I’m a little late to post this here but I am the Society of Christian Psychology’sguest blogger of the month. Here’s the post that I put up for today on how to parse the next hot new model of counseling you come across. Check it out at:
http://christianpsych.org/wp_scp/2009/07/20/evaluating-models-of-christian-psychology/
Started the day as usual with some quiet meditative reading on the porch overlooking the lake and the distant sound of many children getting water on the other side (yelling Muzungu (white person) to get my attention). Diane read us this quote from John Fawcett’s “Christ’s Precious” (published by W. Milner in 1839, p. 82)
I am but a stranger in this world, wherever I may be situated, or however I may happen to be distinguished. And such, it is my privilege that I am so. [However] when I look not upon myself as a stranger and a pilgrim, when I am captivated with anything in this place of my exile, I forget myself, and act far beneath my character, as a candidate for an immortal crown.
Fitting. It is easy in the US to forget our “exile” status. We focus, instead, on our own status. But here in Africa, there is little to do but remember how fragile life is and how we must depend on God for our daily existence.
Today we met with Justin Remera, a psychiatric nurse at Gahini hospital. The hospital was built in 1920s. He is the head of mental health. He sees some 30 patients per day and has a caseload of 500 with PTSD. He sees lots of “epilepsy” and has documented some 350 new cases in the past 2 years. But they have normal EEGs, thus it is trauma related not brain injury. Justin told us that there is an openness to therapy here because they see the benefits.
Problems noted by him? no medications other than Haldol. Infrastructure needs. His office is the size of a small closet and he has had violent patients and no escape (his desk and chair are away from the door). Also, next to his office are rooms where patients were screaming (while we were there). Seems they may have been doing some minor surgery without anesthetic. He also mentioned problems with demobilizing military and their own trauma as well as his own burnout.
Next we went to Kigali and met with the the permanent secretary of Defense. One of the persons there talked about having 520 peer counselors in the military to deal with the problem of HIV. Nothing dealing with PTSD. They have NO chaplains in their military.
Next, we visited the National Council of Protestant Churches of Rwanda. Specioise told us that 52% of the country are protestant. They have a program to deal with gender based violence, to educate the the church about laws designed to protect women. Their booklet combines Rwandan laws and biblical passages.
For our final meeting, we visited with Jean Baptiste at World Vision. He is new to WV in Rwanda but not new to WV (previously in Mali). He is a tall man with much presence. He spoke very openly and honestly about the issues of NGOs in the country and the problem of lukewarm Christians. He suggested they were much more problematic than rank atheists or Muslims. He gave us some advice as how to work with both churches and government officials. Josephine, a woman Diane had worked in Rwanda on previous trips, was there and spoke of the continued need to train and care for Rwandan caregivers.
Our day ended in Gahini with a farewell dinner. Members of the church and community (the local mayor) attended a dinner at the Seeds of Peace retreat houses. The dinner was outside under a canopy. During dinner we watched the local youth perform traditional dances with drums, singing and costumes. The young women danced with wooden milk bottles on their heads. We learned their trick. A heavy stone in the bottom of the bottle helps it stay on their head. Ouch! The night ended with gifts from our hosts to us and a few words of thanks from us.
Today we visited Nsinda Prison (population 8000) to interview those convicted of genocide. As we pulled up to the prison we met a large group of prisoners returning to the prison from the fields. They had only 1 guard with a machine gun and another with a stick. Many prisoners carried produce. Again, it felt like we were transported back a century. It was a dusty ancient looking place with shirtless male prisoners carrying huge logs on their shoulders (for firewood for their cooking fires). We were ushered to a bare cinder block room with a log and metal roof. 4 stools were brought for us. One of us noticed several wasp hives attached to the roof. In walked 19 prisoners all accused and convicted of mass murder. Quite a few were women and two had babies. One baby nursed throughout the session. The one guard stood outside the room with the door open to the out of doors. We asked them about their experiences. These individuals denied much wrongdoing, felt their former government led them astray, confessed, asked for forgiveness but felt they were denied it. They espoused genocidal ideology in that Tutsis were accused of killing the president and succeeding in forcing out the Hutus in the country.
Oh, as we entered the prison, we were greeted with “Nothing but the Blood” in native tongue over a loudspeaker. Apparently, there was a church service going on. What a contrast between the song (which recognizes guilt and the need for cleansing and the perceived innocence of the genocidaires (“I only mutilated dead bodies.”)
Awoke to the call to prayer by the local imam. Did not sleep well. Sinus headache due to the ever present charcoal smoke. We left Butare for Kigali to meet with with the president of the senate (2nd in command of the country) but he was suddenly unavailable. Something about the presence of UN VIPs. I guess that trumps us. Instead we met with the a key person at the ministry of mental health. She lamented the need to use BA level psychology grads and lay helpers to do the vast majority of their counseling. Lunch at Moucecore where we learned more about their ministry to prevent HIV, to protect children’s rights, teach the bible and train individuals to be community leaders.
