Tag Archives: mental health

May 15, 2012 · 2:46 pm

2 reasons why finding the root problem may not be a good goal for counselors


How important is it for a counselor to diagnose the client’s root problem? Consider these analogies:

Imagine being diagnosed with cancer in one part of your body but having your doctor tell you that it isn’t important to discover whether the source of that cancer lies elsewhere. You wouldn’t be happy and you would likely seek another opinion. Or, consider this analogy: you keep cutting off the tops of dandelions only to find that they keep coming back. Not a very wise decision. Instead, you find the tap-root and remove it if you really want to stop the weed from growing.

In the last week I have had three conversations about identifying the source or primary cause of someone’s emotional struggle. In each case I was asked questions about the source of the problem.

Is it a chemical imbalance? Is it the result of childhood trauma? Is the primary problem his sin?

I understand these questions. They are reasonable and important to ask. As a counselor, I am trying to assess how a particular psychological problem develops in an individual. But, maybe these questions aren’t as helpful as they first appear. Here are two reasons why we ought not put too much stock into seeking out the root problem and a suggestion for a different approach than the “why” question.

  1. “Why” questions almost always lead to a simplistic/categorical answer. Most psychological (or spiritual) problems have multi-factored roots. There are biological predispositions, experiences, behavioral choices/habits, perceptions, beliefs, etc. all working together to “allow” the problem to develop. Usually, we do not find this kind of complexity very helpful. We like to narrow things down to single or primary problems. Narrowing down to either/or categories helps us “understand” the problem and exert energy towards a single solution. However, when we demand a primary cause, we will almost always misrepresent the problem and may communicate to others a distorted image of what is taking place. Saying that a psychological problem is the result of sin or neurochemicals or family upbringing ALWAYS flattens the problem and as a result puts too much hope in any intervention.
  2. “Why” rarely leads to the most important question, “so, now what?” Let’s say that we can figure out why you struggle with Obsessive-Compulsive Disorder (OCD). Your mother contracted a virus during the 7th month of her pregnancy and that virus altered your prenatal brain and caused your OCD. Okay…so now what? Notice how the why question provides interesting information and possibly helpful in eliminating the problem in future expecting mothers…but as enticing as it is, the diagnosis doesn’t help much with the, “so now what do I do about it.” In fact the desire to figure out the “why” never is as clear and easy as I have just made it in the virus example and so the search for “why” doesn’t lead to the “so now what” question at all. Now, I don’t want you to think that I care little for historical data gathering. The multifactorial etiology of our problems are worth exploring. We ought to take a look at how early childhood experiences shape our current behavior. We ought to explore the possibility of a biological predisposition to our anxiety. We ought to examine how our beliefs about self, other, and God influence our current problems. However, we explore these historical facets not because they answer the “why” question but because they help us understand “how” we function and whether we want to alter some of these shaping influences.

An Alternative Approach?

I’ve just tipped my hand in the last point. How is a better question. Finding out how a particular feature (belief, habit, experience, perception, biological process, etc.) influences current life and how a person might respond to or engage differently over a problematic emotional expression is more likely to bear good fruit. Consider these examples:

  1. How does your history with pornography and secret shame influence your seeking accountability from your other men in the church?
  2. How do you react to trauma triggers and what different responses to triggers might you want to practice?
  3. How do you want to think about or assess your unwanted sexual desires and feelings?

So, asking why we do what we do or why we are the way we are is interesting but not always the most helpful question from a counselor. Instead, explore your perceptions, reactions, thoughts about what is happening and explore how you might come to feel, think, or engage the problem from a different perspective or with a different goal in mind.

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May 3, 2012 · 1:59 pm

eye contact and amygdala stimulation?


I’m in the midst of a CE training by Janina Fisher–Traumatic Attachment & Affect Dysregulation–and here is something she just said (not quote…my recollection),

When you make eye contact with another, you stimulate the amgydala. The arousal of this part of the brain arouses emotions, especially those connected with desire for or fear of intimacy. The point is that eye contact stimulates the attachment system which in turn plays on our feelings about being in relationship with others.

