Long-term counseling gives me the unparalleled opportunity to witness firsthand the subtle yet powerful healing that God brings.
—Archibald Hart
Long-term counseling can be long indeed. Take the case of an elderly woman who had been seeing me for eight and a half years.
About twenty years earlier, she had been given the conservatorship of her wealthy, elderly parents. However, about a year into the conservatorship, her parents sued her, alleging that she was defrauding their estate. Naturally, she denied the accusation, and it didn’t go anywhere in the courts.
But shortly after, the daughter developed chronic pain. She felt pain in nearly every part of her body. She would have surgery for one problem only to discover the pain had moved elsewhere. After ten years of testing, research, and operations in a major research hospital, it was determined the problem was psychogenic. She was referred to me.
So I employed the usual procedures: we tried biofeedback and relaxation training; we explored her early childhood. But nothing new was revealed, and the pain continued. After a few years of seemingly no progress, I suggested we break off therapy. But she insisted we continue. I tried again each year to break it off, but each year she insisted we continue.
Then one day—about eight and a half years into counseling—she froze as a glimmer of truth shone momentarily into her consciousness. She realized that she had, in fact, stolen from her parent’s estate.
It was a classic case of repression: the thought that she could rob from her own parents was so unacceptable that she totally repressed the thought, and that had gotten converted into serious pain.
Now I was confronted with a very emotionally disturbed person. She had learned something about herself, but she didn’t know what to do with it. There was no going to her parents; they were dead by then. She wondered, What do I do now? Go to the police? I’d rather hang myself. I cannot live with this embarrassment, this shame.
It was a delicate stage in our counseling. Her shame could have acted as a trigger for a serious breakdown, or more tragically, suicide.
In fact, we were able to move quickly from shame, to guilt, to forgiveness, so that within a year and a half, the woman told me she was ready to stop counseling. Today she lives in a retirement community with her husband, free from her physical and psychological pain.
This is long-term counseling at its longest and most satisfying. It’s an extreme case that a pastor is not likely to get into. But it illustrates well many of the dynamics that pastors face in long-term counseling.
The Limits of the Long
First we must define what long-term counseling is for a typical pastor. That’s best done by comparing it to short-term counseling.
Short-term counseling deals with crisis intervention (death in the family, divorce, loss of a job) or supporting and guiding people through significant transitions (marriage, retirement). The problem is circumscribed (e.g., helping a parent deal with a rebellious teenager, or showing an employee how to get along better with his boss)—it doesn’t require a major adjustment in personality to resolve.
Long-term counseling goes a layer deeper into a person’s psyche. It tries to help people with serious psychological problems (e.g., depression or schizophrenia) to function normally. It usually involves reconstructing some part of a person’s personality.
As a general rule, the more severe the problem, the longer counseling is needed. That usually means the earlier a problem is created in a person’s life, the longer that counseling is needed. Serious child abuse cases, for example, clearly need long-term counseling.
Also, if a problem has biological roots, then long-term counseling is likely in order. A pastor I was counseling had a serious sexual disorder, and I concluded that ultimately his problem could be traced back to an over-energized sexual drive. This man’s sexual genes were just out of control.
In addition, some depressions, like Premenstrual Syndrome, are biologically based, resulting from hormonal changes not psychological issues.
To put it another way, long-term counseling focuses more on the unconscious than the conscious. The unconscious is all the stuff we’re unaware of, both psychological motives and biological forces that control us without us knowing it. Short-term counseling works with the apparent and redirects and channels it. Long-term counseling focuses more on discovering what’s hidden.
That’s the qualitative difference. In terms of time, and in terms of a pastor’s work, short-term counseling deals with problems that can be handled in two to six weeks; long-term counseling may require up to a year or two.
Long-term counseling affords sufficient time for a pastor to build trust with a counselee, for the counselee to be willing to open the deeper dimensions of his or her life to the pastor, so that together they can explore the unconscious roots of the person’s problems.
When to Take a Long-Term Case
Most pastors are not trained in unveiling the unconscious motives and drives of counselees. And even when trained, they have many demands placed upon them that preclude much, if any, long-term counseling. Still, there are occasions when it is wise for a pastor to counsel long-term.
• No adequate referral is available. When a person with serious problems comes along, most pastors will want to refer the person to a competent professional. But some pastors can’t do so because they live in a community in which pastors, in fact, are the most competent professional counselors.
