Tag Archives: psychotherapy

Learn the Shape of Yourself and Other Advice for Counselors


The best counselors know themselves well. No, I don’t mean that the best counselors are self-centered. Rather, good counselors understand their biases, foibles, strengths and challenges. The best counselors know themselves inside and out and notice when they start to project their own thoughts and feelings onto others.

Why is this capacity so important? A counselor must see and note the difference between yourself and the client in front of you. This is vitally important if you are going to be of any help to that person. When we fail to see the difference, we end up counseling the other person as if they were an extension of ourselves. As a result, we fail to challenge our own biases and assume what helped us will help them.

Enter writer Mary Karr to illustrate this problem from the vantage point of writing a memoir.

Mary, author of several memoirs, has written a new book on how to write a memoir. I heard her being interviewed on NPR’s Fresh Air program today (find the audio here) and was taken by her advice to writing students. In response to a question about how to know if memory of events is accurately described, Mary tells of how she stages a fight (unbeknownst to her students) and then asks them to write about what they saw. As you might expect, each student sees something different. Why? Because they project their own lives and experiences onto the event. Even those with perfect recall, those who can get the dialogue just right, never fail to project their own assumptions into the story. Mary reminds listeners that it is impossible not to project ourselves into our observations. “We don’t so much as apprehend the world as we beam it from our eyeballs.” What can we do about this problem? She implores that writers to,

Learn the shape of yourself. Learn what you tend to project onto the landscape so that you can account for that tendency in your life and question it…

Learn to know the shape of yourself. What excellent advice for counselors.

Just last week I met with a man with decades of cross-cultural missions work on several continents. We spoke about the best ways to help students and new arrivals succeed cross-cultural ministry. This man reminded me that the best cross cultural education is not reading volumes about another culture (as good and helpful as that can be) but learning to know oneself inside and out so as to see the projections we tend to place on “the other.”

Want to avoid hurting others? You will surely need to know good counseling techniques and methods. you will want plenty of experience differentiating between types of problems. But, if you fail to really understand yourself and your tendencies, your utilization of those techniques may not be what the client needs.

Best advice to know yourself?

  1. Don’t take yourself too seriously.
  2. Ask your friends who you really trust to give it to you straight about your annoying habits.
  3. Get into your own therapy and don’t hide who you really are from the counselor.

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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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Why counseling? To be fixed or found?


Chuck DeGroat and Johnny LaLonde have written a post that some might find helpful when considering therapy or counseling (I use these words interchangeably). At some point in our lives, we all feel like life is getting out of control. We need help. We begin to wonder if there isn’t someone out there who can help us. But, even as we think these thoughts, we may also think, “what is the point? How can therapy fix this problem?”

Well, to give a partial answer, check out this first post over at Q Ideas. The authors argue that we should all be in therapy. However, they suggest that the purpose of such counseling is not so much to fix our problems but to understand ourselves, to admit our weaknesses, to be “found” or known. Now, these may sound like things that only wealthy people have the time to do. And yet, I would argue that in our isolated, individualized society, the normal communal means of being understood, supported, known, etc. are not often present in our lives.

Three paragraphs in this first post jump out for attention:

Don’t I go to therapy to get fixed? Believe it or not, I don’t advocate therapy because it fixes people. Now, while some forms of therapy help people get past difficulties that stifle them (e.g. panic attacks, major depression, bipolar symptoms), Christians should recognize there is always a deeper and more transformative purpose to counsel and care.

This was the ancient art called curam animarum—the care of souls. And the wisest therapists will foster this process. Now, the vast majority of clinicians practicing today have been trained in fix-it strategies—cognitive and behavioral solution-based processes which are aimed at quick, painless fixes. This is what sells. This is what insurance tends to pay for. But there is a profound difference here—fix-it strategies try to remove pain while deep soul care attempts to learn from it. Sometimes in the process we are afforded the mercy of pain relief. But it is not the goal. And so I counsel people to search carefully, to interview therapists, to ask many good questions.

