Category Archives: Counseling and Psychotherapy Theory and Practice

The Clinical Interview as an Assessment Tool

Chair

The following is another excerpt from a chapter I wrote with my colleagues Roni Johnson and Maegan Rides At The Door. This excerpt focuses on ways in which clinical interviews are used as assessment tools. The full chapter is forthcoming in the Cambridge Handbook of Clinical Assessment and Diagnosis. For more (much more) information on clinical interviewing, see our textbook, creatively titled, Clinical Interviewing, now in its 6th edition. If you’re a professor or college instructor, you can get a free evaluation copy here: https://www.wiley.com/en-us/Clinical+Interviewing%2C+6th+Edition-p-9781119215585

The clinical interview often involves more assessment and less intervention. Interviewing assessment protocols or procedures may not be limited to initial interviews; they can be woven into longer term assessment or therapy encounters. Allen Frances (2013), chair of the DSM-IV task force, recommended that clinicians “be patient,” because accurate psychiatric diagnosis may take “five minutes. . .”  “five hours. . .”  “five months, or even five years” (p. 10).

Four common assessment interviewing procedures are discussed next: (1) the intake interview, (2) the psychodiagnostic interview, (4) mental status examinations, and (4) suicide assessment interviewing.

The Intake Interview

The intake interview is perhaps the most ubiquitous clinical interview; it may be referred to as the initial interview, the first interview, or the psychiatric interview. What follows is an atheoretical intake interview model, along with examples of how theoretical models emphasize or ignore specific interview content.

Broadly speaking, intake interviews focus on three assessment areas: (1) presenting problem, (2) psychosocial history, and (3) current situation and functioning. The manner in which clinicians pursue these goals varies greatly. Exploring the client’s presenting problem could involve a structured diagnostic interview, generation and analysis of a problem list, or clients free associating to their presenting problem. Similarly, the psychosocial history can be a cursory glimpse at past relationships and medical history or a rich and extended examination of the client’s childhood. Gathering information about the client’s current situation and functioning can range from an informal query about the client’s typical day to a formal mental status examination (Yalom, 2002).

Psychodiagnostic Interviewing

The psychodiagnostic interview is a variant of the intake interview. For mental health professionals who embrace the medical model, initial interviews are often diagnostic interviews. The purpose of a psychodiagnostic interview is to establish a psychiatric diagnosis. In turn, the purpose of psychiatric diagnosis is to describe the client’s current condition, prognosis, and guide treatment.

Psychodiagnostic interviewing is controversial. Some clinicians view it as essential to treatment planning and positive treatment outcomes (Frances, 2013). Others view it in ways similar to Carl Rogers (1957), who famously wrote, “I am forced to the conclusion that … diagnostic knowledge is not essential to psychotherapy. It may even be … a colossal waste of time” (pp. 102–103). As with many polarized issues, it can be useful to take a moderate position, recognizing the potential benefits and liabilities of diagnostic interviewing. Benefits include standardization, a clear diagnostic focus, and identification of psychiatric conditions to facilitate clinical research and treatment (Lilienfeld, Smith, & Watts, 2013). Liabilities include extensive training required, substantial time for administration, excess structure and rigidity that restrain experienced clinicians, and questionable reliability and validity, especially in real-world clinical settings (Sommers-Flanagan & Sommers-Flanagan, 2017).

Clinicians who are pursuing diagnostic information may integrate structured or semi-structured diagnostic interviews into an intake process. The research literature is replete with structured and semi-structured diagnostic interviews. Clinicians can choose from broad and comprehensive protocols (e.g., the Structured Clinical Interview for DSM-5 Disorders – Clinician Version; First et al., 2016) to questionnaires focusing on a single diagnosis (e.g., Autism Diagnostic Interview – Revised; Zander et al., 2017). Additionally, some diagnostic interviewing protocols are designed for research purposes, while others help clinicians attain greater diagnostic reliability and validity. Later in this chapter we focus on psychodiagnostic interviewing reliability and validity.

The Mental Status Examination

The MSE is a semi-structured interview protocol. MSEs are used to organize, assess, and communicate information about clients’ current mental state (Sommers-Flanagan, 2016; Strub & Black, 1977). To achieve this goal, some clinicians administer a highly structured Mini-Mental State Evaluation (MMSE; Folstein, Folstein, & McHugh, 1975), while others conduct a relatively unstructured assessment interview but then organize their observations into a short mental status report. There are also clinicians who, perhaps in the spirit of Piaget’s semi-clinical interviews, combine the best of both worlds by integrating a few structured MSE questions into a less structured interview process (Sommers-Flanagan & Sommers-Flanagan, 2017).

