Tag Archives: therapy

October 19, 2025 · 5:50 am

Moral distress? Moral trauma? An important update on definitions and concepts


The folks at Harvard’s Human Flourishing Program, led by Dr. Tyler VanderWeale, have published a paper updating the definitions of moral injury and distress. If you work with people suffering betrayal trauma–especially religious betrayal trauma–you may want to take the time to read their piece and recognize the aspects of moral trauma that may not be well addressed in the classic treatment of PTSD.

What is moral distress and trauma?

Years ago, moral injury was something described primarily in terms of an added impact on veterans of war. The symptoms of moral injury were seen to be in addition to PTSD, defined as an added injury when an individual perceived themselves as having transgressed basic human morals (e.g., a soldier is forced to kill civilians who are being used as shields by enemy fighters). It was commonly understood as the idea that I have done something so terrible that it is unforgiveable (or I have supported leaders who have done something that betrays basic humanity). Key features of moral injury focused on the experience of guilt/shame whereas key features of PTSD centered on horror and terror.

As the concept became better understood, we began to understand it’s existance among civilians as well. Here are some examples:

  • Someone who did something wrong (e.g., distracted driving) and badly wounded or killed another person
  • First responders who have to triage and, in essence, decide who lives and dies (e.g., the impossible decision between two terrible outcomes)
  • Victims of abuse who may have enlisted friends who also became victims of abuse
  • Someone who supported and defended a well-known leader who was later found to be harming others

Understanding moral distress of victims of trauma

This paper expands the idea of moral distress beyond the (perceived) perpetrator to that of the experience of victims of trauma/abuse. Consider the new definition offered by VanderWeale and summarized in a recent newsletter,

In trying to bring these concepts together, we conceived of such moral distress as lying on a “moral trauma spectrum” that included matters of both the severity and the persistence of distress. After months of synthesis of prior work, we defined “moral distress” as “distress that arises because personal experience disrupts or threatens: (a) one’s sense of the goodness of oneself, of others, of institutions, or of what are understood to be higher powers, or (b) one’s beliefs or intuitions about right and wrong, or good and evil.” When that distress became sufficiently persistent it would constitute “moral injury.” For such moral distress or moral injury, it was not only that some moral code was violated, but rather that whatever took place somehow challenged one’s whole understanding of right and wrong, or of good and evil, or of the goodness of oneself, others, institutions, or even the divine. That disruption of one’s moral understanding would then give rise to, sometimes severe, distress. When that distress was persistent and would not go away it would be appropriate to speak of “moral injury.” When the distress was sufficiently severe so as to seriously impair functioning over extended periods of time, it might sometimes even be appropriate to speak of “moral injury” disorder.

(Newsletter from Human Flourishing Program, received via email Sept 17, 2025)

Re-read the bolded text. It is not just that some moral code was violated by myself, but that one’s whole understanding of right/wrong of self, others, institutions or the divine has crumbled. Notice how this distress might be observed in individuals having experienced certain types of traumas:

  • Victim of sexual assault seeks help from justice system but ends up feeling blamed for it
  • Whistleblower in a church who seeks institutional support to stop the abuse by a leader but is then scapegoated for disrupting the ministry
  • Someone who is scammed out of money feels they have irreparably harmed others
  • Child experiencing abuse by a family member and when telling a parent is then told to be quiet no longer believes they have value
  • Person prays for justice and expects to be exonerated but ends up feeling abandoned and forgotten by God

How might this change our treatment of trauma?

The treatment of trauma focuses first on the care of one’s nervous system. Learning to modulate and calm one’s body is essential since the very nature of chronic trauma is an overactivated vigilance system even when the danger has passed. As a person develops capacity to return more quickly to baseline then there may be more of a focus on addressing the narrative and memory of how the traumatic experience changed perceptions of self and the world.