And then this reflection:

But at the same time, I’m not convinced Christian therapists do this as well as secular therapists at times. Let me explain. Many settle for what Dietrich Bonhoeffer called “cheap grace,” a quick fix approach which stands in stark contrast to the “costly grace” of searching and knowing ourselves, through exploring our stories and examining our motives. This kind of care is, indeed, much more rare. Christian counseling which is reduced to mere Bible memorization, or repentance or a behavioral regimen misses the point.

Fixed and found?

I imagine that the authors would agree that both are possible. Therapy can lead to being fixed and found, to find relief and care for the soul. Therapies that ignore the need for immediate mercy and relief are of little value. I once talked to someone who had just completed a decade of psychoanalysis (3 sessions per week!). His therapist, a well-known analyst had just released him as having completed analysis. My new friend was looking for a therapist to deal with his longstanding panic disorder. I have also seen Christian counselors who have so emphasized discipleship that they paid little attention to easy helps for their addict clients. On the flip side, simple behavior change (now that is an oxymoron!) may provide some relief but miss insight into self and what God is up to in the world. In seeking only relief, we miss out on deepening our relationships with God and others. A superficial life lived may hurt lest, but is it worth living? 

Note at the bottom of the post there is a link to another post about how to choose a counselor. If you are looking for one, consider one who can have difficult conversations with you, one who does not over-simplify the problem, one who cares about your growing relationship with Christ, one who can provide ideas to bring immediate relief, and best of all, one who listens more than talks.

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Repost at www.biblical.edu: What is Christian Psychology?


For many of you this is the season of buying Christmas presents. For me, it is the season of paper grading time. I have 46 term papers due tonight. Thankfully, I do have a TA helping with grading for the first time in a VERY long time. So, that is my excuse for no new posting today. However, our faculty blog is reposting a version of my recent blog on Dr. Diane Langberg’s definition of Christian Psychology. Alone, her definition isn’t intended to be comprehensive (as she does not choose to define psychology). Probably would be better to title this a definition of Christian psychotherapeutic intervention. The focus in this definition is on the character of the therapist and the submission to the Spirit’s working in the life of the counselee. The point of the definition is to remind us that we can define the boundaries of psychology from a Christian perspective and yet fail to see the relational aspects of the work that we do.

If you missed it, this link will show you the original post here on November 26 and some helpful questions and comments.

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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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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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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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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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Narrative therapy and emotion 1


This month, Richard Smith and I are teaching an on-line class entitled, Christian Counseling in Postmodern Culture. Dr. Smith is managing the culture side of things in this class and has students thinking about the impact of consumerism, the “empty” self of the modern era, and “infantilist ethos” (from Barber’s 2008 Consumed)

This week Dr. Smith gave the class this quote:

At heart postmodernity [is] the same anthropology: both see humans as primarily units of consumption for whom choice is the defining characteristic… The difference between modernity and postmodernity is not that great looked at in this way: The cult of the autonomous ego, an endlessly acquisitive conqueror and pioneer devolved into a commodious individualism characterized by an unencumbered enjoyment of consumption goods and commodities.  (Brian Walsh and Sylvia Keesmaat).

A mouthful? Boil it down to this…postmodernist philosophy is very much concerned about the self. Not all that new. Now, postmodernism is much more than that and NOT all bad. But my point here is this: a counselor working in this culture must be able to connect with the client and help them construct/reconstruct their story rather than just give them lists of universal truisms to apprehend. Not that there isn’t universal truth but that the approach to them must  done in a dialogical and storying manner.

Enter narrative therapy.

Thus, I intend to blog a bit on this topic during the rest of August by summarizing and commenting on Working with Narrative in Emotion-Focused Therapy: Changing Stories, Healing Lives, by Lynne E Angus and Leslie S. Greenberg (APA, 2011).