Although the MSE involves collecting data on diagnostic symptoms, it is not a psychodiagnostic interview. Instead, clinicians collect symptom-related data to communicate information to colleagues about client mental status. Sometimes MSEs are conducted daily or hourly. MSEs are commonly used within medical settings. Knowledge of diagnostic terminology and symptoms is a prerequisite to conducting and reporting on mental status.

Introducing the MSE. When administering an MSE, an explanation or role induction is needed. A clinician might state, “In a few minutes, I’ll start a more formal method of getting … to know you. This process involves me asking you a variety of interesting questions so that I can understand a little more about how your brain works” (Sommers-Flanagan & Sommers-Flanagan, 2017, pp. 580–581).

Common MSE domains. Depending on setting and clinician factors, the MSE may focus on neurological responses or psychiatric symptoms. Nine common domains included in a psychiatric-symptom oriented MSE are

  1. Appearance
  2. Behavior/psychomotor activity
  3. Attitude toward examiner (interviewer)
  4. Affect and mood
  5. Speech and thought
  6. Perceptual disturbances
  7. Orientation and consciousness
  8. Memory and intelligence
  9. Reliability, judgment, and insight.

Given that all assessment processes include error and bias, mental status examiners should base their reports on direct observations and minimize interpretive statements. Special care to cross-check conclusive statements is necessary, especially when writing about clients who are members of traditionally oppressed minority groups (Sommers-Flanagan & Sommers-Flanagan, 2017). Additionally, using multiple assessment data sources (aka triangulation; see Using multiple (collateral) data sources) is essential in situations where patients may have memory problems (e.g., confabulation) or be motivated to over- or underreport symptoms (Suhr, 2015).

MSE reports. MSE reports are typically limited to one paragraph or one page. The content of an MSE report focuses specifically on the previously listed nine domains. Each domain is addressed directly with at least one statement.

Suicide Assessment Interviewing

The clinical interview is the gold standard for suicide assessment and intervention (Sommers-Flanagan, 2018). This statement is true, despite the fact that suicide assessment interviewing is not a particularly reliable or valid method for predicting death by suicide (Large & Ryan, 2014). The problem is that, although standardized written assessments exist, they are not a stand-alone means for predicting or intervening with clients who present with suicide ideation. In every case, when clients endorse suicide ideation on a standardized questionnaire or scale, a clinical interview follow-up is essential. Although other assessment approaches exist, they are only supplementary to the clinical interview. Key principles for conducting suicide assessment interviews are summarized below.

Contemporary suicide assessment principles. Historically, suicide assessment interviewing involved a mental health professional conducting a systematic suicide risk assessment. Over the past two decades, this process has changed considerably. Now, rather than taking an authoritative stance, mental health professionals seek to establish an empathic and collaborative relationship with clients who are suicidal (Jobes, 2016). Also, rather than assuming that suicide ideation indicates psychopathology or suicide risk, clinicians frame suicide ideation as a communication of client distress. Finally, instead of focusing on risk factors and suicide prediction, mental health professionals gather information pertaining to eight superordinate suicide dimensions or drivers and then work with suicidal clients to address these dimensions through a collaborative and therapeutic safety planning process (Jobes, 2016). The eight superordinate suicide dimensions include:

  • Unbearable emotional or psychological distress: Unbearable distress can involve one or many trauma, loss, or emotionally disturbing experiences.
  • Problem-solving impairments: Suicide theory and empirical evidence both point to ways in which depressive states can reduce client problem-solving abilities.
  • Interpersonal disconnection, isolation, or feelings of being a social burden: Joiner (2005) has posited that thwarted belongingness and perceiving oneself as a burden contributes to suicidal conditions.
  • Arousal or agitation: Many different physiological states can increase arousal/agitation and push clients toward using suicide as a solution to their unbearable distress.
  • Hopelessness: Hopelessness is a cognitive variable linked to suicide risk. It can also contribute to problem-solving impairments.
  • Suicide intent and plan: Although suicide ideation is a poor predictor of suicide, when ideation is accompanied by an active suicide plan and suicide intent, the potential of death by suicide is magnified.
  • Desensitization to physical pain and thoughts of death: Fear of death and aversion to physical pain are natural suicide deterrents; when clients lose their fear of death or become desensitized to pain, suicide behaviors can increase.
  • Access to firearms: Availability of a lethal means, in general, and access to firearms, in particular, substantially increase suicide risk.

(For additional information on suicide assessment interviewing and the eight suicide dimensions, see other posts on this site).

Five Stages of a Clinical Interview

Baseball Seager

The following is a preview from a chapter I wrote with my colleagues Roni Johnson and Maegan Rides At The Door. The full chapter will be in the Cambridge Handbook of Clinical Assessment and Diagnosis . . . which is coming out soon.

