisor relationship

Counselors avoid entering into nonprofessional relationships with former clients, their romantic partners, or their family members when the interaction is potentially harmful to the client. This applies to both in-person and electronic interactions or relationships. (A.6.e)

When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately. (A.8)

So, notice the focus: avoid “extending the boundary” or what we used to call forming multiple relationships with current or former counselees or their family members. Document when you do so to illustrate informed consent, limiting of potential harm, and efforts made to rectify harm when it unintentionally happens

What about the AACC code?  It begins (ES1-140) with these paragraphs,

Dual relationships involve the breakdown of proper professional or ministerial boundaries. A dual relationship exists when two or more roles are mixed in a manner that can harm the counseling relationship and/or the therapeutic process. This includes counseling, as well as personal, fraternal, business, financial, or sexual and romantic relationships. Not all dual relationships are necessarily unethical—it is client exploitation that is wrong, not the dual relationship in and of itself. However, it remains the responsibility of the counselor to monitor and evaluate any potential harm to clients. (emphasis mine)

While in a counseling relationship, or when counseling relationships become imminent, or for an appropriate time after the termination of counseling, Christian counselors do not engage in dual relationships with clients. Some dual relationships are always avoided—sexual or romantic relations, and counseling close friends, family members, employees, business partners/associates or supervisees. Other dual relationships should be presumed as potentially troublesome and avoided wherever possible. (emphasis mine)

The AACC code then prohibits counseling relationships with family and close friends and warns against those “best avoided” (e.g., business associates, club members, etc.). Finally the code addresses counseling relationships within the church,

Christian counselors do not provide counseling to fellow church members with whom they have close personal, business, or shared ministry relations. Dual relationships with any other church members who are clients are potentially troublesome and best avoided, otherwise requiring justification. Pastors and church staff helpers should take all reasonable precautions to limit the adverse impact of any dual relationships. (ES-140-f)

This wording marks a change from the previous AACC code where dual relationships were more positively addressed. The old rule stated this, “Based on an absolute application that harms membership bonds in the Body of Christ, we oppose the ethical-legal view that all dual relationships are per se harmful and therefore invalid on their face.  Many dual relations are wrong and indefensible, but some dual relationships are worthwhile and defensible.”

Agreements? Disagreements? Both codes ban the ending of counseling relationships for the purpose of changing the professional relationship to different relationship, or to engage in sexual activity with a client or a member of the client’s family. The AACC codes requires 3 years before marrying a former client (assuming all other concerns raised are not an issue) whereas the ACA code requires 5 years before engaging in an intimate relationship. The ACA code as extensive concerns about the teacher/student relationship as well as the supervisor/supervisee relationship. The AACC code says little about these (though some can be inferred). The biggest difference, however, is found in the stronger language banning dual relationships in the ACA code where the AACC code warns against possible harm but leaves the door open as long as the counselor knows they have to prove no harm happened and informed consent.

 

 

 

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April 12, 2014 · 10:32 am

Comparing ACA and AACC ethics codes: Addressing counselor values impact


Over the next few post I plan to review similarities and differences between the ACA and AACC codes (see this post for the first in this mini-series). Today I want to look at how the two codes talk about counselors as they manage their own value systems with their clientele.

The ACA code raises the issue of values like this:

  • Section A Introduction

Counselors actively attempt to understand the diverse cultural backgrounds of the clients they serve. Counselors also explore their own cultural identities and how these affect their values and beliefs about the counseling process.

  • A.4.b. Personal Values

Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.

In addition, the ACA clearly states that when there are significant values differences, a counselor is NOT to make referral on the basis of values differences alone. Values clashes cannot be treated as lack of competency in a particular area of counseling.

  • A.11.b. Values Within Termination and Referral

Counselors refrain from referring prospective and current clients based solely on the counselor’s personally held values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.

The AACC code addresses the value systems of the counselor in these sections

  • ES1-010 Affirming Human Worth and Dignity

…Christian counselors express appropriate care towards any client, service-inquiring person, or anyone encountered in the course of practice or ministry, without regard to race, ethnicity, gender, sexual behavior or orientation, socioeconomic status, age, disability, marital status, education, occupation, denomination, belief system, values, or political affiliation. God’s love is unconditional and, at this level of concern, so must that be of the Christian counselor.

