Tag Archives: mental health

December 11, 2012 · 5:44 pm

Hope when it won’t get better?


Last night we ended our counseling & physiology class. All semester we have been looking at counseling through the lens of the body and its problems. All counseling problems are physiological since all counselees come with a body. But of course, some problems have more complex etiology and require counselors to understand how the body is part of the problem and solution. This semester we looked at a wide variety of problems: trauma, anxiety, addiction, sexual problems, bipolar disorder, autism, multiple sclerosis, traumatic brain injury, and much more. In addition, we explored how insomnia is the “mental illness multiplier” and some basic self-care and mindfulness provides much relief across all problems. And yet, we barely scratched the surface of the physical stuff we’d like to know.

But last night, we considered the problem of chronic illness, illnesses like chronic fatigue, fibromyalgia, and irritable bowel syndrome. Here’s the question I posed. What gives us hope when we no longer seek the removal or end of an illness? Most people come to counseling because they want to make their marriages better, end depression, find a new career, etc. But would you go knowing that all you can do is find marginal improvement and new ways to accept a chronic condition?

We discussed the unique problem of receiving endless advice (“Have you tried this? Have you considered that?”), the tendency to resist new ideas even while hoping a miracle will come along, and the fear that others will believe that your chronic condition is, “all in your head.”

Back to the question we asked, “What gives you hope when you don’t hope it will get better?”

Some answered that they found hope in finding other similar sufferers (though some danger in connecting with someone who only wants to vent). Others found hope in those who would be willing to listen and validate and help articulate lament. Still others found hope in those who would help them find just one more thing they can do to cope.

What would you find helpful and hope building?

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December 5, 2012 · 10:27 am

Side effects of Counseling?


Next Monday is the last night of my Counseling & Physiology class (well, last night for the students as I have a boatload of papers to read and grade). As you might imagine, we spend a bit of time talking about psychotropic medications, their value, and probable side effects. Most students fall into one of two categories. Either they have personal and (largely) positive experiences with medications or they have concerns about side effects and observe the tendency of our culture to over-medicate.

But, it would probably be good for me to remind students that there are side effects to counseling or therapy as well. Most clinicians are trained to inform their first time clients that things sometimes get worse before they get better. Counseling requires that you attend to your problems, problems that you may have been in denial about. Talking about painful things usually means you think about them more outside of the hour with the counselor. In addition, you may find that the problem you entered with was only the tip of the iceberg. Or, you may find that the work to be done in therapy is much harder and slower than you thought, or the solution much different than you imagined.

There are a few other side effects that are worth pointing out.

  • You may discover you aren’t the righteous victim you thought you were; that you need more grace and mercy than you want to admit
  • You may discover you have bigger blind spots leading to new areas  to die to self
  • You may discover that others can love you despite your flaws
  • You may discover the joy of accepting some things you thought not possible to accept
  • You may discover better goals than the goal of getting beyond your troubles
  • You may discover strengths you didn’t know you had; success with new habits you had previously believed beyond you

Yes, counselors ought to talk to their clients about the side effects of proceeding in therapy (both general and specific to the particular intervention). Not to have this conversation is to not serve the client well. They need to know what they can expect from you and what other options they might choose. Of course, we also should discuss the side effect of doing nothing at all.

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November 26, 2012 · 4:56 pm

Do counselors need a brand?


Just read Lori Gottlieb’s “What Brand is Your Therapist?” NY Times Magazine essay. It is a worthy read for all new (and some of you older) therapists out there. I say this not because I agree with her methods or goals (i.e., easy clients who don’t cry), but because it points to the need to sell/brand as a counselor.

Those of us who get into the helping business rarely think about these things. Lots of people need help. I want to help people. Voila, I can make a living helping those in need. To accomplish this goal, we spend most of our time in school trying to learn that art of therapeutic relationships, diagnostics, and intervention strategies.

All good, but something is missing! Your brand!

As Lori points out (or more specifically, her branding consultant),

“Nobody wants to buy therapy anymore,” Truffo told me. “They want to buy a solution to a problem.” This is something Truffo discovered in her own former private practice of 18 years, during which she saw a shift from people who were unhappy and wanted to understand themselves better to people who would come in “because they wanted someone else or something else to change,” she said. “I’d see fewer and fewer people coming in and saying, ‘I want to change.’ ”

There is truth here. Given the economy, given the culture, given the flood of counselors in some locations, therapists do need to find ways to let people know what they provide. And yes, selling is important. Preachers sell when they preach (otherwise, they should just read Scripture and sit down). So too, counselors sell to interested clients.