Later, she quoted someone (named Benjamin), “To be known or recognized is immediately to experience the other’s power. The other becomes the one who can give or withhold recognition: who can see what is hidden; who can reach, conceivably even violate, the core self.”

Thus, some clients (those who are ambivalent) find our “seeing them” (via empathy) as anxiety provoking. Counselors do well to help the client notice these reactions without over-stimulating reactions (which likely would trigger fight/flight reaction).

How you feel about making eye-contact with another depends largely on (a) how you feel about that person, or (b) how you feel about yourself. Both feelings depend on prior experiences and perceptions of self and other.

Try out a few moments of eye contact, either with someone you have authority over (supervisee, child, student) or someone who has power in your life (spouse, boss, teacher). What reactions did you have? Reactions in your body, thoughts, feelings? What impulses did you have? What does this tell you about how your brain works in regard to knowing and being known?

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April 24, 2012 · 10:32 pm

Why is some trauma complex? A helpful distinction from Judith Herman


Counselors talk about trauma as if all traumas lead to traumatic reactions. They do not. Some people have significant distress from what might be considered slight traumatic experiences (surely an oxymoron!) while others appear not have any negative or ongoing reactions to very large distressing events.

There’s another problem. We sometimes talk as if all traumatic reactions are the same. This is also not the case. While the symptoms of posttraumatic stress disorder (PTSD) are well-known to many (i.e., intrusive re-experiencing of trauma experiences, emotional numbing and other attempts of avoiding memories or triggers, and hypervigilance), you can find counseling students and practitioners who are less aware of a cousin of PTSD: Complex Trauma.

Defining Complex Trauma

I’m reading Treating complex Traumatic Stress Disorders: An Evidence-Based Guide, edited by Christine Courtois and Julian Ford (Guilford Press, 2009). This is an excellent text if you are interested in exploring the symptoms, neurobiology, and treatment protocols for complex trauma. In the foreword, Judith Herman helps the reader clarify the main difference between regular and complex trauma

These days, when I teach about complex PTSD, I always begin with the social ecology of prolonged and repeated interpersonal trauma. There are two main points to grasp here. The first is that such trauma is always embedded in a social structure that permits the abuse and exploitation of a subordinate group… The second point is that such trauma is always relational. It takes place when the victim is in a state of captivity, under the control and domination of the perpetrator. (xiv, emphases mine).

For trauma to become complex one needs to experience the trauma at the hands of those who are most perceived to control a social unit (family, community, etc.). It needs to be repeated and woven into the fabric of distorted relationships. You can see that prolonged abuses experienced as a child prior to development of an understanding of the world and of the self would have more devastating impact than an unfortunate and distressing event that happens as an adult. If I experience a horrific accident and an unexpected attack by a stranger, I would not, usually, begin to feel unsafe amongst friends and family. I would likely continue to trust them even as I might not trust the larger community. However, if I experience repeated abuse by a teacher, a parent, a relative, a church leader as a young child, I do not have the prior experiences of safety to rely on and thus, I am likely to experience all of the symptoms of PTSD and then some more.

What More Symptoms?

Courtois and Ford give a cursory description of complex trauma on the first page of the book,

…involving traumatic stressors that (1) are repetitive or prolonged; (2) involve direct harm and/or neglect and abandonment by caregivers or ostensibly responsible adults; (3) occur at developmentally vulnerable times in the victim’s life, such as early childhood; and (4) have great potential to compromise severely a child’s development.

Adding to the typical symptoms of PTSD, complex trauma victims also struggle to regulate emotions, impulses, somatic experiences, consciousness, and evidence significant distortions in views of the self and others leading to difficulty forming trust relationships and finding meaning in life and faith.

Those interested in learning more about the current thinking on complex trauma conceptualization and treatment may find this book useful. Others may wish to check out the latest articles at www.traumacenter.org, one of the leading centers in the country focused on the problem of trauma.

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April 17, 2012 · 10:11 am

3 important goals for trauma recovery


In the last week we have been discussing the best words used to describe the process of trauma recovery (see related post below). While words are important and carry much meaning, it may be more helpful to consider what recovery goals are in order for trauma victims. While we know recovery road can be long and arduous, it helps to know when we make progress and a general sense of the direction we are headed. In the days before GPS, if you went on a long car trip you probably consulted a map on several occasions in order to make sure you were headed in the right direction. So also, when you are working to get better after a traumatic experience, you want some sense you are still working on good goals. This need is especially great if the traumatic symptoms are complex and the treatment not brief (think war, genocide, child sexual abuse, etc.)