  • ES1-120 Refusal to Participate in Harmful Actions of Clients

Within this section are paragraphs discussing the application and limits of the “do no harm” virtue to certain client behaviors deemed not to fit within the biblical framework articulated at the beginning of the ethics code. The AACC code expressed an ethic to avoid supporting or condoning (while respecting and continuing to help) in the following areas: abortion-seeking, substance abuse, violence towards others, pre or extramarital sex, homosexual/bisexual or transgender behavior, and euthanasia. On this last issue, the ACA notes that the duty to breach confidentiality may be optional (thus indicating a values insertion since in all other cases we have a duty to breach confidentiality so as to warn others or protect the life of our client).

  • 1-530: Working with Persons of Different Faiths, Religions, and Values

Counselors work to understand the client’s belief system, always maintain respect for the client and strive to understand when faith and values issues are important to the client and foster values-informed client decision-making in counseling. Counselors share their own faith orientation only as a function of legitimate self-disclosure and when appropriate to client need, always maintaining a posture of humility. Christian counselors do not withhold services to anyone of a different race, ethnic group, faith, religion, denomination, or value system.

  • 1-530-a: Not Imposing Values

While Christian counselors may expose clients and/or the community at large to their faith orientation, they do not impose their religious beliefs or practices on clients.

  • 1-550: Action if Value Differences Interfere with Counseling

Christian counselors work to resolve problems—always in the client’s best interest—when differences between counselor and client values become too great and adversely affect the counseling process. This may include: (1) discussion of the issue as a therapeutic matter; (2) renegotiation of the counseling agreement; (3) consultation with a supervisor or trusted colleague or; as a last resort (4) referral to another counselor if the differences cannot be reduced or bridged (and then only in compliance with applicable state and federal law and/or regulatory requirements).

Differences between codes?

There are many but let me identify two. Notice that the most significant difference between the two is on the basis of the AACC code biblical/christian ethic regarding what is good and what is harmful behaviors. Both codes express the need to respect persons without regard to their beliefs, values, identities, and actions. The AACC code differentiates between imposing of values and exposing of values. What is the difference between exposing and imposing? I suspect it will be in the eye of the beholder. However, I suspect that one of the results of the ACA code is that faith and spiritual values will be less likely to be brought up by counselors since “not imposing” is more emphasized than “exploring.” There is much literature out there suggesting that the failure to explore and utilize spiritual resources actually harms clients in that it slows recovery.

Both codes address the issue of values differences between client and counselor. Both point to a path (though different) about what to do when this happens. The ACA code places pressure on the counselor to work it out while the AACC code suggests a path to resolution either with re-negotiation or referral. Which one sounds better to you?

When the difference is with a colleague? 

Both ACA and AACC codes addresses differences with colleagues. In section D (Relationships with other professionals), the ACA code states,

D.1.a. Different Approaches. Counselors are respectful of approaches that are grounded in theory and/or have an empirical or scientific foundation but may differ from their own. Counselors acknowledge the expertise of other professional groups and are respectful of their practices.

The AACC codes says something similar,

1-710-a: Honorable Relations between Professional and Ministerial Colleagues. Christian counselors respect professional and ministerial colleagues, both within and outside the church. Counselors strive to understand and, wherever able, respect differing approaches to counseling, and maintain collaborative and constructive relations with other professionals serving their clients—in the client’s best interest.

Fun facts

The ACA code never uses the word “faith”, does suggest counselors need to address self-care (includes spirituality), and does suggest counselors seek to utilize client’s spiritual resources…”when appropriate.”

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April 1, 2014 · 8:33 am

GTRI featured in an online, free journal


Our Global Trauma Recovery Institute is featured in the most recent issue of the EMCAPP Journal for Christian Psychology Around the World. Pages 172-211 include an overview of GTRI, two essays by Diane Langberg (The Role of Christ in Psychology; Living to Trauma Memories) and one by me (Telling Trauma Stories: What Helps, What Hurts).