The clinical interview is a fundamental assessment and intervention procedure that mental and behavioral health professionals learn and apply throughout their careers. Psychotherapists across all theoretical orientations, professional disciplines, and treatment settings employ different interviewing skills, including, but not limited to, nondirective listening, questioning, confrontation, interpretation, immediacy, and psychoeducation. As a process, the clinical interview functions as an assessment (e.g., neuropsychological or forensic examinations) or signals the initiation of counseling or psychotherapy. Either way, clinical interviewing involves formal or informal assessment.

Clinical interviewing is dynamic and flexible; every interview is a unique interpersonal interaction, with interviewers integrating cultural awareness, knowledge, and skills, as needed. It is difficult to imagine how clinicians could begin treatment without an initial clinical interview. In fact, clinicians who do not have competence in using clinical interviewing as a means to initiate and inform treatment would likely be considered unethical (Welfel, 2016).

Clinical interviewing has been defined as

a complex and multidimensional interpersonal process that occurs between a professional service provider and client [or patient]. The primary goals are (1) assessment and (2) helping. To achieve these goals, individual clinicians may emphasize structured diagnostic questioning, spontaneous and collaborative talking and listening, or both. Clinicians use information obtained in an initial clinical interview to develop a [therapeutic relationship], case formulation, and treatment plan” (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 6)

A Generic Clinical Interviewing Model

All clinical interviews follow a common process or outline. Shea (1998) offered a generic or atheoretical model, including five stages: (1) introduction, (2) opening, (3) body, (4) closing, and (5) termination. Each stage includes specific relational and technical tasks.

Introduction

The introduction stage begins at first contact. An introduction can occur via telephone, online, or when prospective clients read information about their therapist (e.g., online descriptions, informed consents, etc.). Client expectations, role induction, first impressions, and initial rapport-building are central issues and activities.

First impressions, whether developed through informed consent paperwork or initial greetings, can exert powerful influences on interview process and clinical outcomes. Mental health professionals who engage clients in ways that are respectful and culturally sensitive are likely to facilitate trust and collaboration, consequently resulting in more reliable and valid assessment data (Ganzini et al., 2013). Technical strategies include authentic opening statements that invite collaboration. For example, the clinician might say something like, “I’m looking forward to getting to know you better” and “I hope you’ll feel comfortable asking me whatever questions you like as we talk together today.” Using friendliness and small talk can be especially important to connecting with diverse clients (Hays, 2016; Sue & Sue, 2016). The introduction stage also includes discussions of (1) confidentiality, (2) therapist theoretical orientation, and (3) role induction (e.g., “Today I’ll be doing a diagnostic interview with you. That means I’ll be asking lots of questions. My goal is to better understand what’s been troubling you.”). The introduction ends when clinicians shift from paperwork and small talk to a focused inquiry into the client’s problems or goals.

Opening

The opening provides an initial focus. Most mental health practitioners begin clinical assessments by asking something like, “What concerns bring you to counseling today?” This question guides clients toward describing their presenting problem (i.e., psychiatrists refer to this as the “chief complaint”). Clinicians should be aware that opening with questions that are more social (e.g., “How are you today?” or “How was your week?”) prompt clients in ways that can unintentionally facilitate a less focused and more rambling opening stage. Similarly, beginning with direct questioning before establishing rapport and trust can elicit defensiveness and dissembling (Shea, 1998).

Many contemporary therapists prefer opening statements or questions with positive wording. For example, rather than asking about problems, therapists might ask, “What are your goals for our meeting today?” For clients with a diverse or minority identity, cultural adaptations may be needed to increase client comfort and make certain that opening questions are culturally appropriate and relevant. When focusing on diagnostic assessment and using a structured or semi-structured interview protocol, the formal opening statement may be scripted or geared toward obtaining an overview of potential psychiatric symptoms (e.g., “Does anyone in your family have a history of mental health problems?”; Tolin et al., 2018, p. 3).

Body

The interview purpose governs what happens during the body stage. If the purpose is to collect information pertaining to psychiatric diagnosis, the body includes diagnostic-focused questions. In contrast, if the purpose is to initiate psychotherapy, the focus could quickly turn toward the history of the problem and what specific behaviors, people, and experiences (including previous therapy) clients have found more or less helpful.

When the interview purpose is assessment, the body stage focuses on information gathering. Clinicians actively question clients about distressing symptoms, including their frequency, duration, intensity, and quality. During structured interviews, specific question protocols are followed. These protocols are designed to help clinicians stay focused and systematically collect reliable and valid assessment data.

Closing

As the interview progresses, it is the clinician’s responsibility to organize and close the session in ways that assure there is adequate time to accomplish the primary interview goals. Tasks and activities linked to the closing include (1) providing support and reassurance for clients, (2) returning to role induction and client expectations, (3) summarizing crucial themes and issues, (4) providing an early case formulation or mental disorder diagnosis, (5) instilling hope, and, as needed, (6) focusing on future homework, future sessions, and scheduling (Sommers-Flanagan & Sommers-Flanagan, 2017).