What three goals?

Esad Boskailo, as noted on p. 94 in his memoir (written and reported by Julie Lieblich) works toward these three goals that in turn support the ultimate goal: thriving (notice that the goal is not being free of symptoms, free of triggers, or back to life as if the trauma did not happen).

  • Acknowledge losses
  • Foster resiliency (i.e., build the capacity to use current coping resources)
  • Find meaning in life again

I think these do function well as helpful signposts or intermediate goals in the process of recovery from traumatic experiences. Now, I don’t believe these goals are necessarily in sequence. For some clients, they stumble on something that gives new meaning to life and thus are better able to acknowledge losses. Others get to work on building better coping mechanisms (e.g., a vet puts away items that cause him or her to dissociate, an adult victim of CSA stops cutting and develops acceptance strategies, etc.) and then can acknowledge losses.

So, in the murky water of therapy (and it surely is murky!), the trauma victim can find some comfort in activities pointing to these intermediate goals. Each day they reject self-condemnation for not being who they used to be before the trauma, they are moving toward thriving. Each day they embrace available coping resources (e.g., a friend who will call or pray), they are moving toward thriving. Each day they find one meaningful experience, they are moving toward thriving.

the how we meet these goals is, of course, the 64,000 dollar question…and not something we can set in stone. I will write on some general activities that are common in most treatment modalities in the coming days.

Related articles

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April 16, 2012 · 10:48 am

In Counseling, Who is the Teacher?


Most counselors and therapists get into the field of counseling because they want to help people. This is a good thing! Imagine if they only wanted to make money or to be the center of attention. But, underneath the goal of wanting to help people lurks an insidious goal:

being seen as wise.

Being seen as wise (notice the difference between being wise and being seen as wise) tempts us to become the teacher, the teller, the obnoxious sage.  Teaching, telling, training are all activities that may happen in counseling, but only when necessary. Truth be told, we counselors resort to teaching and telling because it gives us a job to do and makes us feel good. This is especially true when we work with the most severely traumatized people. Here someone is hurting in front of us. We can see that they are stuck. Who wouldn’t want to pull them out of the mud? Now, there may well be important teaching moments–gently instructing someone on the symptoms of trauma and/or the physiology of trauma. This might be important for the client who believes that the symptoms are really signs they are sinning and that they can just choose to stop being triggered.

In Counseling, Who is the Teacher?

“The patient is the ultimate teacher about trauma, and a good therapist is a good listener.” (Boskailo, p. 81)

While the counselor has much to offer in regard to teaching, training, and goal setting, we must remember that the client is the one teaching us about their trauma experiences and how much they can deal with at a given time. For example, Boskailo reminds us (see above link for book) that while telling the trauma story is an important part of the healing process, the “how” of telling (and the “how much”) is something each client will need to teach us. One client may need to tell and re-tell the same story each week. Another may be better helped by drawing. Still another may tell once and never again.

We counselors are the student in these kinds of matters. It is our job to listen well and learn well!

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April 6, 2012 · 10:16 am

Ethics violations: Why we all think we won’t screw up…and one thing you need to protect yourself from you


Every counselor, social worker, psychologist, and other mental health workers get professional ethics education. Such training is designed to teach us to “do no harm.” What mental health professional gets into the field to do harm? We all believe we are going to work for the betterment of our clients.

So, why do we sometimes fail to act in accord with good professional ethics?

Rarely is it because we don’t know the rules. Consider the most recent issue of the APA Monitor on Psychology and the short ethics piece by Alan Tjeltveit (a colleague of mine and fellow CAPS member) and Michael Gottlieb. (You can read the electronic version here; turn to page 68.)  In it, the authors nail the reason why with this quote,

Too many professionals complete their training without the emotional education and awareness needed to avoid self-deception and to act in the prudent, considered manner that society expects and that represents professional ethical excellence. (p. 72)

Self deception

We fail to take a skeptical (note…not fearful) stance toward our own thoughts, feelings, and attitudes. Since we know we are going to work for the good of others we often stop considering that some other values that we hold might get in the way. For example, I might value avoiding conflict and so not address a safety concern with my client for fear they will get angry with me. Or, as the authors of the article point out, I might practice when I am too distressed to help others–because I believe I can still manage the situation (see page. 70).