When we make room for the spiritual/moral impacts of both trauma and how communities respond to people who have suffered trauma, we can better address the moral distress experienced. Treatment modalities that only focus on the reduction of nervous system overload may miss addressing the existential and spiritual crises that haunt survivors. This is especially true when (a) faith communities implicitly (or explicitly) discourage expressing doubt about God, or (b) when clinicians ignore spiritual and moral discussions in therapy. Inviting and validating the very deep moral questions of hurting people is essential for their recovery, even when answers are not readily (or ever?) available. Any treatment that ignores moral distress will not be sufficient to the task of recovery. While I am hopeful that some of the recent trauma treatment modalities may speed recovery, I notice that these newer treatments often ignore questions of existence, narrative, and faith and focus almost solely on nervous system function. This may be needed in the first line of care but let us now be more alert to moral distress and injury in those who have survived abuse, assault, and other forms of betrayal trauma.

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June 17, 2024 · 5:52 am

Why am I STILL afraid? Some thoughts on what recovery from chronic anxiety looks like


I provide psychotherapy for many with chronic and debilitating anxiety. Anxiety is the most common malady in the world and comes in all sizes and shapes: panic, phobias, OCD, GAD, social anxiety, PTSD and more. For some it is very context driven (e.g., fear of flying) and for others it is constant and wide-ranging (e.g., OCD, PTSD).

Frequently, when a person comes to therapy, their first and enduring question is, “Can you make this go away? I just need it to stop.” They have struggled for a long time and have tried many things. Some have tried medications, others tried to limit exposure and avoid situations that would trigger the anxiety, and almost everyone has tried to talk (aka berate) themselves out of their feelings. “If I really trusted God this would not be happening!”

This desire to extinguish anxiety is completely understandable. Anxiety is horrible, consuming, and exhausting! We want it to go away and never come back. But–and this may seem absolutely disappointing to many—having the goal of zero anxiety is actually detrimental to a positive outcome and recovery.

Let’s explore what therapy is/does and why changing your relationship to anxiety is a better goal than trying to extinguish it.

What does therapy for anxiety look like?

Therapy for anxiety (at least what I practice) tends to have these common features1:

  • Compassion, understanding and curiosity about the physiology of anxiety
  • Experimentation on what short-circuits anxiety and identifying what intensifies the sensations
  • Practice relaxation/mindfulness/distraction with increasing exposure to feared stimuli
  • Exploring experiences/beliefs/values that may contribute to ongoing anxiety (e.g., a part is burdened with shame, perfectionism, assumptions of failure, etc.)

Notice the flow and trajectory. Compassion…Understand…Experiment…Practice…Examine (held beliefs). The flow isn’t really linear but it is hard to examine underlying beliefs or childhood experiences when you are in the middle of a panic attack.

Sessions early on look like understanding what is happening in our bodies when we are anxious. As we progress, we explore successes and challenges. We notice things that helped a little, or things that may have intensified anxiety. For example, having a friend try to convince you that your worries are unfounded may feel good at first but then leave you feeling more shame and more helpless. Or, maybe listening to a great podcast on the way to work reduces anxiety by a good 30 percent. This is, in essence, somatic psychotherapy.

The goal: PIVOT

When I am afraid, I put my trust in you. Ps 56:3

Notice the verse above says, “when.” Not if. When. We will be afraid, maybe often. And when that happens, we will do something. But what? How? In practical terms, we pivot.

What is pivoting and why do we do it? Pivoting is moving our mind/body/attention away from the cascade of fears. Instead of trying to dialogue with anxiety, we pivot away. Why do we pivot? We do so because anxiety is a TERRIBLE and completely unfair and unreasonable discussion partner. And since anxiety intrudes without your permission, you are not obligated to talk with it nor accept it as if anxiety is you.

Here is how it might work for me once I have recognized that what is happening is that my mind and body are locking onto an intrusive fear. I name the fear, then I pivot my mind by looking intently at the Ansel Adams photograph of El Capitan next to me. I describe the shadows and features I see. Or, I pivot my body by getting up and feeling the sensation of walking. I may pivot to my senses by smelling my coffee and taking a deep breath in and out. I do this pivot again and again in order to de-couple from the thoughts. And I actively use my body to lower felt tension. At first, this many seem about as successful as jumping off a cliff while flapping your arms. And yet, over time, your pivot will decrease your anxiety.