Termination

Termination involves ending the session and parting ways. The termination stage requires excellent time management skills; it also requires intentional sensitivity and responsiveness to how clients might react to endings in general or leaving the therapy office in particular. Dealing with termination can be challenging. Often, at the end of an initial session, clinicians will not have enough information to establish a diagnosis. When diagnostic uncertainty exists, clinicians may need to continue gathering information about client symptoms during a second or third session. Including collateral informants to triangulate diagnostic information may be useful or necessary.

See the 6th edition of Clinical Interviewing for MUCH more on this topic: https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=sr_1_1?crid=1J46F6YFDV7XG&keywords=clinical+interviewing+6th+edition+sommers-flanagan&qid=1561646075&s=books&sprefix=clinical+inter%2Cstripbooks%2C242&sr=1-1

The Pediatric Sleep & Wellness Conference in Seattle and The Suicide Prevention and Intervention in Bozeman: Informational Flyers Flying

In the coming weeks I’m honored to be able to present on two of my favorite topics: Parenting and Suicide Assessment.

These two upcoming events (in Seattle, April 27 and in Bozeman, May 16 and 17) have nice landing urls for information and registration.

If you happen to be in one or both of these areas, I’d be happy to see you. Please let me know, so we can say a real, non-virtual hello.

The links.

Seattle: https://pediatrictrainingacademy.com/conference/?fbclid=IwAR0ov1b6RgqIY3qHRG7qPAC2Nf9PyHpkbI5fOodtp8umUUTMbDW2sh9v438

Bozeman: https://www.byep.org/saw

Boze Coop

Happy Wednesday! JSF

 

Alfred Adler All Day Long

alfred adler photo small

It’s too bad, but IMHO we don’t ever seem to take enough time to celebrate the ideas and deeds of Alfred Adler. If, by chance, you’re not sure who the heck I’m talking about, then I’ll take that as validation of my point. Who was Alfred Adler? . . . sadly, that’s a question many people can’t answer.

Today, April 4, 2019, I’m doing a webinar on the similarities and distinctions between Alfred Adler’s “Individual Psychology” (aka Adlerian therapy) and cognitive-behavioral therapy. Most people who study these things, including Albert Ellis, recognize that Adler’s work was ahead of his time and much of what he wrote about can be considered foundational to cognitive therapy. Staunch Adlerians sometimes put it more dramatically when they say, “In the beginning, there was Adler.”

Today’s webinar has inspired me to renew my efforts to spread the gospel of Alfred Adler. If you read this blog regularly, you know I’ve done this before. You can read some of my previous Adler posts by clicking here: https://johnsommersflanagan.com/tag/adler/

Today, I feel like I’m taking the lazy way out. But Adler would likely correct me. He didn’t much believe in the word lazy. Instead, Adler would reformulate lazy as discouraged, or more specifically, in this, and many cases (think of your children, perhaps), what appears to be laziness is a function of having goals and aspirations that are beyond one’s reasonable skills and available time. I think that could be the case here. Although I’d like to shower you with lots of new and exciting Adlerian information, instead, I’m posting the first five pages of the Adlerian chapter of our Counseling and Psychotherapy theories textbook. Here it is . . . five pages of the start of a chapter that only begins to describe the life and work of the amazing Alfred Adler.

Chapter 3: Individual Psychology and Adlerian Therapy

We often wonder about Alfred Adler. Who was this man whose theories and approach predate and contribute substantially to ego psychology (Chapter 2), the cognitive therapies (Chapter 8), reality therapy (Chapter 9), feminist therapy (Chapter 10), and constructive perspectives (Chapter 11)? How did he develop—over 100 years ago—influential and diverse ideas that are foundational to so many different approaches to therapy, and so thoroughly infused into contemporary culture? His beliefs were so advanced that he seems an anomaly: He’s like a man from the future who landed in the middle of Freud’s inner circle in Vienna.

Introduction

Despite the ubiquity of Adler’s ideas, many contemporary mental health professionals don’t recognize, acknowledge, or appreciate his contributions to modern counseling and psychotherapy (Carlson & Englar-Carlson, 2017). Perhaps this is because Adler provided services for working class people, rather than the wealthy elite; or because he was an early feminist; or because his common sense ideas were less “sexy” than Freud’s.

What is Individual Psychology? (. . . and what is Adlerian Therapy?)

Individual psychology was the term Adler used to describe the psychotherapy approach he founded. Watts and Eckstein (2009) recounted Adler’s rationale for choosing the name Individual Psychology: “Adler chose the name individual psychology (from the Latin, individuum, meaning indivisible) for his theoretical approach because he eschewed reductionism” (p. 281).

