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by Dr. Nathaniel R. Strenger

Of Integration and Bicycles

A previous supervisor of mine, beloved and idolized in my training years, recently passed away. An affecting memorial gathering reunited me with some old peers, and we once again marveled at the depths of his imparted wisdom and the acuity with which he observed our early efforts as clinical psychologists. And as I again sat in the office where we had met for weekly consultations, a memory bubbled to recollection:

That supervisor and I, by then comfortable regularly reviewing the video recordings of my rookie clinical sessions, were sitting in front of the television screen putting each therapeutic moment under the proverbial microscope looking for overlooked nuance. As he often did, he made an incisive observation, gentle yet cutting in such a way that made me refashion my whole understanding of a patient. And once again he left me wide-eyed at his seasoned acumen.

“How do you do that?” I asked. “I would never have noticed that.” With a twinkle he replied, “Nathaniel, I’m just riding a bike.”

Riding a bike; what a response. Learned. Sage. Infuriating. What was I to do with that? I was looking for some Ikea-like paper fold-out with illustrated instructions—step-by-step directions for building a PSYKOLOG or something (praying I have all the necessary parts, of course). Instead, my supervisor gave me some cutesy adage, like Yoda blathering on about lifting spacecraft out of swampy Dagobah sludges.

The irritation is not unlike that which folks encounter when inquiring about “integrative” therapy—that is, learning how to integrate theologies and psychologies into a whole mental health treatment. Many look for specific and sequenced skills, clearly defined and always coming to fruition. Often, they instead encounter vague posturing or reflections that are more philosophical or intuitive than quantified. Of course, there is value in both. And I think they both merit closer reflection. So, let us get into the nitty-gritty: Riding a bike.

There are obvious, quantifiable skills needed to ride a bike. One learns to alternate foot-force left and right to pedal with coordination. One calibrates that balancing act, sensing any teetering and learning to shift weight back and forth to stay upright. And one learns to do all of this while constantly scanning the ever-changing environment for potential obstacles. These make up just a small sampling of the dizzying array of skills a person masters when first learning. It is a whole lot of work—a small miracle, really.

When one is first starting out, these skills require a disturbing amount of attention. This is why supervision is advised. But gradually, all the neuropathways laid are so solidified, so automated, that they form a kind of gestalt-like way of being. The learned and integrated skills melt into one another to become a less quantifiable mode, a procedure, an intuitive posture.

And once all these little skills automate themselves in procedural memory, they are remarkably resilient. A 2010 case study, out of the Netherlands, followed a 58-year-old man afflicted with “gait freezing,” a phenomenon associated with severe Parkinson’s disease. He could no longer walk without detailed visual-motor guidance, and the simple act of putting one foot in front of the other required reinstruction. But then, and there is astonishing video, they put the man on a bicycle, and he rode flawlessly, even playfully. Parkinson’s may have deteriorated his execution of the small, isolated skills. But the procedure, the posture, the way of being, remained.

Academics, like Baylor’s Dr. Holly Oxhandler and the almost legendary Dr. Kenneth Pargament, work steadily to delineate the competencies required in religiously/spiritually integrative therapies. The string of published papers organizes those competencies into three categories.

As is the case for cyclists too, integrative therapists must develop certain skills. They learn to suss out relevant spiritual or religious narratives in a patient’s history. They learn to assess those narratives for their clinical consequences, adaptive or maladaptive. They know when and how to integrate appropriate faith leaders into networks of care. And they know how to wield client-preferred rituals and practices, all contraindications considered, for the sake of therapeutic growth.

Pargament, Oxhandler, and their colleagues also identify a certain knowledge base required to build integrative competency. Rooted in career-spanning humility, the competent clinician seeks familiarity and widening knowledge of the many theologies, traditions, and worldviews populating a caseload. Nurturing a growing awareness of these different traditions and their historical positions within broader society is an invaluable project here. That is because it empowers the integrative clinician to bear any relevant skills wisely and with greater finesse.

Finally, the literature goes, competent integrative therapists cultivate certain attitudes and ethical perspectives. Self-reflection, multicultural curiosity, perspective-taking, and critical thinking are all included here. And these character traits become necessary if the competent clinician is to stay agile, sincere, and creative. They promote ethical practice in what can be tricky, but profoundly productive, clinical terrain.

Reviewing these three areas of competency, one starts to evaluate which can be most traditionally taught and which must only be cultivated over time. Integrative clinicians rightfully do seek specific skills, even bases of knowledge, that are sequenced and tangible. Reading a book or completing a training delineating specific integrative skills can prove helpful. Like the IKEA foldout, they provide digestible and quantifiable gains. But they are not round out full competency.

The less tangible knowledge and corresponding attitudes make up a certain integrative character, a mode of being, an intuitive posture. And these are formed in ways mirroring the bicyclist. The skills are there and nurtured, and when they meld together with those skills attained to form a whole mode. When they do so, they start to function like a three-legged stool, a trinity so to speak, in which each requires the presence of the other two. The integrative therapist applies certain skills, draws on growing knowledge, and forms a certain character…and with time the integrative therapist learns to ride that bike.

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