Notice what I do not do. I do not,

  • debate the fears
  • beat myself up for having fears
  • assume success is the cessation of anxiety

Why does it take so much work to fight anxiety?

We have been habituated into fear. Changing the automatic response takes work. It wasn’t our choice to be afraid but now we have to find a way to pivot out of something we never wanted. It isn’t our fault but now it is something we must respond to, just like someone with a migraine didn’t choose it but now will have to discover what helps curtail one. As we practice our pivots we will find they become slightly easier and more effective, just as when you practice a sport or an art, you will notice you are becoming more skilled.

What if my goal is not extinguishing anxiety?

In short, it is building a new relationship with anxiety where you accept that it exists but does determine how you will live. You acknowledge it but do not engage it. In doing so, you accept the challenge of building a competing neurocircuit alongside the fear pathway and activating that experience on repeat. The best competing circuits have deep meaning and connections with others. Here are some examples:

  1. Instead of trying to avoid making mistakes, look for mystery and experimentation
  2. Instead of trying to avoid panic, lean into doing something with your body that you have not doe (advanced yoga or stretching, increased weight lifting, knitting)

I want to leave you with one thought. If you learned something new about how anxiety is expressed in your body and if you learned how to gain even a little mastery over your body’s anxiety response then you have already begun to change your relationship to fear! You are beginning to be in charge rather than feeling controlled by fear. Your success is not always winning against fear but knowing that when you are afraid, you will put your trust in God and in the body he has given you.

_____

1These are common factors to all anxiety therapies though they may differ when focused on a particular kind of anxiety. In addition, I always recommend a medical evaluation to rule out other potential causes of anxiety as well as consideration of medications that may help support recovery.

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October 29, 2023 · 12:57 pm

Am I doing this Trauma Healing Thing Right? Part 5, Finding a therapy and a therapist


So, now that we have identified some barriers to recovery (myths and red flag moves by helpers) and noted essential items you need for this journey—like compassion and curiosity, let’s conclude this series by exploring how to choose a therapist and a model. 

It can feel impossible to find a quality therapist and downright overwhelming to choose a particular model of trauma care. If you have started to look you probably began first to explore credentials and general styles of therapy (models). 

Do you choose Christian or biblical or secular? How much does licensing and credentials matter? 

Which model? CBT, TF-CBT, DBT, PE, EMDR, Tapping, CPT, Brain spotting, NET, PFA, Debriefing, and somatic psychotherapy? Neurofeedback? IFS?

Medications? Ketamine? Transcranial magnetic stimulation?

Or maybe skip the therapy altogether and focus on yoga, mindfulness, meditation, art, or acupressure?

Feeling overwhelmed yet? 

If you have been looking for very long, you probably heard someone sing the praises of one of these types of therapists or models over others and noted it to be a miraculous cure for them. And just as likely you have heard, “that didn’t work for me.” 

Cutting through the fog

Several of the models listed have some scientific support. And some others have a lot of hype and anecdotes but little in the way of actual substantiated research. Randomized control trials, the gold standard of research, attempt to look past correlational data to determine if a positive result can be attributed to the intervention used. Sometimes we learn that a particular model is effective even while we do not fully understand why or what part of the model is having a positive impact. But, it should be noted that many RCTs tend to be small in sample size and somewhat limited in generalizability. In other words, it worked for the research group but until it is replicated many times with different populations, we won’t yet know if it works for most or for you or me. 

One more frustrating part is that disciples of a model may suggest to you that an intervention they use is more successful than the researchers who developed and studied said model. We have this annoying habit of overestimating the value of the thing we have learned to do. 

