Part I
A-B. I keep envisioning myself counseling while playing basketball, shooting hoops in the office parking lot with “troubled” young men. Mostly I ask questions, rebound, and listen. But we also practice becoming aware of our automatic thoughts and feelings when we miss or make, testing alternative or replacement thoughts from time to time. We talk through social skills bounce passing, or we analyze the A-B-C’s of of recurring challenges from home or school or work while shooting free throws. I use corny sports metaphors to frame discussions of goals, relationships, values, or a relevant psychological construct. We take a short break to practice breathing and stillness. Of course the weather is always fair, the ball is always pumped up, the rim is always forgiving, and the clients all love basketball!
Frankly I do not have clear and strong preferences for future counseling settings and clients. I come into this program on the heels of really wonderful experiences in a one year pastoral care program and a two year training program for spiritual directors. In both settings I was constantly amazed by the healing, stabilizing power of a safe, non-judgmental space to share with a caring and attentive listener. When we got to “farmer Carl’s” chapter in this class I said amen with every page. I also come into the program having been a counseling and psychiatric client off and on for 15 years, at first trying to escape from and now trying to make the best of life with recurring depression. At this point, my main goal in pursuing a counseling practice is to pass it on. I want to pass on the encouragement, empathy, and healing tools I have received -- the most important tool being that safe, non-judgmental space and relationship.
I am part of the RSA grant program facilitated by Dr. Wager, so I expect and am excited to head into rehabilitation counseling settings. I would love to work with youth transitioning from school to life after school. I would love to work with prison re-entry or diversion programs. I would love to work with clients with severe mental illness. I would love to work with seniors. I am having a hard time thinking of client populations or settings where I do not want to work, which may show a lack of self-awareness on my part. I am hoping the upcoming intro to rehab counseling class with Dr. Hawley will help me narrow my interests.
Though my preferences are not clear, I can at least make an educated guess about my future practice and clients. Following through with my RSA grant I will work for a state agency or associated organization, most likely in an outpatient platform, one-on-one or in small groups with people receiving state vocational-rehabilitation services. I will work with a wide variety of clients -- perhaps their families and potential employers, too -- who have a wide variety of functional disabilities. We will collaborate to set goals for living, working, and loving, and we will find ways to pursue those goals. And I hope we get to play some basketball along the way! In all seriousness, I hope to find ways to incorporate therapeutic goals into familiar games or my clients’ favorite activities.
C. For a recent project I read and thoroughly enjoyed Thinking, Fast and Slow, by Daniel Kahneman, so a few of the concepts from that book will pop up in this paper. He introduced me to the “Two Systems Theory” of the mind, where system 1 is a collection of unconscious or not-fully-conscious, automatic, relatively fast cognitive processes, and system 2 is the conscious, reflective, easily-tired activity we usually identify as thinking or reasoning. It seems to be a prevalent theory in various forms. My wife, who is a therapist for children and youth dealing with trauma, uses the metaphor of “upstairs/downstairs brain” to model the mind for kids and their families. The basic activities of survival and life happen downstairs, and the more complicated activities like reasoning and planning happen upstairs. This helps my wife explain ways and times we might get chronically “stuck” downstairs, how to get unstuck, and how to parent kids when they are stuck. I also like Johnathan Haidt’s “elephant and rider” metaphor, where the rider is our conscious reason and the elephant everything else; the elephant is mostly running the show and the rider is there for public relations.
Potential precursors to this two part theory of mind abound: conscious/unconscious, reason/emotion, spirit/flesh. The old mind/body dualism is now just within the mind itself, a mind/mind dualism. What part of our experience or behavior is not the mind? That is one problem I have with theories of mind I have encountered, generally. They seem to grow and grow, in their efforts to include everything having to do with our neurological system, until they might as well be a theory of human life. Ellis adds the E and B to RT, Beck adds the B to CBT, behaviorists take cognitions and emotions into the fold of behaviors. All this is great and makes sense, and I know that it is very important to find ways to link our subjective mental models to objective maps of the brain and body. Nevertheless, I have often found myself wishing we would reserve “mind” for conscious reasoning and use other constructs for the rest. I am a big fan of Biblical language for different aspects of human subjectivity (breath, heart, soul, etc), and other religious traditions have as much and more to offer.
Reluctantly, I suppose, my current view of the mind is the two-systems theory, more like Haidt’s elephant and rider model, emphasizing the power differential (but not animosity) between the two systems. To the extent that I can I hope to place the “mind” alongside other constructs, as a team player; we are more than our minds.
One “aha” moment from my intro to mental health counseling class this semester was learning to consider mental illness and mental health as different spectra, rather than two ends to a single spectrum. Or, we can leave illness/health on one continuum and add a wellness continuum alongside. This approach is very encouraging for me personally, since it is unlikely I will be able to eliminate depression from my life, and I expect it is helpful to others with chronic conditions. Nonetheless, illness and health are co-defining, pulling on each other and the always shifty idea of “normal” functioning, normal thinking, normal feeling. The notions are instinctual and universal, even though the details vary considerably from culture to culture, context to context. I try to hold the terms lightly, and I hope to use them lightly in practice.