What is your brand?

Now, our sales need to be honest and accurate. We don’t sell quick fixes (though we might sell short-term solution focused interventions such as marriage tune ups or parent training). We don’t sell change we can’t deliver. But within these parameters, we ought to consider branding our work. My friend and career counselor, Pam Smith, encourages her clientele to develop elevator statements (be able to articulate what you do in the space and time of an elevator ride). I imagine that branding is similar.

  1. Can you articulate what kind of services you offer that make you unique? (Don’t overreach and make it sound like YOU are the IT factor; don’t put others down).
  2. Do you have a specialty (population, intervention, location, etc.)? Something that you do well? Do you know how to state your strengths in a confident manner?
  3. Can you frame counseling goals in such a way as to make them attractive to those who may have lost hope?
  4. Are you talking to referral sources (church leaders, schools, communities) and educating others about what you do well?

While developing a brand won’t make you a better therapist, the lack of some semblance of brand probably means few will find out what kind of therapist you really are. Don’t be turned off of branding just because there are those who care more about having a brand than actually doing something of value. Maybe a better way to think about it is to ask, “Lord, in what ways do you seem to be calling me to your mission?”

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October 23, 2012 · 3:54 pm

More on “Can Your Body Make You Sin?”


I’ve written about this topic here and here before. In those posts I argue that there is a better question for counselors to consider than the one of culpability. Last night, we started the 2012 edition of Counseling & Physiology with the question of culpability and whether or bodies/brains can cause us to sin outside of our will. We also looked at our tendency to focus on judging whether a person is culpable for their sins (e.g., someone with Tourette’s who swears, someone with a TBI who is easily enraged, someone who is chronically anxious or still another who falls prey to addictive behavior). One of my main goals was to get students thinking about whether they under or overestimate the body’s role in counseling problems.

In the second post listed above I indicate the possibility of a better question than culpability. However, one of my students last night raised a question that went something like this,

Doesn’t the fact that you will choose how to respond to a client indicate that you have to judge the cause of the problem? If you encourage a client to consider psychoactive medications, aren’t you suggesting it is a body problem? If you focus on habits or heart issues, aren’t you assuming the problem is primarily a spiritual, will or behavioral control problem?

This was a great question and my answer was something like the following.

No and yes. Functionally, you will choose an area to work first. This does not mean you think that the type of intervention you choose indicates the main problem. It may only indicate that you think one intervention is an easier entry gate to counseling than another.

Here’s an example. Even if my client is severely depressed and I believe that the primary cause of this depression is their longstanding bitterness and anger towards God, I may encourage a psychiatric evaluation and the consideration of an antidepressant. It may be that once their mood improves, we can make better progress in investigating some spiritual matters in their life.

Human sins and weaknesses have multi-factored sources

Have you ever thought of the various sources of human sin? Here’s a visual of all of the things I think of that are a part of nearly every human sinful behavior. The sizes of the factors surely change depending on the situation. For some, will, high-handed rebellion, may be most of the pie. In other cases, bodily weakness may be the prime source. Also, some of these surely overlap and are not distinct. I may have started out in a rebellious state when I started doing drugs. Now, my body and psychological habits are equal players in why I maintain a drug habit.

What else would you add to this chart? Note that I place “will” in the smallest concentric circle. I imagine that we have far less conscious control over sin than we sometimes ascribe. Habits, unconscious motivations, and foolish (unthinking) choices probably dictate more of our behavior than our direct, willful, planned rebellion. Of course, none of this has ANY influence over culpability or morality as Scripture clearly indicates our guilt even when we are unaware of the Law’s commands. When Jesus says, “Father, forgive them for they know not what they do,” it tells us that consciousness of sin has little to do with our need for forgiveness.

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September 14, 2012 · 3:46 pm

Thomas Szasz, critic of psychiatry, dies


Did you see the obituary notice for Thomas Szasz, a 92-year-old psychiatrist who made it his life’s work to attack his own profession? If not, read the NYT’s article here. Szasz’ beef with psychiatry centered on two complaints: the diagnostic system treated individuals as having “things” rather than describing what they do (thus making it seem like people have diseases AND the coercive nature of treatments (forced treatment and meds for psychotic individuals.

What makes Szasz important to Christian counseling is that many biblical counselors and nouthetic counselors touted Szasz in their criticism of secular psychology and psychiatry. The Bobgans and Jay Adams used Szasz quotes to bolster their own criticisms.