Other pastors can’t find a theologically sympathetic counselor to whom to refer people. So rather than risk doing more harm than good to the person’s faith, the pastor may want to undertake the counseling responsibilities.
• The client can’t afford professional care. Pastoral counseling is often the only counseling offered gratis to the community. Although some churches charge for counseling on a sliding scale, often they are the only ones willing to slide off the scale completely to help.
• The pastor is in a rut in short-term counseling. Every once in a while it’s important to see the deeper dynamics that work in people’s lives. That will shape how the pastor counsels the short-term client, even if he or she decides to keep the counseling short term; it will also help the pastor better spot long-term problems that need long-term counseling.
No matter the reason though, the pastor who decides to take a client long term will want to get as much training as possible in working with the subconscious. He or she should also have available, in the community or long distance, a professional with whom regular consultation can be made.
Problems to Avoid
No matter the circumstances of the pastor and potential counselee, there are some problems pastors should not counsel.
• Severe personality disorders. These require such special understanding and unique treatment that pastors are better off not taking people with these problems. Among the most problematic are the paranoid, histrionic, and borderline personalities (see The Diagnostic and Statistical Manual of Mental Disorders, Third edition, revised. Published by the American Psychiatric Association, 1987.
For example, borderline personalities can be vindictive, erratic, and seductive. They also are great manipulators.
One borderline personality I was working with started to manipulate me in two ways. First, when things weren’t getting better immediately, she threatened lawsuits. Second, she would repeatedly threaten to commit suicide.
She knew, for instance, that Sunday night at 9:30 I relished watching Masterpiece Theater, my favorite program of the week at the time. Well, one Sunday night, right in the middle of the show, I received a telephone call from my answering service: “A patient in serious trouble needs to talk to you immediately.”
It turned out to be this woman. So I phoned her and asked, “What’s the problem?”
“I’m going to take my life,” she said. “I’m sitting here right now with a razor blade in my hand; I’m going to cut my wrists, right at this moment, while I’m talking to you.”
Since I knew this woman and her pathology, and since this was a recurring pattern, I replied directly: “You’re not to interrupt me during Masterpiece Theater. You call my office tomorrow and set up an appointment.”
You’ve got to be able to sleep after you’ve done that. You’ve got to be absolutely sure of your diagnosis. And that comes from training and experience with this type of pathology. Other people will call up 9:30 Sunday night and say, “I have a razor blade in my hand; I’m going to cut my wrists,” and I’ll say, “Please don’t. I’ll see you in ten minutes.”
Unless the pastor has such training and experience, such people will likely manipulate the pastor into states of anxiety and guilt that will undermine his or her ability to do other ministry.
• Immoral Compulsions. Problems in which psychological compulsion is mixed with moral wrong may need, at first, to be addressed apart from the moral weight of the church. It may be better then, that pastors, who represent the church, refer such cases.
For example, sexuality issues—gender identity, homosexuality, transsexualism, addiction to pornography—tend to produce deep guilt in people. In some cases, they need to deal with the guilt issues directly, and a pastor may be the best person to do that.
In other cases, the guilt issue masks the underlying pathology, and the pastor’s role as a representative of the church and its moral standards will find that it gets in the way of effective therapy. In these cases, such people ought to be referred to a non-pastoral counselor.
I’ve counseled with many men who are troubled by a compulsive use of pornography. They have become addicted to it. In dealing with such men, I’ve had to separate the moral aspects of their behavior (use of pornography) from their psychological disturbance (compulsivity), in order to bring them to the place of healing.
I have to set aside any judgmental attitude in order to gain their trust and build a therapeutic relationship. This means that I do not always point out the immoral nature of their behavior. This would only create further guilt and interfere with our relationship. I focus on the neurotic, underlying disturbance in their personality.
A pastor cannot always counsel a person this way. It is difficult to willingly set aside Christian standards. In fact, it is necessary for pastors at times to condemn certain behavior simply to be consistent.
Actually then, the pastor who provides a moral conscience collaborates with and counterbalances the counselor, who must provide a non-judgmental atmosphere so that a client will practice self-exploration. Both pastor and counselor are needed for the healing process, but in some cases it is nearly impossible for the same person to serve both functions.