D. Though I have frequently experienced performance anxiety, depression, frustrating struggles with motivation and sleepiness, stormy shame and guilt during my vocational journey, my co-workers over the years have always commented on my laid-back affect, stability, friendliness, and introversion. I like working with teams or on my own. Generally I have not enjoyed running programs or community organizing; or, rather, I enjoyed them somewhat, but I burnt out quickly.
My values come from Christianity, or at least that is how I identify them. The fruits of the Spirit are one of my frequent self-pep talks: love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, and self-control. Temperamentally my introversion often stands out, although I can talk my share when I get warmed up. I am a big people-pleaser, non-confrontational, so I have gotten myself into several pickles that way. I will need to be very clear and intentional in setting healthy boundaries with myself, clients, and co-workers. Although I am not super-conversational, I love to hear people talk about their lives, how they exist in the world, and I always have questions or want to know more specifics. I never feel like I have heard it all or have fully sounded the contours of some experience. I am banking on this incessant curiosity about human subjectivity to be a driving force in my practice.
Part IV
A-B. After juggling several possible combinations, I decided to go with an Adlerian and Behavioral combo. My spiritual direction training program leaned heavily on Jung, so I have some good experience working with his constructs, but Adler just seems too perfect of a fit for rehab counseling to pass up. Adler gives me a broad and life-affirming foundation for the eminently practical and applicable behavioral approaches. Farmer Carl is the man, but Adler may have been client-centered before it was cool.
The biggest drawback for Adlerian theory may be the lack of research. The evidence section in the Corsini chapter mentions some promising research relating to a particular lifestyle assessment, however most of the support for Adlerian principles and constructs seems to come from research into other theories or common factors. In the September 2018 issue of the Journal of Individual Psychology dedicated to promoting research into Adlerian therapy, Richard Watts writes that, while Adlerian constructs have some decent research legs, there has been little work done to directly investigate the efficacy of Adlerian therapy.
Behavior therapies, on the other hand, are knocking it out of the park, racking up the “evidence-based” runs. Martin Anthony writes, in the Corsini chapter, “the list of empirically supported psychological treatments [from the APA] includes 80 treatments for particular disorders of which more than three-quarters are behavioral or cognitive-behavioral treatments, and several others include behavioral elements” (224).
C. As a theory and world-view emphasizing holism, lifestyle, social context, and encouragement, Alderian theory almost seems tailor-made for a rehabilitation setting. Rehab clients have a variety of challenges and goals -- independent living, physical and mental recovery, employment, improving family life and social engagement -- but I am hard pressed to think of a goal Adler would see as beyond his scope of work: “life, work, and love.” What arena of life is beyond the reach of a theory of encouragement? Adler’s attempt to address the whole lifestyle of a person and offer pro-social treatment is reflected in the mission statements for the RSA -- employment, independence, and integration -- and DARS -- independence, inclusion, and integration. Although, as a good socialist, I expect Adler might try to temper our American insistence on independence.
Adlerian theory lines up well with my own values. Adler sat face to face with his clients and actively advocated for social equality. He did not think counseling was only for the “sick,” but could benefit anyone and everyone. He attempted to increase mental health in various settings, rather than only attempting to decrease mental illness. Adlerian theory views mental illness functionally and lightly: Maniacci and Maniacci write in the Corsini chapter, “Psychopathology can be conceptualized (in part) as a matter of ‘goodness of fit’ between the terrain [of a person’s life] and [that person’s] map” (63).
Adlerian theory somewhat supports my criticism that theories of mind tend to overtake all aspects of life. Adler emphasizes the “whole” person, not just the mind. In any case, this theory seems less mind-centric than other theories. On the other hand, Adler may not be too keen on two-systems theory, as it cleanly divides mental life into two types. There is more of a gradient or continuum between conscious and unconscious processes than two-systems theory would say. Kahneman does a wonderful job describing how system 1 and 2 interact, but he does not really explain how they bleed into each other and are a single mind. Or is there a meta-system that governs both?
Behavioral theories especially appeal to my values through their openness and humility. Observe, measure, test. They seem to be the most ready to change and adapt to new knowledge and evidence, and I hope to follow that tradition. It also is a great fit with rehabilitation settings, where time is limited and the goals are varied. A behavioral therapist does not need to interpret a person’s entire life in order to help with a specific goal or problem. “Behavior” is a basic, flexible, and easily understood construct, although, like most basic psychological terms, it gets fuzzier and fuzzier the closer you look at it. I am also excited about the “third wave” behavioral theories and their embrace of mindfulness practices and terms. Breathing-based prayer and “centering prayer” -- a type of contemplative prayer based on the Cloud of Unknowing -- have been lifelines for me in the midst of depression and anxiety.
D. I am trying to limit my constructs to five (I wish I could use the entire hexaflex, but I will only borrow one construct from Hayes). First off is “lifestyle,” a key concept for Adler and one that seems appropriate for a rehab setting. Lifestyle is our way in the world, and it involves things we can and cannot control. It is an expansive concept, and in practice I would not have the time to do a full Adlerian life analysis with clients. However, we could use a more limited assessment tool and keep the lifestyle discussion in the mix.