Most people know individual psychology as Adlerian therapy, the contemporary applied term. Adlerian therapy is described as “a psychoeducational, present/future-oriented, and brief approach” (R. E. Watts & Pietrzak, 2000, p. 22). Similar to psychoanalytic psychotherapy, Adlerian therapy is also insight-oriented. However, therapists can use direct educational strategies to enhance client awareness.

Adler was a contemporary—not a disciple—of Freud. During their time, Adler’s ideas were more popular than Freud’s. Adler’s first psychology book, Understanding Human Nature, sold over 100,000 copies in six months; in comparison, Freud’s Interpretation of Dreams sold only 17,000 copies over 10 years (Carlson & Englar-Carlson, 2017). Jon Carlson (2015) referred to Adler as “the originator of positive psychology” (pp. 23-24).

Adler wove cognition into psychotherapy long before Albert Ellis and Aaron Beck officially launched cognitive therapy in the 1950s and 1960s. In the following quotation, Adler (1964; originally published in 1933) easily could be speaking about a cognitive rationale for a computerized virtual reality approach to treating fears and phobias (now growing in popularity in the 21st century):

I am convinced that a person’s behavior springs from his [or her] idea.… As a matter of fact, it has the same effect on one whether a poisonous snake is actually approaching my foot or whether I merely believe it is a poisonous snake. (pp. 19–20)

In his historical overview of the talking cure, Bankart (1997) claimed, “Adler’s influence on the developing fields of psychology and social work was incalculable” (p. 146). This chapter is an exploration of Alfred Adler’s individual psychology and his vast influence on modern counseling and psychotherapy.

Alfred Adler

Alfred Adler (1870-1937) was the second of six children born to a Jewish family outside Vienna. His older brother was brilliant, outgoing, handsome, and also happened to be named Sigmund. In contrast, Alfred was a sickly child. He suffered from rickets, was twice run over in the street, and experienced a spasm of the glottis. When he was 3 years old, his younger brother died in bed next to him (Mosak, 1972). At age 4, he came down with pneumonia. Later Adler recalled the physician telling his father, “Your boy is lost” (Orgler, 1963, p. 16). Another of Adler’s earliest memories has a sickly, dependent theme:

One of my earliest recollections is of sitting on a bench bandaged up on account of rickets, with my healthy, elder brother sitting opposite me. He could run, jump, and move about quite effortlessly, while for me movement of any sort was a strain and an effort. Everyone went to great pains to help me, and my mother and father did all that was in their power to do. At the time of this recollection, I must have been about two years old. (Bottome, 1939, p. 30)

In contrast to Freud’s childhood experience of being his mother’s favorite, Adler was more encouraged by his father. Despite his son’s clumsy, uncoordinated, and sickly condition, Adler’s father Leopold, a Hungarian Jew, firmly believed in his son’s innate worth. When young Alfred was required to repeat a grade at the same middle school Freud had attended 14 years earlier, Leopold was his strongest supporter. Mosak and Maniacci (1999) articulate Adler’s response to his father’s encouragement:

His mathematics teacher recommended to his father that Adler leave school and apprentice himself as a shoe-maker. Adler’s father objected, and Adler embarked upon bettering his academic skills. Within a relatively short time, he became the best math student in the class. (p. 2)

Adler’s love and aptitude for learning continued to grow; he studied medicine at the University of Vienna. After obtaining his medical degree in ophthalmology in 1895, he met and fell in love with Raissa Timofeyewna Epstein, and married her in 1897. She had the unusual distinction of being an early socialist and feminist. She was good friends with Leon and Natalia Trotsky and she maintained her political interests and activities throughout their marriage (Hoffman, 1994).

Historical Context

Freud and Adler met in 1902. According to Mosak and Maniacci (1999), Adler published a strong defense of Freud’s Interpretation of Dreams, and consequently Freud invited Adler over “on a Wednesday evening” for a discussion of psychological issues. “The Wednesday Night Meetings, as they became known, led to the development of the Psychoanalytic Society” (p. 3).

Adler was his own man with his own ideas before he met Freud. Prior to their meeting he’d published his first book, Healthbook for the Tailor’s Trade (Adler, 1898). In contrast to Freud, much of Adler’s medical practice was with the working poor. Early in his career, he worked extensively with tailors and circus performers.

In February 1911, Adler did the unthinkable (Bankart, 1997). As president of Vienna’s Psychoanalytic Society, he read a highly controversial paper, “The Masculine Protest,” at the group’s monthly meeting. It was at odds with Freudian theory. Instead of focusing on biological and psychological factors and their influence on excessively masculine behaviors in males and females, Adler emphasized culture and socialization (Carlson & Englar-Carlson, 2017). He claimed that women occupied a less privileged social and political position because of social coercion, not physical inferiority. Further, he noted that some women who reacted to this cultural situation by choosing to dress and act like men were suffering, not from penis envy, but from a social-psychological condition he referred to as the masculine protest. The masculine protest involved overvaluing masculinity to the point where it drove men and boys to give up and become passive or to engage in excessive aggressive behavior. In extreme cases, males who suffered from the masculine protest began dressing and acting like girls or women.

