Tag Archives: therapy

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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September 9, 2009 · 11:45 am

ICAT as a new therapy model?


Take any psychotherapies class and you will get your usual dose of the classic models built on grand schemes attempting to explain the meaning of life and human behavior: psychoanalysis (and later versions of object relations), humanist/client-centered, behaviorism, cognitive (and later combinations of the two), and various forms of family systems models. Students in advanced courses may learn a bit about various combinations of these models but usually such classes leave learners picking and choosing a theoretical home–or becoming eclectic by trying to take parts of each model.

But nowadays, models are built not to explain the meaning of life but to show “what works” in therapy. Sometimes model builders stumble onto a technique and then attempt to provide evidence how and why such interventions work. For example, I would classify Les Greenberg’s EFT, Francine Shapiro’s EMDR and Marsha Linehan’s DBT (though DBT has much more robust evidence supporting and has validity whereas Shapiro’s techniques have reliability but lack validity in my mind) as these kinds of models.

Now comes another model to try to capitalize on a number of proven techniques: Integrative Cognitive Affective Therapy. Right now, it seems to be used and studied for the treatment of Bulimia. But, I expect to see it grow over the years to any number of problems (just as DBT is not just used for Borderline Personality Disorder anymore).

What is ICAT? It is an attempt to improve upon the weaknesses of Cognitive-Behavioral Therapy (CBT) while maintaining the robust empirical power of the model. What are CBT’s weaknesses? Stephen Wonderlich says they are “1) a limited view of emotional responding; 2) inadequate consideration of interpersonal factors; 3) insufficient attention to therapist-client relationship; and 4) overemphasis on conscious-controlled cognitive processing.”*

ICAT attempts to improve on CBT by paying very careful attention to emotion, mindfulness, and other aspects of a person’s experience of self and world. Again, Wonderlich describes ICAT as “a collection of interventions drawn from an array of cognitive behavioral and emotion-focused therapies and based on a testable theoretical model…”

ICAT for Bulimia exists in a 21 session form as of now. It focuses on experiencing and identifying key emotions involved in the Bulimic process, making initial changes to eating habits, developing alternative coping mechanisms to deal with distressing emotions, dealing properly with desires, practicing self-regulation and challenging discrepancies between ideal and actual self. What makes it different from CBT is its focus on emotion and collaborative work between patient and counselor.

In many ways, it seems to adapt other model’s focus on validation, affect, mindfulness, and distress tolerance. Over and over it appears that understanding and addressing subtle emotional interpretations of life are the building blocks to changing pathological behaviors.This is not the first attempt to build an affective version of CBT. Some attempted to talk about constructivist CBT but that did not take hold. I suspect this model has a better chance at catching on.

*Wonderlich, Stephen (Summer, 2009). “An introduction to Integrative Cognitive Affective Therapy for Bulimia Nervosa” Perspectives: A Professional Journal of the Renfrew Center Foundation, pp 1-5.

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June 12, 2009 · 4:37 am

Why do people come to therapy?


In staff meeting yesterday Diane Langberg quoted J. Hillman (Dream Animals, 1997, p. 2):

“People come to therapy really for blessing. Not so much to fix what’s broken, but to get what’s broken blessed”

Sounds accurate to me

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September 3, 2008 · 1:15 pm

Biblical Counseling is too focused on big truth?


Haven’t had much time to write of late since the pressure is on for more formal writing assignments. But, in prep for a presentation in a few weeks I have been thinking about this question. Is the biblical counseling model of change too much focused on truth? Heretical thought for some I’m sure. (For those who don’t remember I consider myself both a biblical counseling and a Christian psychologist).

Let me start with some shoddy diagrams of two classic models of change.

1. Presenting problem –>Diagnosis Made–>Counselor generated insight (reality/truth) –> Corrective action (counseling as troubleshooting ways to cement corrective action outside of session). Counseling in this model focuses on truth/reality applied to counselees life outside of session. Benefit? Problem/solution focused; objective change. Drawback? Feelings and Relational activity is minimized (though not denied). The relationship is used to get to the activity of change.

2. Presenting problem  –> Diagnosis Made (but may not be told) –>Counselor generated insight (NOT given) –>Introspection via counselor generated questions. Counseling in this model focuses on introspection and counselee generated insight. Benefit? No pressure to perform, feelings encouraged. Drawback? No real relationship focus as it is purely 1 way. No focus on objective change (assumed it will naturally happen).

So, model one is more cognitive. Model two is more dynamic. Both models want or respect the valuate of relationship but usually see it as a necessity to get to what really heals (truth or insight).

The biblical model is most like model one. In many respects, the focus on truth is good. We fallen creatures need constant reorientation. We are easily deceived. And yet, which truth? Notice Jesus with the woman at the well (John 4). He doesn’t start out with the biggest truth (she’s an adulterer). Notice that we often need more immediate truthes to be the focus. Peter needs the hand as he sinks, not a lecture. David needs Nathan’s story first. We learn that God doesn’t tell us all our sins right off the bat. We couldn’t take it. Do we in the biblical counseling world over-focus on the big truths of faith, trust, sin, idolatry, etc. that we miss the “smaller” truths that God is with us, that his hand is present right now in some small tangible way?