The One Protection You Most Need

As necessary as it is to keep taking ethics updates from continuing education providers, it is even more important to have a close colleague who doesn’t take you too seriously and is willing to ask the hard questions. Yes, we need an operating sense of values. We need to be tuned to our conscience. We need the Holy Spirit’s help in loving our neighbor as ourself. But, more importantly, we need to stop trusting in our own judgment and acknowledge that hidden values sometimes operate more powerfully than we expect. Desires to be liked, to avoid conflict, to maintain power, to satisfy longings have ways of creeping in. One of the reasons God puts us in community is that we need others to speak into our lives.

Do you want to avoid ethical missteps? Who exists in your life who has the access and capacity to speak into your life; to ask questions others might not think to ask?

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March 15, 2012 · 8:27 am

BREAKING NEWS? Professional Counseling Licensing Rule Changes on PA Governor’s Desk


Yesterday, The Governor of Pennsylvania, Tom Corbett, received HB816 after having been passed by both house and senate bodies. HB816 amends the rules for licensing social workers, professional counselors, and marriage and family therapists. These changes may enable a large number of MA counseling graduates, those who received degrees that currently do not meet licensing standards, finally get their licenses. Further, it reduces the amount of postgraduate supervised hours needed before being eligible for licensure.

Read the bill as it stands waiting to be signed by the governor here. Here are the key changes

  1. Reduces postgraduate supervised practice from 3600 to 3000 hours
  2. Eliminates the requirement to have graduated from a minimum 48 hour MA degree if received prior to June 30, 2009. Licensees still have to complete a total of 60 credit hours but having a 36 hour degree is no longer going to eliminate them from eligibility.

The rest of the requirements (passing a national exam, good character, etc.) all remain.These changes are also for social workers and marriage and family therapists.

For alums of Biblical Seminary’s 36 hour MA counseling degree, this should mean that they can now proceed to getting the required missing coursework and the required total of 60 credits rather than going back to get a new degree.

Pray that the governor signs!

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January 31, 2012 · 10:48 am

New drugs for depression?


This morning, NPR’s Morning edition ran a news report on some medicines that may help in the fight against depression. What makes this an interesting story is that the drugs are not typical (a street drug and a motion sickness drug) and that they work quite quickly–some even in one day! In addition, these drugs do not appear to work on the neurotransmitters serotonin or norepinephrine–the focus of most of our current antidepressants–but on glutamate, another neurotransmitter.

Listen to or read the story here.

Ketamine (known on the street at Special K) may have some capacity to form new connections between neurons. The assumption is that those who suffer with depression have had significant loss of neural connections.

Like with every drug, there may be some serious side effects with Ketamine: experiencing light trails (hence why clubbers use it) and foggy memories.

Findings, however initial, should (a) encourage us that better relief may be possible for millions of people, (b) remind us how little we really know about the brain, and (c) remember that those who suffer from serious depression and who seek medical treatment also must suffer with the experience of being a guinea pig of practitioners. This last point cannot be underscored enough. Medicines are never a panacea. And, we rarely can tell why one drug seems to work with some and doesn’t with others. In fact, much of what we know about drugs is shrouded in theory. Give a serotonin boosting compound to depressed people and they seem to get better suggests that the problem is that depressed people have too little serotonin in their synaptic clefts. Of course, this is mostly theory since some data may suggest that some have lower levels of serotonin and are not depressed at all.

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January 13, 2012 · 5:43 am

The trick to tolerating that which you cannot change?


Some things can’t be changed. You just have to endure them. There are “little” endurances such as waiting for a line in the grocery store, a dentist to finish drilling your tooth, for a boring speech to end. Then there are much larger endurances to suffer through like living in unabating poverty or under a dictator.