The Vienna Psychoanalytic Society members’ response to Adler was dramatic. Bankart (1997) described the scene:

After Adler’s address, the members of the society were in an uproar. There were pointed heckling and shouted abuse. Some were even threatening to come to blows. And then, almost majestically, Freud rose from his seat. He surveyed the room with his penetrating eyes. He told them there was no reason to brawl in the streets like uncivilized hooligans. The choice was simple. Either he or Dr. Adler would remain to guide the future of psychoanalysis. The choice was the members’ to make. He trusted them to do the right thing. (p. 130)

Freud likely anticipated the outcome. The group voted for Freud to lead them. Adler left the building quietly, joined by the Society’s vice president, William Stekel, and five other members. They moved their meeting to a local café and established the Society for Free Psychoanalytic Research. The Society soon changed its name to the Society for Individual Psychology. This group believed that social, familial, and cultural forces are dominant in shaping human behavior. Bankart (1997) summarized their perspective: “Their response to human problems was characteristically ethical and practical—an orientation that stood in dramatic contrast to the biological and theoretical focus of psychoanalysis” (p. 130).

Adler’s break from Freud gives an initial glimpse into his theoretical approach. Adler identified with common people. He was a feminist. These leanings reflect the influences of his upbringing and marriage. They reveal his compassion for the sick, oppressed, and downtrodden. Before examining Adlerian theoretical principles, let’s note what he had to say about gender politics well over 90 years ago:

All our institutions, our traditional attitudes, our laws, our morals, our customs, give evidence of the fact that they are determined and maintained by privileged males for the glory of male domination. (Adler, 1927, p. 123)

Raissa Epstein may have had a few discussions with her husband, exerting substantial influence on his thinking (Santiago-Valles, 2009).

Reflections

What are your reactions to Adler as a feminist? Do you suppose he became more of a feminist because he married one? Or did he marry a feminist because he already was one?

Theoretical Principles

Adler and his followers have written extensively about the IP’s theoretical principles. Much of what follows is from Adler (1958), Ansbacher and Ansbacher (1956), Mosak and Maniacci (1999), Carlson, Watts, and Maniacci (2006), Sweeney (2009), and Carlson & Englar-Carlson, 2017).

People are Whole and Purposeful

Adler emphasized holism because he believed it was impossible “. . . to understand an individual in parts” (Carlson & Johnson, 2016, p. 225). Instead of dichotomies, he emphasized unity of thinking, feeling, acting, attitudes, values, the conscious mind, the unconscious mind, and all aspects of human functioning. This holistic approach was in direct contrast to Freud’s id, ego, and superego. The idea of an id entity or instinct separately pushing for gratification from inside a person was incompatible with Adler’s holism.

A central proposition of individual psychology is that humans are purposeful or goal-oriented (Sweeney, 2009). We don’t passively act on biological traits or react to the external environment; instead, we behave with purpose. Beyond nurture or nature, there’s another force that influences and directs human behavior; Adler (1935) referred to this as “attitude toward life” (p. 5). Attitude toward life is composed of a delightful combination of human choice and purpose.

Everyday behavior is purposeful. When Adlerian therapists notice maladaptive behavior patterns, they focus on behavioral goals. They don’t aggressively interrogate clients, asking, “Why did you do that?”—but are curious about the behavior’s purpose. Mosak and Maniacci (1999) articulated how Adler’s holism combines with purposeful behavior:

For Adler, the question was neither “How does mind affect body?” nor “How does body affect mind?” but rather “How does the individual use body and mind in the pursuit of goals?” (pp. 73–74).

Rudolph Dreikurs (1948) applied the concept of purposeful striving to children when he identified “the four goals of misbehavior” (see Putting it in Practice 3.1).

Putting it in Practice 3.1

Why Children Misbehave

Adler’s followers applied his principles to everyday situations. Rudolph Dreikurs posited that children are motivated to grow and develop. They’re naturally oriented toward feeling useful and a sense of belonging. However, when children don’t feel useful and don’t feel they belong—less positive goals take over. In his book The Challenge of Parenthood, Dreikurs (1948) identified the four main psychological goals of children’s misbehavior:

  1. To get attention.
  2. To get power or control.
  3. To get revenge.
  4. To display inadequacy.

Children’s behavior isn’t random. Children want what they want. When we discuss this concept in parenting classes, parents respond with nods of insight. Suddenly they understand that their children have goals toward which they’re striving. When children misbehave in pursuit of psychological goals, parents and caregivers often have emotional reactions.

The boy who’s “bouncing off the walls” is truly experiencing, from his perspective, an attention deficit. Perhaps by running around the house at full speed he’ll get the attention he craves. At least, doing so has worked in the past. His caregiver feels annoyed and gives him attention for misbehavior.