Particularly Appropriate Cases
If pastors are not the appropriate people to take on some long-term cases, they are especially appropriate to take on others.
• People with distortions about God. I counseled one woman who told me, “I can’t close my eyes in prayer and visualize God without my father’s face sneering down at me, wagging his finger at me. I can’t pray, ‘Our Father …’ without breaking out in a sweat.”
Unfortunately this woman is not alone. Many people, because of verbal or sexual abuse by their fathers, have a distorted image of God. Such people need long-term counseling to deal with their past and their God. And a pastor is in a better situation than a counselor to help people reshape their image of God.
• Sufferers from guilt. Many guilt-related problems are also appropriate for a pastor to work with.
I worked with one mother whose teenage daughter shot and killed her father and then herself. The mother was left carrying the guilt. “What did I do wrong?” she plaintively asked me.
Obviously, I take on such cases, but I think it’s especially appropriate for a pastor to counsel such people. Ultimately, guilt—healthy guilt, not neurotic guilt—is a theological issue, a topic the pastor is better trained to address. A pastor also has unique liturgical resources—services of confession and public worship—that can help people realize God’s forgiveness.
The Importance of an Agenda
In short-term counseling, the crisis often determines the agenda. Pastors make a big mistake, however, if they follow that same pattern in long-term counseling.
Without a plan, sessions can get easily sidetracked and never get back to the starting point. This is especially true if the client is not paying for the sessions. A lot of time can be wasted, both for the pastor and the counselee.
In fact, no matter where on the counseling-theory continuum a counselor falls, it’s important to have an agenda for each session and for the overall process. This is even true of those who practice Rogerian therapy, a seemingly non-directive counseling in which the counselor “just” listens. On the surface, this method seems to put total responsibility on the client for determining the agenda. In practice, however, the counselor still sets the agenda for each session, although in close cooperation with the client.
In any case, an agenda is vital. A surgeon has to have a plan before an operation or a series of operations: “I’m going to open his chest and get to his heart; then I’ll open his leg and find two good veins, remove them, then …” So a therapist has to have a plan, a strategy.
For example, a man in his mid-fifties comes to see me. He says, “I’m in my third marriage, and it’s falling apart. I just don’t seem to be able to make a go of marriage. The moment I get involved, the moment I marry, somehow the relationship turns sour; I get autocratic, domineering. I get jealous, and the woman just ups and leaves. I desperately want to have a good marriage. I want to be close to someone. Can you help me?”
After our first session, I must begin setting an agenda, at least for the next session. First though, I must determine the extent of the problem; I may even use a sheet or two of paper to write out my analysis: “It’s a relationship problem, especially with women. He doesn’t treat women with respect. The behavior is technically within normal limits: he’s never beaten the woman; he’s never been in trouble with the police. His wife just doesn’t like his attitude. She doesn’t like his manner, the lack of respect. And so, these women up and leave.” And so forth.
Then I determine what I think the overall goal of the counseling should be: “Ultimately I want this man to be able to have a happy and lasting marriage. The immediate goal then, is to help this man better relate to women.”
With that plan in mind, I’ll determine what we should do for the next session: “First, we have to explore his history, especially his first and second marriages.”
At the end of that first session, I may suspect that we need to explore his relationship to his mother, how as a child he related to his mother, whether his mother was domineering, and so on.
At the end of that session, I may discover that he had a reasonably normal relationship with his mother, so then I’ll want to move forward in his life. The agenda for each of the next twenty sessions, then, cannot be spelled out session by session. But each session will be planned within the context of the larger plan. And at the end of each therapy session, I put in my notes a reminder of what should be the focus of the next week.
The plan should be dynamic, of course. I usually use the first part of the session as an update, to see what’s happened to the counselee in the past week. Sometimes I find there’s been a crisis (a death, a serious argument, an accident), and that will have to be attended to. And if I have the larger plan, I needn’t worry that such events will sidetrack us. We know where we’re headed, and we know we’ve made a temporary stop to deal with some unrelated issues. Soon enough we’ll be back on the road.
In addition, I like to share as much of the overall plan as possible with clients. I like them to know where we are in the process. This helps them stay hopeful, that even though progress seems slow or non-existent at times, there is a plan that is being followed.