The journal also contains an essay by Edward Welch (www.ccef.org) where he muses his development as a biblical counselor, explores the matter of emotions and some of the stereotypes of biblical counseling. The journal also includes a large number of essays about Paul Vitz as well as a number about the Society of christian Psychology.

Take a look!

 

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February 19, 2014 · 12:46 pm

When you imagine something does your brain think you see it?


What is the difference between imagination and reality? Sometimes, not that much.

The February 2014 edition of the Monitor on Psychology (v. 45:2, p. 18) lists a brief note about a study published in Psychological Science that looks at eye pupil constriction when imagining light. Here’s the abstract from the link above (emphasis mine):

If a mental image is a rerepresentation of a perception, then properties such as luminance or brightness should also be conjured up in the image. We monitored pupil diameters with an infrared eye tracker while participants first saw and then generated mental images of shapes that varied in luminance or complexity, while looking at an empty gray background. Participants also imagined familiar scenarios (e.g., a “sunny sky” or a “dark room”) while looking at the same neutral screen. In all experiments, participants’ eye pupils dilated or constricted, respectively, in response to dark and bright imagined objects and scenarios. Shape complexity increased mental effort and pupillary sizes independently of shapes’ luminance. Because the participants were unable to voluntarily constrict their eyes’ pupils, the observed pupillary adjustments to imaginary light present a strong case for accounts of mental imagery as a process based on brain states similar to those that arise during perception.

So it seems that thinking about something causes your brain to respond as if it is really seeing. What might this mean about those who are trying to break free of addictions?

  • Would imagining heroin use create observable changes in they body that would make it harder to maintain abstinence
  • Would recalling sexual images create responses that make sexual addictions harder to break?

So, what is the difference between imagining an affair and actually engaging in one? From a brain perspective, maybe not that much. Certainly Jesus’ expansion of the seventh commandment suggests there isn’t a difference between the two from God’s perspective. And yet, we know that actual adultery creates more damage to more people than merely fantasizing about having an affair.

Rumination: the health killer!

I’m currently teaching students a course on psychopathology. Each week we consider a different family of problems. Thus far we have explored anxiety disorders, mood disorders (depression, mania), anger/explosive disorders and addictions. Soon we’ll look at eating disorders, trauma, and psychosis.

There is one symptom that almost every person fitting one of those above categories experiences–repetitive, negative thought patterns.

Rumination.

The content of the repetitive thoughts may change depending on the type of problem (i.e., anxious fears, depressive negative thoughts, illicit urges, fears of weight gain, fears of being hurt, irritability, etc.) but the heart of the problem is the vicious cycle that negative thought patterns produce.

While there are many very good ancillary mental health treatments (Did you know that daily exercise, getting a good 8 hours of sleep each night, and eating a diet rich in protein supports good mental health and may even prevent re-occurrence of  prior problems?) it is essential for those of us who struggle with imagining negative events to find ways to shut down the production of rumination. Mindfulness techniques, thought-stopping, alternate focus may help to interrupt imaging bad feelings, thoughts, events and thereby interrupt the body reacting as if those bad things are indeed happening.

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February 14, 2014 · 11:34 am

Free Issue of Journal of Traumatic Stress


As a member of International Society of Traumatic Stress Studies (ISTSS), I am able to offer you a link to a free issue of their journal, Journal of Traumatic Stress.

Click this link for the February issue page with links to download individual articles.  Several essays relate to PTSD treatment for veterans, at least one essay re: child maltreatment in Uganda.

 

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January 21, 2014 · 6:26 pm

How to love someone with trauma


If you know someone grieving or going through a life altering trauma, then this article by David Brooks is for you. It gives you just a few pieces of advice as to how to relate well and to avoid some common pit-falls. Consider some of his examples:

1. Know the difference between the role of “firefighter” and “builder” and why trauma victims need “builders” for the long haul.

2. Bring soup.

3. Don’t try to make it make sense.

 

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