After lunch we met with the rector (dean) of Kigali Health Institute. They confirmed the need for masters and doctoral counselors with knowledge of mental health problems. They have no problems with specifically christian counseling training and would like us to help them create a masters program and also teach or do distance ed for them. From this meeting,we drove across the city to Barakabao Foundation another ministry of the Bishop to care for over 5000 orphans. These orphans are in either foster families or child-headed homes–and they do it all with 12 staff. As some of the staff spoke, you could see their own stress and trauma. When it comes to orphans, they see 5 different types: genocide orphans, orphans whose parents died in refugee camps in the DRC, orphans born through rape, those whose parents died due to HIV, and those whose parents are in jail.
The day ended in Gahini at the retreat house. The hot meal and bed are welcome sights after such a long day of meetings. On the good note, I had a 2 minute call home. Sam answered and was overjoyed to hear me. Told Kim I was fine. Not sure if I’ll get further opportunities. I admit I’m homesick. I’ve not gone this long of a time without talking to Kim.
Filed under christian psychology, counseling, Psychology, Rwanda
In staff meeting yesterday Diane Langberg quoted J. Hillman (Dream Animals, 1997, p. 2):
“People come to therapy really for blessing. Not so much to fix what’s broken, but to get what’s broken blessed”
Sounds accurate to me
Filed under counseling, Great Quotes
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.
In place of my usual physiology Phriday post, I give you this…
“I think I need a psychiatric evaluation? Can you test me?” These are some of the questions I get from time to time. And they reveal an ongoing confusion about testings, assessment, evaluations, the world of psychiatry, psychology, and neurology. Interestingly, if you type in “psychiatric evaluation” into wikipedia, you actually get redirected to an entry on psychological evaluations and testing. So, let me try to differentiate a bit here:
What is a psychiatric evaluation? It is done by a psychiatrist who is a physician with special psychiatry training (courses and residencies). This evaluation is comprehensive but medical in nature. Expect the person to ask for your physical, behavioral, and cognitive histories, order blood tests or other medical exams, evaluate (by observation and interview) your mood, your reality testing, and mental status etc. Ultimately, after an extensive (and usually expensive) interview, the doctor will arrive at a psychiatric diagnosis (if appropriate) and may also recommend medicines to help with the problem–which they can prescribe. A few also provide ongoing talk therapy but most do not. Rather, they recommend you find a therapist for that part. They will follow up with med checks as needed to titrate or refine your medicines. When a person has a very difficult, complex, or lengthy history of mental health, or, when the person is needing a diagnosis for legal reasons, a psychiatrist is a good choice. They are usually gifted at extracting subtle physical and behavioral matters that may help correctly pinpoint the problem. While a person might well get anti-depressants from their regular doctor, a good psychiatrist is better able to deal with complex matters and follow you more closely to get the right compound and dosage.
Neurological Evaluation. Stating the obvious, a physician with neurological specialties and qualifications does a neurological evaluation. Neurologists specialize in…wait for it…the nervous system (brain, spinal cord, and 12 cranial nerves). A neurological evaluation includes many of the things evaluated by psychiatrists but with special attention to your motor and sensory systems, your reflexes, and similar kinds of things. You might more likely see a neurologist when you obviously have a neurological issue. Neurologists are more likely to specialize in ADHD, brain injuries, and psychiatric problems that result from dementias or other known physical problems. They are often better able to give and interpret MRIs and other imaging that might be appropriate. They will also prescribe and follow medications.
Psychological Evaluation, AKA testing, psych assessment. These are offered, mostly, by doctoral level psychologists. These evaluations will cover much of the same history, mental status, and provide diagnoses when appropriate. Interviews, just like the previous two options, are essential. However, what sets psychological evaluation apart is its use of standardized tests. These may be paper and pencil or electronic. They may be filled out by the client or by family members. The results provide a snapshot of behavior, or cognitive functioning, or mood by contrasting the individual results against a peer group. For example, a child may complete a computerized test to assess attention span. The results are compared to thousands of children taking this test who either are “non ADHD” and or ADHD. A good psychologist collects data from multiple data points (test data, interviews by client and maybe family, observations, etc.) and uses that data to make interpretations and recommendations for ongoing care. Usually, the best psychological evaluations begin with a very objective, specific question. Just throwing a bunch of tests at a person to “see what comes up” isn’t all that helpful. Just because something pops up doesn’t mean it is meaningful.
It is true that masters level therapists (licensed or not) give and interpret some tests. But most of the best tests can only be given and interpreted by doctoral level, licensed psychologists.
There are other types of evaluations. Neuropsychologists are doctoral psychologists with specialized training and help pinpoint brain injury, unravel more complex learning disabilities, etc. Neuropsychiatric evaluations are done by another similar but slightly different professional. You can check out their interesting history on this wikipedia page.
So, how do you choose what is best for you? Answer a few questions.
1. What do I really want to know when it is all said and done? What might help me decide how to proceed? The more specific you are, the more likely you can get the answer you want.