Timely Counseling
“Structuring” is the technical term professional counselors use to define the nature, limits, and goals of the counseling process. Part of structuring includes determining not only an overall goal but also time limits. For pastors, this part of structuring is absolutely crucial—their demanding schedule will be overwhelmed otherwise.
Setting time limits begins with setting the limits of the counseling unit. The fifty-minute hour has evolved as the standard. In less than half an hour you can hardly get caught up. In longer than fifty minutes, there’s usually overload.
While we may feel awkward about cutting a needy person off after fifty minutes (it seems too sterile, hardly pastoral), the extra minutes requested often turn into an hour. If that happens just a couple of times, then other responsibilities quickly get shortchanged.
We also need to remember that most of the healing in therapy takes place not in the session but between sessions. Between sessions the person reflects on what’s been said. The session is actually only a boost, an energizer in the healing process.
If you spend too much time in counseling, you run the risk of interfering with a normal healing process. If you give too much antibiotic, you’re not only going to kill the germs, you’re going to kill a whole bunch of healthy organisms as well.
Besides setting limits on each session, long-term counselors should determine how long they’ll see a particular person. Usually it’s unwise to commit yourself for longer than six months. You may, in fact, think that the problem will require a year or two, but you don’t announce that to a counselee. That not only could discourage a counselee, it commits the pastor to a term of counseling that may be unrealistic.
As part of that decision, you have to determine how often you’ll meet—once a week, every other week, or once a month—as well as the specific appointment: “Let’s meet each Tuesday afternoon at three o’clock.”
In fact, the pastor should have clearly defined times of the week when counseling takes place. To counsel on the run, to respond only when someone needs it is not good long-term practice. It undermines your ability to give quality counseling. And frankly, it wears the counselor out. Counseling is demanding enough without the added burden of haphazard scheduling.
What Does Progress Look Like?
In long-term counseling we aim for a change in the person’s basic beliefs, lifestyle, or personality. Such change takes place very slowly, and sometimes it’s hard to see much progress. If we recognize what types of changes ought to be taking place in each stage of long-term counseling, we are in a better position to determine if the counselee is making progress.
• Early stage. In the early stage the goal is to get through the outer defense system. Even people who come for counseling are reluctant to share who they are. Their early confessions are superficial. I’ve worked with people who couldn’t trust me with intimate knowledge about themselves even after six months of counseling.
One test I use when working with pastors is to ask, “Tell me a little about your sexuality.” Until they trust me, they’ll change the subject. That is not frustrating to me, but it is a sign that I haven’t reached the goal in the first stage of long-term therapy.
• Middle stage. You know you’re in the middle stages when people start sharing deeper concerns. Embarrassing things, almost shameful things begin to emerge. And so there’s a sense of progress as one moves deeper into the inner world of that person; they begin to trust you more with the private thoughts, even fantasies.
After coming to me for six months, one pastor finally began telling me that he had strong homosexual feelings. He was married, had a lovely family, had never been near a gay man, but all his fantasies were of men.
Once a person has opened himself in this way, I may think that’s an open invitation to explore further. If I go too fast, however, I will encounter resistance, either in the form of changing the subject or in defensive anger.
In this stage, the man who was domineering toward his wife finally began sharing with me his sexual fantasies, and they were fantasies of abuse and flogging. If, in fact, this was a way of getting back at his domineering mother, and if I had pushed and asked, “Is this a way to get back at your mother for domineering you?” I might have gotten an angry denial: “What ever gave you that idea! I would never dream of hurting my mother!” That would have set the counseling back. I need to be sensitive to the pace of revelation that the counselee wants to set.
I can cause even more resistance if I respond to the anger at a level the counselee is not ready to accept. If the next week I say, “Why did you get angry last week?” he may respond with denial: “What do you mean? I wasn’t angry.” The man may still not be willing to accept the emotions about his mother that are swirling within him.
I need to explore the anger, but I’ve found it better to tone down the question to a level of understanding people are usually ready to deal with: “To me you seemed upset last week. What do you think was going on?”
Then they are more able to process it: “Well, I don’t think so. But let me think about it. You could be right.”
• Final stage. In the final stage, the counselor and client begin to pull together in a meaningful way the information and insights that have emerged. The client now begins to see connections, how decisions and actions lead to consequences and how those consequences can be avoided if she makes the right decisions.