Pick your person first

So, don’t start with which model you should choose from. Yes, models and ideologies matter and influence the work done in session. But there is something more important to consider. It is…drum roll…the character and person of the counselor. Trust and connection in therapy has more to do with success than the model being used. We have already identified the characteristics of a good therapist in the last post: 

  • Goes at your pace.
  • Is curious about what you need. 
  • Wants to learn what helps you more than tell you what you should do.
  • Is aware of and adjusts when you are overwhelmed.
  • Invites your pushback and doesn’t get defensive.
  • Listens more than talks.
  • Checks in to make sure you are talking about the things that matter to you the most.
  • Does not criticize your faith journey.

If you have such a person now, ask yourself if you are holding back. Don’t judge yourself if you are, but ask what it might mean. It may mean there is something you are not ready to talk about. Good for you to know what you need. It may mean there is some bit of safety that still needs to be built in the session. It may mean something is off in the therapy. See if you can find a way to discuss this dynamic without talking about the thing you are holding back. How your therapist navigates this bit of information will tell you much about the safety and trust in the relationship. 

But I don’t have this person yet, how do I find them?

I recommend you start by asking people who you trust, who they have heard does good work. Get firsthand reports whenever possible. You want to ask, 

“Who would you go to or send your family member to if you knew they needed a good therapist? What makes them a good therapist?”

Once you locate someone who seems to fit the bill—experience…known to be a good listener…has credentials and training—you will still need to find out if this person is going to be right for YOU. 

Once you get an appointment, interview them in that first session and keep in mind these questions as you progress in your therapy. 

  1. What models/authors do you most likely follow?
  2. What are early signs that therapy is working? Signs that maybe something else is needed?
  3. What do therapy sessions look like? Hopefully, their answers include some form of:
    • Grounding/calming. Before/during/after triggers in session and practiced at home. It should be tailored to your needs and flexible. 
    • Small exposure to trauma via your story—not rushed in the therapy process—with more grounding sandwiched around the exposure. This should be well-planned and short, and not a whole session focused on traumatic stories and triggers. The goal is not reliving trauma but remembering, lamenting, and then shifting weight to the present.
    • Narrative or meaning focus (who am I? who is God? Was it my fault?). Exploring and grounding in new narratives This often comes later in therapy work.  
    • Grief work. Most therapies will have some exploration of grief and lament. Naming what was lost and what has been suffered is necessary for good healing.  
    • Finding and celebrating strengths and resilience. An important part of recovery is seeing where and how you have grown and developed new capacities. 

But, what model should I be looking for?

I won’t be able to tell you what works for you. But use the following questions to determine what works for you now. It might be that you need one supportive therapy now and a different one later. 

  • Are you struggling with being on high alert all the time? Do you want to find something that helps you calm your body? Consider something that helps you practice calming and stabilizing your body. Somatic psychotherapies that follow work by Janina Fisher may be most appropriate for you. 
  • Are you a writer? Consider more narrative focused treatment like NET or CPT. 
  • Do you find yourself stuck in patterns of bad relationships and self-harming behaviors? Consider a DBT oriented group or therapist.
  • Do you find yourself in a frozen state (vs flight/fight/fawn)? Consider something that is less exposure oriented. You may find that certain exposure-oriented interventions (CBT/EMDR/PE) are unhelpful in early phases. Similarly, if you have many traumas versus one, consider something that goes much more slowly and helps you stay connected to parts of yourself. You may find that someone who follows the work of Diane Langberg or Judith Herman is a better fit for you. Also, the work of IFS can help you make some safe room for exiled/shamed parts.   

Concluding thought

The work of trauma recovery is slow, repetitive work. You learn something, then need to learn it again. You feel some growth,  and then feel yourself slipping, especially when you hit anniversaries and reminders. Give yourself permission to keep trying old and new things. 

The journey of recovery (whether in therapy or just waking up to another day) is an ongoing reminder that something has died. Maybe for you it is a relationship or trust or a body that didn’t bear the invisible wounds. You will grieve these things. Try to grieve without confusing grief with shame and guilt. You may have to relearn that grief does not mean shame. 