2. Do I think I need to focus more on physical options or behavioral options?
3. Do I think I’m likely to need medications? The physician types are better. Psychologists cannot prescribe meds (unless you live in Hawaii or are in the military).
4. If I am given a diagnosis, what do I need it for? Both doctoral level psychologists and psychiatrists are capable of giving you diagnoses. However, some people or systems value one opinion over another. Figure out if it matters for your purposes.
5. Am I looking for specific behavioral/relational suggestions? Then psychological evaluations are more appropriate.
6. Am I looking to form an ongoing therapeutic talk based relationship? See the psychologist.
A few days ago a young woman/teen was found partially clothed and semi-conscious under a Philadelphia bridge. At the time I am writing this post, it is assumed (nothing too outlandish here) that she was assaulted and raped and left for dead. Whether or not this turns out to be the exact situation for this injured woman matters not for the rest of the post. What does matter is that we know that rape happens.
How does one get to the place of treating another human being like an object and caring nothing for that person’s feelings, interests? We’d like to believe that rape, murder, slavery, trafficking, and the sort are different sorts of animals than the wee little sins we commit. But such heinous acts have exactly the same roots as “normal” objectification.
Take porn for example. On first blush, there is not any interpersonal crime in looking at a pornographic image. The assumption goes that the individuals in the pictures have voluntarily allowed themselves to be photographed and are happy with what they are doing. Of course, we know that these two assumptions are not always true. But even IF we accept the assumption, we must also accept that the viewer of the pictures cares nothing about the person in the picture. They exist for one reason only–to provide pleasure for the viewer. They have no feelings, they are only objects on a page.
The one dimensional image allows the viewer to begin the process of not seeing the other and not seeing their abuse of the other. And we are well aware of the common path of porn use. Start with a scantily clad image, move to complete nude, then to more and more dramatic pictures of sex acts which often include bondage, pain, or other grotesque acts.
Most people would have trouble watching a friend or a loved one engage in such an act, much less act out such activity on someone in pain. Most of us couldn’t just rape a stranger–at least at this point. But the root is the same: ignoring the personhood of the person in front of us. The person who is able to rape, traffick, or enslave has just been more successful in protecting themself from empathy, putting themself in the shoes of another, etc. We haven’t yet gone that far but notice that we begin such activities by our ability to objectify people on television or even in our everyday life. We murder (in our hearts) the incompetent bagger at the grocery store. We care little about his or her life. I’m not putting a passing hateful thought on par with rape but when we fail to recognize the person on the other side we begin to make it possible to deny the humanness of the other, whether a victim of a crime or the perpetrator.
Reminds me of Miroslav Volf’s quote in Exclusion and Embrace (p. 124):
“Forgiveness flounders because I exclude the enemy from the community of humans even as I exclude myself from the community of sinners.”
Filed under Abuse, christian psychology, Christianity, deception, pornography, sin
My friend, former teacher, mentor, Ed Welch, has posted a blog on the CCEF website on the topic of psychological testing and how biblical counselors might view it. You can see his blog here as well as my comment on their site: http://www.ccef.org/psychological-tests-are-you-or-against#comment-28
Ed, as you will see, isn’t really against testing, recognizes value in it, but doesn’t really think they are all that special–no more so than a really good interview. And, in part, he is right. A really good counselor/interviewer and learn a lot. In my mind, though, testing provides confirmation of what you are learning about the counselee PLUS uncovers subtle data that you might not get quickly or at all (especially through the more objective forms of testing).
It seems people think about testing in one of two ways: either they think testing uncovers secrets that couldn’t be gotten without a test or they dismiss it as pure theory. It is neither. Good testing provides a response profile that one can look at and compare to either the general population or a specific population. That, in itself, isn’t all that helpful but when combined with a specific assessment question, the examiner can interpret the data and build good hypotheses to direct future counseling and intervention.
I love to do psych testing. I find that interacting with test results and counselees provides dialog points that wouldn’t have been as easily discovered or talked about without the data in front of us. For example, if someone takes a personality test and one of the scales suggests that they are approaching the test in a manner consistent with those who are trying to look better than they really are, that provides an opportunity to discuss an pattern in their life that we might not have had the chance to do so easily.
Tomorrow I’m posting about the problem of repetitive thoughts. Was talking in supervision, today, about the problem and my eminently wise supervisor suggested that one of the issues about repetitive thoughts is that we forget that they aren’t reality and so we listen to them. Actually, she said it much nicer but that is the best I can do.
She suggested telling clients to consider (write down) these repetitive, negative thoughts and imagine that they were being said by someone following them around. This objectifies the thoughts and gives one an opportunity to talk back to them.
So, imagine that someone is following you around and saying aloud your thoughts. What would you want to do to them? How might that picture help you to reject certain negativistic self-talk or rumination about others?
Kind of like Gollum’s (Lord of the Rings) debate with himself. We all have a little Gollum in us, right?
Filed under counseling, Psychology
Musings on Faith and Psychology 