So, how about this model for change that is both solution focused AND interpersonal.

Presenting Problem –>Collaborative Diagnosis/Goal setting –> *[empathy ->validation ->here/now ->collaboration on meeting goals/objectives and responding to thoughts, feelings, behaviors] –> small habit change attempts –> post hoc insight.

In this model the primary work is in the interpersonal dynamics (the stuff in the brackets) and insight is more what happens after change takes place: “Oh, that’s what I was thinking then and this other way helped me to change that.” If this alternative model is a bit more accurate in portraying how people actually do change via God’s grace then this is my big question: how might this model change how we use the Scriptures in counseling.

Make any sense?  If anyone has artistic capability to render these diagrams I’d love to see how you’d do them.

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July 1, 2008 · 2:02 pm

Power grabs by therapists


We counselors and therapists have ways of asserting our power over our clients. Usually, we do it via subtle messages and phrases. I was reminded of this fact last week during a seminar by Paul Wachtel of CUNY. He told of a case he had of a semi paranoid and hostile client who made many complaints. After one such complaint against him, Wachtel responded with,

Isn’t it interesting that you see me as being just the way your father was

These type of insights offer pseudo-neutral “observations” that are really accusatory and given to show our intellect (but draws them away from their affective state). Further, when we are irritated and make a statement like this we are really saying that my frustration isn’t about me but is about you. I’m objective here, you are not.

When we give insights to clients we need to ask whether or not the client already understands them, will feel that we are working WITH them (not talking at them), and be motivated to do more exploration. As Wachtel stated, insights are often “implicitly adversarial” (never about us either!).

These kinds of linguistic power grabs aren’t just done by analytic oriented therapists (who might be inclined to make distant insights into clients’ unconscious). Cognitive therapists do the same by implicitly and explicitly telling clients that they are irrational and if only they could think like we therapists, they would be so much better.

Let’s not forget that the words we use with clients tell something about ourselves–maybe more than we wish they would.

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April 28, 2008 · 10:53 am

Practicum Monday: Potentially Harmful Therapies


I was perusing the Journal of Psychology and Christianity (27:1, 2008; pp. 61-65) this morning and saw Siang-Yang Tan’s mini article entitled, “Potentially Harmful Therapies: Psychological Treatments That Can Cause Harm.” He was working of a similarly titled article by the so-called Ralph Nader of Psychology, Scott Lilienfeld of Emory U. (in Perspectives on Psychological Science, v. 2:1, 2007, pp. 53-70).

Some therapies on the PHT list would not surprise you. For example, Tan lists re-birthing techniques where you wrap up your client in blankets put them between the therapist’s legs so they can be healed from their birth trauma. Sadly, a teenager suffocated not that long ago here in PA when an unlicensed person attempted this with her client. Also, Tan lists the use of hypnosis with those with Dissociative Identity Disorder (DID).

But, you may be surprised to find that Critical Incident Stress Debriefing (CISD) also makes the list of PHTs. CISD (aka CISM) has been used for years with police and fire fighters to help them debrief from traumatic experiences and the thinking is that this prophylactic intervention helps exposed individuals avoid problems such as PTSD.  But there is evidence that such care may not only not help some individuals, it might actually harm others by increasing their arousal and those inclined to be hyperaroused appear to do better with no debriefing. For more of a critique of debreifing see DeVilly, Gist, & Cotton’s 2006 article in the Review of General Psychology (10:4) entitled, “Ready! Fire! Aim! …”

While CISD is not without merit and not always harmful, its popularity and widespread use without careful analysis should give us pause.

What widely accepted methods of Christian counseling also have the potential for harm?

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December 12, 2007 · 5:29 am

How long should you keep clinical records?


The APA has updated and republished their “Record Keeping Guidelines” (2007 American Psychologist, 62:9, 993-1004). In this they discuss 13 separate guides (e.g., content of records, responsibility for records, confidentiality of records, retention of records, disposition of records, etc.).

How long should psychologists keep their records? This guideline suggests the full record is kept for a minimum of 7 years after the last service contact (for adult clients). Why should a psychologist destroy records? Some records might contain out-of-date assessment data that is either no longer valid or superseded by better tools. Some records might include information that was based on a very limited context and could be used against the client (e.g., 15 year old is seen for criminal activity but this information comes out at the age of 50…).

But consider the other side of destroying records. I once saw a client at a counseling center who was returning after 12 years for more counseling. This person had been in counseling for 3 years with a previous counselor who was no longer with the agency. Rules had allowed the disposal of his record. When I told him I could not review his prior record (he had asked that I do so) he was surprised and hurt that we did not keep his record. He felt that we had violated his trust in some way and that the good work that he had done was minimized. He felt the agency didn’t care about him and should have handled his history with more kindness.

So, how would you feel to go to your old therapist and find that your records no longer exist? 

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