The domineering man who had abusive sexual fantasies began to realize, If I didn’t go to the porno shop so much, maybe if I just stopped exposing myself to that stuff, it wouldn’t hook me as much. Maybe if I stopped viewing women being abused, I could start seeing my wife in a different light.
In this stage, the counselor suggests courses of action to speed the healing. To the woman who had stolen from her parents, I recommended she make restitution: for her deceased parents we had to go through a little ritual, asking parental forgiveness; for her remaining sister, she shared some of her inheritance and reestablished a relationship with her.
When There Are No Signs of Progress
Some problems, like histrionic disorders, will heal very slowly. It doesn’t surprise me if I go a year or two with little progress. With sexual disorders, on the other hand, if I don’t see progress in a matter of five or six weeks, I become concerned. So the nature of the problem determines what “progress” means.
No matter the problem, though, I sometimes feel as if clients are not progressing. In some cases, I’m right: they’ve repeatedly resisted my probing into their deeper motives—in some cases it’s because they hold religious beliefs that get in the way of healing (for example, one man believed that unless his offender repented and asked his and God’s forgiveness, the person wasn’t entitled to his forgiveness).
When people keep on resisting progress, as I conclude a session I’ll tell them, “For the last ten minutes of the session I would like to find out where you’re coming from. I feel there has not been a lot of progress these last three months, that we have skirted around some issues. And issues that interest you seem to have no relationship to our larger goal. How are you feeling about the process? Do you think we’ve done enough? Is it time to stop coming to me?”
That usually alerts them to the fact they need to keep working. And for those who really don’t want to work, it gives them a gracious out.
In the case of the woman I counseled for ten years, I tried to terminate with her several times from year five to year eight. But every time I tried to terminate, she objected strongly. She was convinced things were getting better. She felt hopeful the process would bring some major outcome. So I stuck with her.
Often, though, I don’t see progress because I’m unable to see what’s going on deep inside an individual. That a counselee still comes, of course, is a signal he or she wants to change. Still, I find it helpful periodically to check in with the client, simply asking if we are making any progress, using such questions as: “How are we doing?” “Is this doing you any good?” “What benefits are you gaining?” and “Where do you think we ought to be going?”
Terminating the Therapy
Termination is the process by which the counselor helps the client summarize what’s happened in the counseling, highlight the main insights, point to progress, plan for the near future, and end the counseling relationship. This can take one session, or up to six months.
A danger in this stage is to terminate prematurely. Because of the demands on my time and the number of people who want to see me, I’m often tempted to end things abruptly. I sometimes think people are ready to move on before they are ready. When I do push them out too quickly, though, I provoke a crisis.
I might say to a counselee, “I don’t think I’ll need to see you for a while. I think we’re done; we’ve accomplished what we set out to accomplish.”
She walks out on cloud nine, full of self-confidence. For a day or two she feels great, and then she begins to feel abandoned. She’s afraid; she feels alone.
And that’s when I get a cry for help: a phone call in the middle of the night; she’s in tears, begging to see me. Sometimes people feel they have to exaggerate their pathology to get the counselor’s attention again. Naturally, I need to bring such people back in and keep working with them.
Then again, some people resist termination because they’ve become dependent on the counselor. They can’t make decisions without checking with the counselor. The counselor becomes substitute husband, father, parent, lover. And the longer the counseling, the more transference develops.
Counseling is never done, however, until the transference is resolved. You cannot terminate long-term counseling in the middle of a transference.
If I try to terminate a counseling relationship while the person is highly dependent on me, the counselee will kick up a fuss: “I’m not ready to quit!”
So I’ll ask, “Well how much longer do you think it would be appropriate for us to counsel?”
If the response is something like, “Well, I’m not thinking of any limit right now” or “Another six months,” then I continue. I must help the counselee work through the dependence before terminating.
I receive a Christmas card each year from the woman I counseled for over ten years. And each year, I am reminded of the challenges and rewards of long-term counseling. It requires tremendous patience, much more than I often have, and forces me to hear some pretty messy stuff that goes on deep in people’s lives.
But long-term counseling also gives me the unparalleled opportunity to witness firsthand the subtle yet powerful healing that God brings. I feel I am collaborating with God’s Spirit, who over time convicts and enlightens and guides the people I’m working with, bringing them to full mental, emotional, and spiritual health.
Copyright © 1992 by Christianity Today