Some of us are better at enduring things than are others. Ever wonder what their tricks they have?

In a word–some variant of dissociation.

If the unpleasantness is likely to be short we may choose to fantasize about a lovely place we’d rather be. We may focus our senses on some other stimuli (temperature, light, color, smell, etc.) in an effort to “quiet” the urge to run. If the unpleasantness is much longer and if we have little sense that we can bring about a change in our situation, then we may lose connection with our current surroundings and our self. While this adaptive feature allows us to survive unimaginable pain, a habituated dissociation will take on a life of its own and begin to change our sense of self and our sense of the world.

In short, we lose faith. We may even stop trying to change what can be changed.

I find this quote by Richard Grant (“Crazy River: Exploration and Folly in East Africa”) about his experience in an overcrowded bus in Tanzania most instructive of the need to dissociate and the long-term impact,

After ten minutes, my right foot was numb and throbbing, and I wanted desperately to shift its position, just by an inch or two, but an inch or two was impossible in the squeeze of other feet and bags, and there were people sittings on the bags, and others standing hunched over at right angles under the roof….The danger and discomfort endured by the passengers was of absolutely no concern to the driver and the assistant, and the passengers endured it with a calm, patient, well-mannered grace. This was normal, everyday life, and the only kind of bus journey they knew. There was an hour to go. I tried to will myself into a blank, passive, indifferent, fatalistic state of mind, which I had come to understand as a basic survival mechanism for the poorest people in this world, although not necessarily helpful for their future. (p. 45-6, emphasis mine)

 

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January 3, 2012 · 10:26 am

How to evaluate a new counseling model or technique: Step one


Being a professor of counseling I get lots of questions like this: “What do you think of _____ (a new or popular counseling model/intervention)? These days, I’m being asked about coaching models, neurofeedback, EMDR, EFT, brainspotting, the use of SPECT scans, the use of psychiatric medications, nutritional supplements, and the like. In past years, I might have been asked about theophostic ministry, DBT, or ECT.

To be honest, I haven’t read every counseling model to the nth degree. I know a bit about a lot of models and a whole lot about some models. So, I try to be careful not to offer too much critique on what I don’t know first hand. That said, I do think there are good ways to go about evaluating any new model and proponents’ claims of efficacy. Over the next few posts I plan to show you how I try to investigate any new (to me) model:

Step One: Start with Suspicion

What? Shouldn’t we give them a fair shake? Yes, of course. And we will. But first, I do think it is helpful to ask yourself, a few key questions about what you are being sold.

  • Who is promoting this model/intervention? What financial benefit are they seeking?
  • What claims or promises do they make about their successes? Do they seem reasonable? Overly optimistic?
  • What supporting evidence is offered? Anything other than anecdotes from the inner circle of disciples? Any empirical evidence?
  • Do supporters distance from everything that has gone on before? How do they connect to mainstream models?
  • How transparent are the authors about what is being done?

None of these questions will answer our ultimate question of the value of any new model. There are excellent new models with almost no empirical evidence. Conversely, there are those who connect their intervention to a piece of mainstream research but do so only tangentially (thereby giving the appearance of scientific support but lacking validity and reliability (i.e., much of the change your brain popular models)).

A model that starts in the popular sphere may turn out to be good. Yet, we still want to gather the data about the motives and purpose of the new model. Take coaching for example. There is good evidence that coaching techniques work. However, much of what you find in popular places (bookstores and the Internet) is about someone trying to make a buck, either to coach you or to sell you a certification to become a coach. Thus, it is important to look at “packaging” to see what we are being sold. We may well want to buy the “product” but buyers need to know that sellers don’t usually talk about the weaknesses of their product.

Watch out for those models that over-sell their results, especially in the area of “complete freedom” from suffering. These are almost always unsupported by empirical evidence and certainly do not line up with good theology. We want complete removal of mental pain. This isn’t a bad desire, but it does set us up to buy the “next best thing” without proper critical evaluation. And well-meaning friends may tempt us to try out some new technique because it worked for them.

And yet, we need to be open to the possibility that there is something new on the horizon. Truthful anecdotes still have some merit. And so, tomorrow I will suggest that step two includes “reading with an open mind.”

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