Remember also that your journey will show you that you are still alive. You survived. Slow your breathing and feel your aliveness. Feel your aliveness—even the pain—telling you that you are here, and you reflect courage and beauty. Take note of the small things growing in and around you. These are the bits of beautiful creation that tell us you reflect God’s glory. You may not feel the beauty but consider that it is still true. 

For further reading about the healing journey, consider reading “Wounded, I am More Awake.” You can read my thoughts on this book beginning here.

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December 18, 2019 · 6:30 pm

Counselor failures: Choosing the wrong goals


Many moons ago, when I was a young counselor, documentation of treatment was left up to the therapist. Many kept no records at all. Some had hand written notes but were only for the therapist to remember the content or a insight they wanted to share at a later time. But, whether a therapist kept notes or not, it would be rare for the client to know anything about their documented diagnosis (even if insurance was paying) and even less about treatment goals.

With the advent of managed care, documentation of service rendered became a reality. At first these documents (diagnosis, treatment plan, quarterly summaries, termination note) were completed without client knowledge. Later, best practices required therapists to share, at least verbally, diagnoses and treatment plans with their clients. Hopefully, today’s client is a bit more informed as to this better practice and is in agreement with the goals of therapy.

But even when agreement exists as to the high level goal, counselors can find themselves working towards goals the client does not want, or, can be working a different path to a shared goal that doesn’t seem to fit the client.

Setting client goals is an easy thing?

While documentation of goals and objectives is relatively new in psychotherapy, setting goals is not. Client comes in, discusses presenting problem, therapist and client explore desired outcomes. As therapy progresses, goals may change due to circumstances or new learnings. Easy, right? Not so fast.

Shared goal, disagreement about the path

Let’s say I go to therapy to work on a phobia I have to flying. We agree on the larger goal and begin to work. Along the way the therapist wants me to try exposure to flying by getting on a high speed train to simulate the sensation of movement and loss of control. I resist because I do not feel ready. The therapist wants me to push through. I resist more. The therapist can continue to press, whether gently or forcefully, but this disagreement will hinder therapy if we do not get on the same page.

Disagreement about the way forward is commonplace in therapy. Sometimes, we therapists believe that our wisdom and insight is best. And, it may be due to the many other clients we have treated with the same challenges. But what the counselor does with resistance tells you a lot about that counselor and their capacity for “withness.” Do they,

  • Check in with the client to see what they are feeling when they resist? (Resistance can be about confusion, disagreement, need for encouragement, concern for consequences, etc)
  • Brainstorm about alternative objectives that might be possible? Sometimes small changes in steps make all the difference.
  • Pontificate about how the chosen path is the best? When we therapists feel defensive we can easily fall back on our expertise as a weapon to convince another that we know best.
  • Ask pointed questions that leave the client feeling shamed? “You do want to get better don’t you?”

Shadow goals

From time to time both therapist and client can work toward an unspoken goal, a shadow goal. Since we are focusing here on counselor failures, let’s consider what kind of shadow goals counselors might begin to pursue. Shadow goals are those that are not verbalized and yet have a controlling influence over the therapist’s words and stance in a session. Here are some examples:

  • Client comes for help with grief over a lost relationship but the therapist wants client to see how she is the cause of the lost relationship
  • Client comes for help in leaving an abusive marriage but the therapist is committed to helping the client stay in the marriage
  • Client presents with a mood disorder but therapist wants client to leave his dysfunctional church
  • Client want to become less dependent on others but therapist wants client to continue to need her help
  • Client seeks treatment for PTSD but therapist wants client to stop being needy or to terminate therapy.

Shadow goals are best addressed in supervision where therapists talk about their clients–and yes, talk about how they feel about clients. As therapists explore their feelings, shadow goals come to the surface and can be acknowledged and addressed. Their presence is not a sign of counselor failure or weakness. They are normal and part of what it means to be human. The only danger is these goals remain hidden and active. As long as they stay hidden (for lack of insight or because of shame), shadow goals will exert control and create confusion on the part of the client and the therapist.

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October 28, 2016 · 1:28 pm

Does your counselor have these two important skills? 


