Tag Archives: therapy

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.

—

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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November 3, 2009 · 5:38 am

Philip Cushman’s prophetic words


One of my all-time favorite books is Philip Cushman’s Constructing the Self, Constructing America: A Cultural History of Psychotherapy. In this 1995 book he details the social constructed nature of psychotherapy. My Social & Cultural Foundations class is reading a summation of this book published in article form and so I picked the book back up and read through some of my more favorite parts.Here’s some of my choice quotes from the beginning:

“When social artifacts or institutions are taken for granted it usually means that they have developed functions in the society that are so integral to the culture that they are indispensable, unacknowledged, and finally invisible.” (p. 1)

“It [psychotherapy] is thought of as a scientific practice, yet it is anything but standardized or empirical, and it has not yet developed a disciplinewide consensus about how to think about patients or what to do with them. It is thought of as a medical practice, yet it has an enormous social and political impact.” (p. 2)

“…in order to understand American psychotherapy, we must study the world into which it was born and in which it currently resides.” (p. 4)

“Origin myths describe the origins of the discipline in such a way as to demonstrate the discipline’s utility for those in positions of power. This means that mainstream historians will shy away from portraying psychology as critical of the status quo and will avoid including within their work a critical exploration of the sociopolitical frame of reference in which the discipline is embedded.” (p. 5)

“…I will argue that the current configuration of the self is the empty self. The empty self is a way of being human; it is characterized by a pervasive sense of personal emptiness and is committed to the values of self-liberation through consumption. The empty self is the perfect complement to an economy that must stave off economic stagnation by arranging for the continual purchase and consumption of surplus goods. Psychotherapy is the profession responsible for treating the unfortunate personal effects of the empty self without disrupting the economic arrangements of consumerism. Psychotherapy is permeated by the philosophy of self-contained individualism, exists within the framework of consumerism, speaks the language of self-liberation, and thereby unknowingly reproduces some of the ills it is responsible for healing.” P. 6

Now, soon after 2000, Cushman wrote about the transition from the empty self to the “multiple self.” By this he was not talking about MPD or DID. He felt that the younger generation was no longer looking to find their true self in therapy but to maintain a fragmented self in a chaotic world. In this sense, “who am I at church, work, school, friends, dating, etc. and how can I keep all my pieces from crashing down altogether.”

But, it is interesting to read his view of psychotherapy as supporting the consumeristic economy (even encouraging it). I wonder how our current economic woes will impact the world of therapy….

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October 23, 2009 · 1:51 pm

The practice of unlicensed counseling


The practice of counseling, therapy, psychotherapy and other related terms is restricted to those with proper licensing in most, if not all, US states. Makes sense on most levels, right? You wouldn’t want to go to an unlicensed doctor for your appendectomy. In opposition to Holiday Inn’s ads, you wouldn’t want just anybody doing professional work on you. License control is supposed to protect the public from harm. Bad docs and bad therapists should lose their license and not be allowed to practice.

But with counseling and therapy, it gets a bit sticky. Lots of different professions do similar activities. Unlike surgeons, you have people from widely divergent schools of thought and training doing very similar things. LCSWs, LSWs, LMFTs, Psychologists, Psychiatrists, LPCs all do talk therapy. They all diagnose and intervene per their view of what is wrong and what needs to change (thoughts, behaviors. feelings, etc.).

And it gets stickier. Pastors, clergy, and religiously trained individuals do many of these as well. While they may not give DSM or ICD9 diagnoses and bill insurance companies, they do talk therapy with people who are depressed, anxious, angry, on the verge of divorce–just like all of those licensed people above.  In my world, there are pastoral counselors, biblical counselors, pastors who counsel, christian counselors, etc. Most of these in PA are not licensed by any body. (In PA we don’t have a pastoral counselor license as some states do.)

In an effort to tighten controls, there is a state effort underfoot (HB 1250) to tighten who can practice as a counselor. There were already controls but now the new bill would disallow someone like myself to hire or supervise an unlicensed (but in my opinion competent) person UNLESS they were actively in the process of becoming licensed.

Why does this matter?

1. There are many competent people doing counseling related work that are not licensed (nor could they be since their training is of a religious or pastoral nature). Should the state control these individuals? Right now they haven’t been actively going after these folk. The law will continue to remain vague: Here’s the restriction for LPC practice:

Only individuals who have received licenses as licensed professional counselors under this act may style themselves as licensed professional counselors and use the letters “L.P.C.” in connection with their names. It shall be unlawful for an individual to style oneself as a licensed professional counselor, advertise or offer to engage in the practice of professional counselor or use any words or symbols indicating or tending to indicate that the individual is a licensed professional counselor without holding a license in good standing under this act. [underline indicates new change in this paragraph]

Who decides what “engage in the practice of…or use any words…” constitutes? Obviously, one cannot intentionally lie but does the term therapy indicate a license?

2. There are many who provide pastoral care who are not ordained clergy. They have graduated from seminary-based programs that are not professional counseling programs. Yes, the current standard makes clear that it does not seek to limit the work of those acting under the legal auspices of a religious institution (i.e., are ordained by the church). But, should the state regulate those who provide biblical counsel but are not ordained? As long as these individuals make clear (informed consent) what it is they do and what they do not do, shouldn’t they be able to make a living? Research indicates that lay people can have tremendous success in helping those with depression and anxiety.

I’m all for protecting the public. But while licenses limit who gets to perform certain duties, it does not eliminate unethical or harmful practice. Further, much of psychotherapy is art as well as science. Artists can learn their trade in a variety of locations. What we need to do is to make sure the public can clearly identify the kind of counseling (and limits of) each counselor does. Second, those who provide biblical counseling ought to have some authoritative body. It would be great if they were recognized and “licensed” by denominations or organizations (e.g. the AACC who is trying to do this).

But I would hate to see the many seasoned, unlicensed counselors lose their ability to ply their trade.

That raises a question of analogy. Can anyone make a legal living cutting hair for a fee without a license?

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September 18, 2009 · 5:13 am

Engaging Biblical Texts in Trauma Therapy


Today I present my 1 hour CE training at the AACC conference. In this presentation I briefly review (a) complex PTSD and its typical symptom presentation, (b) material from my recently published work on best practices for using Scripture in counseling. Then I consider the particular application to therapy with trauma survivors. The goal is not get individuals to believe the truth but to experience it via the interpersonal relationship of therapy.

If you are interested in more, see the pptx slides I have up on my page “Articles, Slides, Etc.” (# 15 on the list).

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