The girl who refuses to get out of bed for school in the morning may be striving for power. She feels bossed around or like she doesn’t belong; her best alternative is to grab power whenever she can. In response, her parents might feel angry and activated—as if they’re in a power struggle with someone who’s not pulling punches.

The boy who slaps his little sister may be seeking revenge. Everybody talks about how cute his sister is, and he’s sick of being ignored, so he takes matters into his own hands. His parents feel scared and threatened; they don’t know if their baby girl is safe.

There’s also the child who has given up. Maybe she wanted attention before, or revenge, or power, but no longer. Now she’s displaying her inadequacy. This isn’t because she IS inadequate, but because she doesn’t feel able to face the Adlerian tasks of life (discussed later). This child is acting out learned helplessness (Seligman, 1975). Her parent or caregiver probably feels anxiety and despair as well. Or, as is often the case, they may pamper her, reinforcing her behavior patterns and self-image of inadequacy and dependence.

Dreikurs’s goals of misbehavior are psychological. Children who misbehave may also be acting on biological needs. Therefore, the first thing for parents to check is whether their child is hungry, tired, sick, or in physical discomfort. After checking these essentials, parents should move on to evaluating the psychological purpose of their child’s behavior.

Social Interest or Gemeinschaftsgefühl

Adler believed that establishing and maintaining healthy social relationships was an ultimate therapy goal. He developed this belief after working with shell-shocked soldiers from World War I (K. Adler, 1994; Carlson & Englar-Carlson, 2017). He became convinced that individualism and feelings of inferiority were destructive; in contrast, he viewed social interest and community feeling as constructive. Another way of thinking about this theoretical principle is to consider humans as naturally interdependent. Lydia Sicher (1991) emphasized this in the title of her classic paper “A Declaration of Interdependence.” When we accept interdependence and develop empathy and concern for others, social relationships prosper.

Adler used the German word, Gemeinschaftsgefühl, to describe what has been translated to mean social interest or community feeling. Carlson and Englar-Carlson (2017) elaborated on the meaning of this uniquely Adlerian concept.

Gemein is “a community of equals,” shafts means “to create or maintain,” and Gefühl is “social feeling.” Taken together, Gemeinschaftsgefühl means a community of equals creating and maintaining social feelings and interests; that is, people working together as equals to better themselves as individuals and as a community” (p. 43, italics in original)

Adlerians encourage clients to behave with social interest (Overholser, 2010). Watts (2000) emphasized that, “The ultimate goal for psychotherapy is the development or enhancement of the client’s social interest” (p. 323). Research has shown that social interest is positively related to spirituality, positive psychology, and health (G. K. Leak, 2006; G. K. Leak & K. C. Leak, 2006; Nikelly, 2005), and inversely related to anger, irritability, depression, and anxiety (Newbauer & Stone, 2010). Some writers consider the positive aspects of religion to be a manifestation of social interest. This was Adler’s position as well (Manaster & Corsini, 1982; Watts, 2000).

Various writers, and Adler himself, noted that Gemeinschaftsgefühl essentially boils down to the edict “love thy neighbor” (Alizadeh, 2012; Watts, 2000). Carlson and Englar-Carlson described it as being the “same as the goal of all true religions” (p. 44). Although Adler wasn’t especially religious, he had no difficulty embracing the concept of love thy neighbor as a social ideal. In contrast, Freud (1930/1961) concluded, “My love is something valuable to me which I ought not to throw away without reflection” (p. 56). This is one of several distinctions between Adler and Freud; for Adler, love is valuable, powerful, and abundant. It should be freely given; for Freud, love is also valuable, but should be conserved.

Striving for Superiority

Adler believed that the basic human motive is the striving for superiority. However, like Gemeinschaftsgefühl, this concept requires a detailed explanation.

The term superiority is an oversimplification. Heinz Ansbacher provided a more comprehensive description of Adler’s striving for superiority in a published interview:

The basic striving, according to Adler, is the striving for Vollkommenheit. The translation of Vollkommenheit is completeness, but it can also be translated as excellence. In English, only the second translation was considered; it was only the striving for excellence. The delimitation of the striving for excellence is the striving for superiority.

Basically, it all comes from the striving for completeness, and there he said that it is all a part of life in general, and that is very true. Even a flower or anything that grows, any form of life, strives to reach its completeness. And perfection is not right, because the being does not strive—one cannot say to be perfect—what is a perfect being? It is striving for completeness and that is very basic and very true. (Dubelle, 1997, p. 6)

Striving for individual superiority can take on a Western, individualistic quality. This wasn’t Adler’s perspective. He viewed excessive striving for self-interest as unhealthy; Adler once claimed he could simplify his entire theory by noting that all neurosis was linked to vanity. Striving for self-interest translates into striving for superiority rather than for social interest (Watts & Eckstein, 2009).