How he was right AND wrong about diagnoses

Szasz was right in that DSM diagnoses tend to treat problems as discrete disease states when in fact they are descriptions of clusters of symptoms. More Venn diagram than discrete thing. Yet, Szasz and his ilk often used examples of diagnoses that he thought were not disease states. Well, some of these diagnoses have turned out more disease than not disease. Take ADHD for example. Many critics complained that there wasn’t anything that could be seen under a telescope…thus ADHD isn’t a real disease. Well, we can see significant differences in brain activity in the frontal lobes of those carrying the diagnosis. While we can’t yet point to a specific cellular structure or gene (and we likely never will since it is more complex than just biology), we are understanding the biological aspects of a number of mental health diagnoses.

Szasz was right that some portions of psychiatry treated those diagnosed as victims and ignored responsibility. Interestingly, as our understanding of genes and brain functioning have improved, the victim mentality has decreased. We are doing better in identifying responsibility even as we are more articulate about the effects of the Fall on the body.

We should thank critics like Szasz for pointing out serious flaws in the foundation of mental health philosophy and practice. And yet we should avoid the all/nothing approach that Szasz and his opponents took in criticizing or defending psychiatry. One common human reaction is to either (a) always look to be the critic, or (b) always look to explain away criticism. Both responses are normal but disastrous to helping others.

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September 4, 2012 · 1:47 pm

Guest post over at Christianpost.com


The website, www.christianpost.com has picked up one of my recent blog posts about whether our bodies can cause us to sin. Never heard of the site before but nice to be noticed. You can see the post here if you missed it on my site: http://blogs.christianpost.com/guest-views/can-your-body-cause-you-to-sin-11696/

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July 31, 2012 · 4:39 pm

Critical Incident Stress Debriefing: Does it work?


As someone who wants to advance faith-based global trauma recovery efforts, I am always on the prowl for effective interventions that could be sustainably used by local caregivers. However, it is always important to ask whether a popular or up-and-coming intervention has been fully vetted. Sadly, “does it work?” and “does it work here?” are often not fully answered before an intervention is promoted as the next best thing.

One of the most popular forms of immediate trauma intervention is called “Critical Incident Stress Debriefing,” a one time group intervention designed to forestall long-term trauma due to stressors. When you think of CISD, think of interventions with police or fire fighters or military after a traumatic experience.

But, does it work? This post here provides a helpful summary of the critique, even though it was published 2 years ago. As I read this I remembered an American Psychologist article on the same topic–but for the life of me I can’t find it. My recollection of this fantasy article is that these interventions seem to be helpful for about 50% of those who participate but that at this point it is not possible to tell which 50% will find it helpful. And further, a portion of the other 50% are actually harmed by it.

 

 

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July 26, 2012 · 9:59 am

What is therapeutic presence?


If you go to a counselor, you’d probably prefer that person to be awake versus asleep, to pay attention to you versus check their smart phone, to respond to what you are talking about versus make non sequitur responses. As I’ve noted here before, it is probably better to have a counselor who cares about you than one who has a big bag of techniques–though most of us would prefer our counselors to care AND be competent.

Therapeutic presence is a way of talking about the act of being with our clients in such a way as to build safe, trust-filled relationships where clients can grow and change. I think most people can easily identify failures of therapeutic presence. Try these on for fun:

CLIENT: I’m just so depressed.

THERAPIST: You think you are depressed? Let me tell you about depression. I have a client who just lost job, family, church, home. Now, that is something to be depressed about. You just had a bad day, that’s all.

Or,

CLIENT: I don’t understand why God would take away this job from me.

THERAPIST: Well, theologically speaking, God does things for all sorts of reasons. He sometimes does this to cause us to trust him more, to reveal some sin, to give him glory.

Notice how both responses fail miserably to be either therapeutic or present with the person in the moment of counseling. Not hard to miss, right? So here’s a question: Why do so many of us counselors, even seasoned ones at that, fail the “presence” test?

My answer? When we fail to be present in helpful ways, it reveals a lack of preparation and a lack of attention to purpose.

Shari Geller and Leslie Greenberg (in Therapeutic Presence: A Mindful Approach to Effective Therapy. APA, 2012) define the building blocks of therapeutic presence as

    • how therapists prepare for being present (in personal life and in session)
    • the process (or therapist activities) of being present (aka purposing to be present)
    • the experience of being present

Sound like mumbo-jumbo? Here’s another way of putting it. What does a counselor need to do to be ready to be in tune with their clients? What do they do to stay in tune when with clients, and are they aware of when they are failing to be in tune? (If I am unaware, then I am likely to get out of tune.)