I love working with counselors-in-training. We get to discuss everything from diagnoses to interventions, ethics to theology, character development to politics. I know I’m biased but along with the population of Lake Wobegon, our students “are all above average.” 

That said, there are two extremely difficult counseling skills every student needs to learn–frequently the hard way. To be an effective counselor, you have to be able to conceptualize a person and their presenting problems well (e.g., wrong assessment leads to wrong treatment) and you have to maintain a clinical alliance throughout the course of treatment. Of course, a counselor needs to be of good and mature character. She needs to have a bank of excellent questions to ask, a knowledge of common intervention strategies, and a good ear to hear what the client is trying to express. These things are necessary foundations for the skill of conceptualization and alliance.

Conceptualization

When you come to counseling to discuss a challenge in your life you want the counselor to be able to understand and put your situation into proper perspective. You expect them to have some expertise beyond your own–otherwise why go? As you tell your story, it always has missing and disjointed parts. There are dead ends and mysteries that may start out feeling important that in time become less a focus than other issues. Your counselor needs to put the problems you raise into some context. What lens to view the problems should be used? 

  • Is the conflict between a mother and teen best understood by the lens of enmeshment, Attention-Deficit, autism, sinful pride, depression, anxiety, rebellion or…?
  • Is the conflict between a husband and wife best understood as lack of knowledge, demandingness, personality disorder, emotional abuse, etc.

An effective counselor uses multiple lenses to view his counselee and holds those lenses loosely in recognition that first impressions need refinement. 

Do you feel heard or pigeon-holed by your therapist? Does your therapist discuss possible ways to look at the problem you have and thus different ways to approach solutions? 

Alliance

Alliance is a hard thing to describe but it encompasses a trust relationship where therapist and client work in concert to explore and resolve a problem. There is agreement on the problem definition and the process of therapy.  There are several things that seem to be part of this concept but fall in two key categories: techniques and stance. A good therapist asks great questions that enable a person to feel heard as they tell their story. A good therapist validates the person even if they do not agree with interpretations of the client. A good therapist makes sure that the client knows they are more than the sum total of their problems. Finally, a good therapist checks in with a client to find out how they are experiencing the therapy session and approach. But good questions and feedback are not the full picture of alliance. The therapist needs a stance that reflects being a student of the person; of collaboration over action. It reflects an understanding of pacing and the client’s capacity to process information.  

A counselor can understand a problem but if they rush ahead or lag behind in pacing, the alliance will fail. Consider this example. Therapist A meets with a client with a domestic violence victimization problem. It is clear to the therapist that the client needs to move out and that the client is resistant to this idea. The clinician presses the client to leave and challenges her to see her husband as an abuser. While the counselor may be correct, the confrontive and authoritative stance is unlikely to bear much fruit and will either create defensiveness or passivity in sessions. One sure sign of poor alliance is when a therapist is constantly thinking about how to get his or her client to do something. 

Meanwhile, Therapist B meets with the same client and explores the ambivalence she has towards her husband and the abuse. Options are discussed, less for movement sake and more for examination of fears and opportunities, hopes and despair. Both therapists have the same sets of good questions, but one is more aware of the pacing of the client and meets her where she is where the other one forces a pace the client is not ready to match. This does not mean a counselor never pushes a client but it does mean they never do that without the understanding and agreement of the client. 

Alliance is not a static feature. It grows and shrinks during the course of a relationship. There are ruptures and hopefully repairs. Sometimes a rupture leads to an even stronger alliance if the repair leaves the client feeling cared for and respected. Ruptures are not always caused by the counselor but it is the counselor’s job to notice and to work to resolve. 

Do you feel like you are on the same page with your therapist? Do you have evidence (not just fears) that your counselor is frustrated by you? When you have a “miss” in a session, does your therapist acknowledge it and talk about how you are feeling about therapy? If you bring up an rupture, are you listened to? 

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May 9, 2014 · 10:36 am

Should therapists talk about themselves to clients? Surprising information


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

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

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

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

Not so fast!