When it comes to basic human nature and potential, Adlerian theory is like Switzerland: Adler was neutral. He didn’t believe in the innate goodness or destructiveness of humans. He believed we are what we make ourselves; we have within us the potential for good and evil.

Striving for superiority is an Adlerian form of self-actualization. More concretely, it occurs when individuals strive for a perceived “plus” in themselves and their lives. Mosak and Maniacci (1999) applied this concept to a clinical situation:

How can self-mutilation move someone toward a plus situation? Once again, that may be a “real” minus, especially in the short-term situation. Long-term, however, that person may receive attention, others may “walk on eggshells” when near that person (so as to not “upset” him or her), and he or she may gain some sense of subjective relief from the act, including a sense of being able to tolerate pain. (p. 23)

Adler observed that people often compensate for their real or perceived inadequacies. Individual inadequacies can be in any domain (e.g., physical, psychological, social). Adler may have believed in compensation partly because he experienced it himself, while growing up. Being inadequate or deficient is motivating. “The fundamental law of life is to overcome one’s deficiencies” (Ansbacher & Ansbacher, 1956, p. 48). Compensation is the effort to improve oneself in areas perceived as weak. The existential philosopher Friedrich Nietzsche expressed the same sentiment, “What does not kill me makes me stronger.”

In an ideal situation, individuals strive to (a) overcome their deficiencies, (b) with an attitude of social interest, and (c) to complete or perfect themselves. Watts (2012) has argued that the Adlerian social interest and striving for superiority are foundational to positive psychology—despite the fact that Adler’s work remains largely unacknowledged within the positive psychology discipline.

 

Breathing New Life into Your Dead, White Counseling and Psychotherapy Theories Course

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Artwork by Rita Sommers-Flanagan**

On April 18 at 1:00p.m. EST, I’ll be doing a Wiley Webinar. This webinar is free, and especially geared toward academics who want to expand their repertoire for teaching counseling and psychotherapy theories. Because this webinar is sponsored by my publisher, John Wiley & Sons, there will be some minor marketing of my textbook, Counseling and Psychotherapy Theories in Context and Practice (3rd ed.). However, you can attend this webinar regardless of the textbook you use. My goal is to help open all of us up to how we can integrate new ideas into existing “older” theoretical perspectives.

Here’s the link to register: https://www.wileyplus.com/wiley-webinar-series/#john-sommers-flanagan

And here’s the official blurb for the webinar:

Teaching traditional counseling and psychotherapy theories courses can feel dull and boring. In this webinar session, John Sommers-Flanagan will share pedagogical strategies for integrating culture into theory, and engaging students with here-now activities that bring the dusty old theories to life. This webinar will include specific recommendations for how to integrate culture and feminist ideas into traditional theories. Learning activities will be demonstrated, including: (a) early intercultural memories; (b) sex, feminism, and psychoanalytic defense mechanisms; (c) empowered narrative storytelling; and (d) spiritual and behavioral forms of relaxation. Handouts for each activity will be available later on this blogsite.

Beyond this short description, I also want to acknowledge the obvious. As a living White person who writes about, teaches, and practices theory-based counseling and psychotherapy, I know that my ability to claim expertise in making cultural adaptations is limited. I don’t want to be the expert on this (or most things). The purpose of this webinar is NOT to “tell” anyone exactly what diversity modifications “should” be made when teaching counseling and psychotherapy theories. Instead, my purpose is to talk about and illustrate ways in which new diversity-sensitive ideas might be creatively integrated into old theoretical perspectives. From there . . . the application of these and your own ideas about how to breathe new life into old theories is up to you and your unique personal and professional worldview.

Given this big preceding caveat, the webinar’s learner objectives are to help participants:

  • Identify compatibilities of culture, spirituality, and feminist thought with traditional counseling and psychotherapy theories
  • Implement an intercultural memory activity with large or small groups
  • Implement and discuss diverse sexualities along with psychoanalytic defense mechanisms
  • Implement a multicultural empowered storytelling strategy
  • Implement and debrief spiritual and behavioral integrations to achieve relaxation

Soon (right around 4/18/19) I’ll be posting more information related to this webinar. In the meantime, let me know your thoughts on this topic. As always, I value alternative perspectives and enjoy hearing your reactions to the posts on this blog.

Transforming Therapeutic Relationships into Evidence-Based Practice

Here are the ppts for today’s Webinar: v2 TherapySites 2019 Final
The handout linked below is an in-depth supplement to a webinar I’m providing for TherapySites.com on March 13, 2019. Although it’s designed to go with the webinar, it’s also a standalone resource for learning more about how to integrate evidence-based relationship factors into counseling and psychotherapy practice.

Webinar Transforming Therapeutic Relationships into Evidence-Based Counseling