Here are some things counselors ought to be asking themselves:

  • Do I have adequate space to move from my private life to being present with my clients? Do I have enough space between clients? The answer is not always an amount of time, but what we do during the space between.
  • As I prepare for sessions, what am I meditating and praying about? For example, if I pray for clients to be free from something that has them bound up, I could accidentally encourage myself to push for change or to talk about a subject that the client is not able or ready to talk about. I’m all for praying for healing. I just think we have other prayers to pray as well. “Lord, help me to be with the client today and not focused on my own personal goals for them.”
  • Am I staying present with their mood, their cognitions, their silences in such a way that it is as easy to talk about what is happening in the session as it is to talk about what happened in the past or might happen in the future?
  • When I sense a disconnect, am I quick to invite dialogue and learn (vs. avoid or defend/explain away)?

Therapeutic presence isn’t everything. I could be present with someone and no healing might take place. But without therapeutic presence, I will only be a barrier to whatever growth is taking place. When I do it well, I imagine that I might see just a tiny glimpse of how Jesus was with the woman caught in adultery, the Samaritan woman, or with Peter after he had abandoned Jesus.

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June 5, 2012 · 8:07 pm

Word choice matters!


Counselors often use what they call “additive” words to help flesh out the thoughts, feelings, and experiences of their clients. For example,

CLIENT: I feel so frustrated about how long it is taking for me to hear about the job I applied for.

COUNSELOR: You’re feeling anxious?

Certainly, my example is superficial and simple but you get the point. Frustrated doesn’t really adequately describe the true feelings of the client. We sometimes need help with defining what we really feel, think, or believe. This word addition happened to me today in a powerful way.

Today I was telling someone about a repeated discouragement I have experienced in recent months. In describing my experience I used the word “rumination” to describe the re-occurring thought pattern. She deftly said just one word.

“Grumbling?” [well, in fairness, that is what I remember]

That one word changes everything. When I choose to describe myself as having a repeating thought–a rumination–I am accurate if I am speaking only about the repeating part of the thought pattern. But notice that “rumination” doesn’t evaluate attitude or belief. What my trusted friend was trying to tell me was that I was allowing myself to have a pity party. I was accepting the disappointment feelings without any evaluation of what it was that I believed about the situation at hand. Truthfully, she was right. I was accepting the thoughts and feelings as accurate rather than interpretative of my situation.

Now, I am not arguing that those who have actual ruminations (a part of OCD) are all grumbling. But, it is a good reminder that the words we use do shape our perceptions of our life! We do not just respond to disappointments, we interpret them.

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May 21, 2012 · 5:31 am

Why we react and then think


Human brain parts during a fear amygdala hijac...

Human brain parts during a fear amygdala hijack from optical stimulus. (Photo credit: Wikipedia)

Ever wonder why? Check out this quote by Richard McNally¹ about the role of the amygdala,

LeDoux discovered two pathways for activating the amygdala, a subcortical structure integral to the experiences and expression of conditioned fear. One pathway rapidly transmits sensory input about fear stimuli to the amygdala via a subcortical route, whereas the second pathway passes through the cortex, taking twice as long to reach the amygdala. Subcortical activation of the amygdala makes it possible for a fight-or-flight reaction to begin even before information about fear-evoking stimulus has reached conscious awareness via the cortical route.” (p. 178, emphases mine)

If this is true, then in anxiety and intense emotion-producing events our brains begin the reaction phase prior to any thought processes. If true, then we might consider

  1. The goal of trauma treatment or anger management is NOT to avoid having reactions but to more quickly reach cognitions and alternative emotions that help moderate a negative reaction
  2. the empirical evidence for the clinical process whereby a client adopts a neutral reaction as opposed to a negative reaction is quite lacking. There are a number of models that process to “cool down” the amygdala, but these treatments often lack serious empirical support.

So, the next time you instantly react in a way that bothers you, don’t be so hard on yourself. Instead stop yourself, take a deep breath, work to analyze the situation and to lean into a post hoc truth. We have our hands full enough with what we know we need to do, we don’t need to worry so much about our first reaction.

¹McNally, R.J. (2003). Remembering Trauma. Cambridge, MA: Harvard University Press.

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