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

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

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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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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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November 21, 2011 · 5:25 pm

DRC/Rwanda Trip: Final Days


October 21-22, 2011, Kigali, Rwanda

Friday morning and we are up by 6 am. Have to pack this morning because we have to be out of our rooms. As soon as we finish the conference we must say our goodbyes and get to the airport. We have breakfast with Robert Briggs of the American Bible Society. He’s on his way to a United Bible Society meeting in Kenya. Our conference begins with Diane

Planning the next steps

Langberg and Carol King covering the topics of lament and grief. After their presentations, the participants practiced writing their own laments. We made time for sharing them with others. We concluded this section with a choral reading of Scriptural laments. This choral reading was compiled by Lynn MacDougall and quite moving for all. We had enough time before lunch for me to teach a bit on vicarious trauma.

After lunch, I did a short teaching on peer supervision. It is important for these caregivers to support each other and so I taught on how to do case consultations and to write-up case study/questions. After finishing this teaching, Baraka led the participants in a “What next” brainstorm. Their main recommendation was to form an association of counselor/caregivers–Rwandan Association of Christian Counseling as a place to get further support, training and to share resources. They wanted a website that would allow them to connect via social media. As they explored their current needs, many said that the number one need is ongoing mentoring. Others talked of finding ways to get paid for their work in counseling. Many spoke of the need for skills and training in dealing with drug and alcohol issues, sexuality, gender-based violence, depression, and anxiety. They asked for trainings 2 times per year. The group decided to appoint a few of the attendees to a committee to see these recommendations to completion.

We concluded our time by asking them to tell us what parts they liked the most. They liked the small group activities. They wanted these to go longer. They liked the role plays and want more. They would like PowerPoint slides (we didn’t do these but handed out outlines) and for speakers to speak slower English. We promised to send them a PDF of our talks and outlines for them to have in electronic form.

Our final activity was to hand out the certificates for real. I got the pleasure of doing this and getting a hug and a picture from each attendee. We said our goodbyes, made a quick change of clothes and headed off to the car to take us to the airport. Just as we were about to get in the car, we were given handkerchiefs each with notes and signatures from the attendees. A sweet parting gift!

Friday night at 7 pm, we boarded our plane (Brussels Air) to start the trip back home. The flight was full and our seats were all over the plane so no debriefing for us. For the next 10 hours (including a stop in Nairobi), I was jammed into a middle seat without leg room (front role of cattle class). Arriving in Brussels by 6 am, we managed to get coffee, chat a bit with each other, and buy some Belgian chocolates for the family. After a total of 28 hours of travel, we arrived back in Philadelphia, PA. 42 hours of no sleep (all day Friday and the night and then most of Saturday) but I arrived home wired and ready to tell my family about what I had seen. Funny, as I tried to tell them about my trip, I found I was having a hard time making sense of everything. I’m not sure it was just because I was tired but more because I had too many thoughts and feelings and was without words to express it all.

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As I post this, I am now 1 month from the end of this trip. It is still hard to be concise about the trip. We learned much, saw much, and have ideas about how we can have an impact on future counseling training in Rwanda and the DRC. Clearly, we need to do more live vignettes for the counselor trainees. And we can impact the area by offering materials to existing schools.

I am blessed to have been able to do this work. Probably more blessed than the recipients! I couldn’t have asked for a more successful trip, better travel connections (well, unless someone has a teleporter lying around), or better travel companions. Can’t wait til the next time.

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February 5, 2011 · 12:12 pm

Single session therapy?


Anybody ever found just one session of counseling productive (meaning you only went once but it was extremely helpful)?

Counseling takes time…usually. You want to get to know your client, hear their history, learn how they think and feel, what they have already tried, and walk with them into some new ways of thinking or responding to their life situations. This kind of work takes time, a lot of time in some cases. And the solutions take even more time.

But I suspect there are some folk who could benefit from just 1 hour of troubleshooting. If you have had one of those experiences, what happened? What was helpful?

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