Chapter one begins with this statement:

Being human involves creating meaning and using language to shape personal experiences into stories, or narratives. (p 3)

Do you agree? I would argue there is much truth in this. We shape our sense of self from our retelling of our experiences (both in words and in unspoken thoughts/emotions). But, we do not re-tell all of our experiences. Rather, we collect some and ignore others. Part of counseling is to dialog with the clients about how they shape their own narrative.

The authors then make this statement about the work of counseling,

As therapists, it is when we listen carefully to our clients’ most important stories that we gain access to how people are attempting to make sense of themselves in the context of their social worlds. In this way, psychotherapy is a specialized discursive activity designed to help clients shape a desired future and reconstruct a more compassionate and sustaining narrative account of the past. (p. 3-4)

Here they are telling us that our stories we tell are shaped by our emotions and at the same time make sense of our emotions.

What is EFT? It is a therapy that sees emotions as “centrally important in the experience of the self.” (p. 6). It was developed (principally by Les Greenberg) out of humanistic and Rogerian ideas of self-actualization and of counselor activities of being with, following the client and guiding. Throw in some F. Perl’s empty chair techniques as well. EFT focuses on emotions. Adaptive emotions are “the most fundamental, direct, initial, and rapid reactions to a situation…” (p. 7). Maladaptive emotions “…usually involve overlearned responses based on previous, often traumatic, experiences.” By this they mean emotions such as shame and abandonment sadness. They define secondary emotions as those reactions that are intended to protect the primary or most vulnerable emotions. Finally, they define instrumental emotions as those expressed for a motivation to achieve an aim.

Why the focus on emotion? Because they seek the goal of being emotionally congruent and adaptive. In this book, they focus on empathic attunement and changing client narratives.

How? Clients identify, experience, explore, story, make sense of, and flexibly manage their emotions (their words). Therapists notice “meaning markers” that reveal client confusion or conflict with the self.

This book will explore the narrative approach to EFT. “Critical life events must be described, reexperiences emotionally, and restoried before the trauma or damaged relationship can heal. New meanings must emerge that coherently account for the circumstances of what happened and how the narrator experienced it…” (p. 11)

Finally, they say,

…no form of psychotherapy is likely to have a big impact on basic temperament traits, but a client’s specific strategies, adaptations, and their internalized life narratives (i.e., macronarratives) have as much impact on behavior as do dispositional traits. (p. 13)

That is an interesting quote and puts the act of storying as more important than disposition.

So, what we will look at in the remaining 7 chapters is how the authors help facilitate new meanings and change their own narrative. The question for us is whether or not the narrative or re-storying approach to therapy is (a) effective in remediating problems, and (b) fits with Christian faith.

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Relationship’s role in therapy?


How important is it to get the right kind of counseling/therapy modality? How important is it to get the right person?

These questions plague both researchers and the people looking to get better. Why do some clients get better and others do not? Why do some therapists have a better success rate and others do not? Does the kind of therapy matter?

Well, as you can imagine, the answer is, “it depends.”

Yes, diagnosis and assessment do matter. If your child begins to struggle with bed-wetting after having been continent, you need to know what the problem is and what to do about it.

But, consider this: various studies make overlapping comments as to what really is going on when people get better

  • One researcher suggests that some 85+% of the reason for change are factors pertaining to the client and what is called “extratherapy” factors (social support, physical health, etc. )
  • Another places the portion the therapist plays in the 13% or so

Confusing? Consider this stark fact presented at a recent conference I attended

Patients receiving placebos from the top (best?) 1/3 psychiatrists fared better than patients who received actual medications from the bottom 1/3 psychiatrists. This was cited from the following study: Kim, D., Wampold, B. E., & Bolt, D. M. (2006). Therapist effects in psychotherapy: A random-effects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data. Psychotherapy Research, 16(2), 161-172.

So, when you are looking for a therapist or psychiatrist, you may want to know if he/she studied at Harvard or a degree mill. But, you may be better served to by one who listens to you, doesn’t fall asleep, and is able to collaborate with you to find a solution that works for you.

The moral of the story? Better to have a good psychiatrist with no meds than a poor one with a gunnysack full of pills.

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