Adapting Adler’s ideas about power and superiority/inferiority, Maniacci and Maniacci write that “people are motivated to move from a perceived ‘minus situation’ to a perceived ‘plus situation’” (62). This hits the nail on the head and links nicely to Tversky and Kahneman’s “prospect” theory. We are always considering goals, fears, and decisions as gains and losses relative to states, usually our current state. Prospect theory also helps to describe our intense loss aversion, which as a rule of thumb, is about twice as strong as the attraction toward gains.
One construct important to both Adlerian and Behavioral theories is ‘teleology,’ or ‘psychology of use.’ It is helpful to assume that behaviors -- especially recurring behaviors, thoughts, or feelings -- serve a purpose. Behaviors are goal oriented, maintained by the person-environment context, even if the person behaving is not consciously aware of their purpose. This leads me to my fourth construct (a three for one): A-B-C. Antecedent, Behavior, Consequence. And with “consequence” we need the key terms positive/negative ‘reinforcement’ and positive/negative ‘punishment.’
Finally, “acceptance” is my last construct, pulled from Hayes’ hexaflex, where he defines it in opposition to experiential avoidance. I am particularly interested in how rehab clients strike the balance between fighting against or striving to overcome their health conditions and accepting their health conditions. Developing the ability to accept painful feelings and thoughts related to a disability may be key for striking that balance.
E. I see all these constructs interacting in a sequence in my practice. While the client may have pressing and pre-identified goals, if possible I would like to start by stepping back together and looking at the client’s entire lifestyle, how they make their way through their various social and environmental contexts. This will help me to get to know the client better, and collaboratively we may see their goals in a broader context, or we may adapt them in ways that would benefit more than just one area of their life. If they do not have clear goals already, we can use this lifestyle discussion as a springboard to goal setting.
As we discuss the clients goals, I will introduce some of the concepts of prospect theory to help describe how people are motivated, or not, in their decision-making. We are typically trying to move from perceived minus to perceived plus (this ties in nicely with ‘teleology’). If we are moving from plus to a higher plus we may find it gradually harder to stay motivated. If we risk moving from plus to minus we will likely find ourselves really, really motivated to avoid that risk. However, if we feel stuck in the minus, we may take some desperate risks, because, heck, it can’t get any worse (yes it can).
If any of the client’s goals have to do with a recurring “problem” behavior or situation, or if the client is having trouble achieving their goals because of person-environment dynamics, we can move to a discussion of the contextual “teleology” of behavior, and we can use the A-B-C concepts to analyze the behavior or situation. We can also use the concept of reinforcement in the context of the client’s values (Hayes) to discuss ways to make their goals easier to achieve and more fulfilling.
Finally, and throughout the process, we can use the construct of “acceptance” and its opposite, “experiential avoidance,” to encourage psychological balance during the recovery journey. Each person has their own individual sweet spot of balance between resist and accept, and at some level we can do both at the same time. But, I believe the client will need some measure of acceptance of feelings and thoughts related to their disability or health condition in order to stay “flexible” and open to possibilities. Without some acceptance, as Hayes explains, we become psychologically dominated by our need to avoid certain experiences or feelings.
F. This Adlerian-Behavioral combo theory is quite psychoeducational, fairly directive, and very focused on the client’s goals. The main intended outcome would be to help the client realize their goals in living, working, and loving. A lofty goal! But, along the way, I hope clients will find more self-awareness, encouragement, and the kind of balance that is summed up by the serenity prayer. “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”
G. In agreement with known facts: I think a “B,” here, because, while I know prospect theory, the teleological view of behavior, A-B-C analysis, and acceptance have solid research foundations, I am not so sure about the research on lifestyle assessments. Also, Adlerian theory is low on research support, generally speaking.
Testable/Falsifiable: “B” again. All the constructs can be investigated, and the efficacy of the approach can be tested. However, the life-affirming, social equality foundation of the theory is more of a personal or spiritual conviction.
Comprehensive: “A.” Between Adler and Behavioral theory we have a wide world to live in. I tried to maintain this comprehensiveness in my theory for rehab settings, where clients and their goals will be very diverse.
Parsimonious: “D.” Adler has such a broad stroke, and Behavioral theory, while maintaining a distinct center, seems to have no distinct boundaries. My combo-version only uses five key constructs, but prospect theory and the A-B-C’s from ABA carry other constructs in tow. This is not a neat and tidy theory.
Heuristic value: “C.” Adler and Behavioral theories go very well together and can be combined in many ways. I think my combination of prospect theory with ABA language could be a great research lens. But, there is no real “hook” to my theory, no key innovation.
Applied value: “A.” All of my constructs are down-to-earth, ready to use, and well-tested, except perhaps for “lifestyle.” However, I would argue that “lifestyle” is particularly applicable in rehabilitation contexts, where clients are pursuing goals in a variety of life domains. Rehab counseling needs a theory for life, work, and love -- and an Adlerian-Behavioral combo is up to the task.
