“Forward, as occasion offers. Never look round to see whether any shall note it…. Be satisfied with success in even the smallest matter, and think that even such a result is no trifle.”
(Aurelius, 167, Book IX, verse 29, as quoted by Bartlett, 1895, p. 756).
“The interaction of planned and unplanned actions in response to self-initiated and circumstantial situations is so complex that the consequences are virtually unpredictable and can best be labeled as happenstance”
(Krumboltz, 2009, p. 136).
“Philosophy, answered Epictetus, doth not promise to procure any thing external to man; otherwise it would admit something beyond its proper subject-matter. For the subject matter of a carpenter is wood; that of statuary, brass: and so, of the art of living, the subject-matter is each person's own life”
(Epictetus, Discourses, Book 1, Chapter 15, as translated by Elizabeth Carter, 1766).
My Journey as a Nurse Psychotherapist
There are two essential conditions which affect the course of the lived experience, that which occurs by fate and that which derives from decisions a person purposefully makes in their life. My career journey as a nurse psychotherapist is a journey in which fate has dipped its influential hand and one in which decisions I have made profoundly impacted my career course as well. By trade, I am a military mental health nurse and inherent to this role is the responsibility of providing psychotherapy to clients. The challenge present in my career is the continuous need to affirm the counseling skill set that I have achieved through my training, since nurse psychotherapists are not as common as other professions such as psychologists and thus not as known or understood. Career journeys are enriched with much learning from experience and examination of my own career journey as a military nursing professional is a helpful effort in describing how I became the nursing professional I am today.
My first exposure to work occurred in Afghanistan. My father is a Civil Engineer who secured employment assisting the people of Afghanistan with building the water and sewer systems of their country. This work was funded by the Canadian International Development Agency. Our life in Afghanistan from 1975 to 1979 was largely peaceful and happy. “From the 1930s to the 1970s, when there was a semblance of a national government and Kabul was known as “the Paris of Central Asia”” (Bumiller, 2009, on-line). Afghanistan of the 1970s was a happy and relatively peaceful place, in which a large part of the population worked in farming and in present day, agriculture remains the employment source for 78.6% of Afghans (CIA, 2017). Our life in Afghanistan ended rather abruptly by war, when the USSR invaded to lend support to the communist party of Afghanistan in 1979. Stephen Lewis notes that one aspect of globalization is the “imposition of good governance on countries (particularly in the developing world)” (Lewis, 2001, p. v) and communist USSR certainly was engaged in what they saw as good practice with the invasion of Afghanistan.
The resulting failures of Soviet military intervention did not bring fortune to Afghanistan but did lead directly to my own work experience. In 2000, I joined the Canadian Forces as a nursing officer. In 2001, Canada joined the US and UK in military intervention in Afghanistan, “to dismantle the Al-Qaeda terrorist network in Afghanistan and to remove the Taliban regime from power” (Canadian Armed Forces, 2017, on-line). Thus, Afghanistan once again became my home in 2006, this time as a military member, as a member of a military coalition with the aim of restoring functional government and stability in that country. In arriving in the country of my youth, I was taken aback by the amount of destruction caused to the country, such as the dust caused by defoliant use of the Soviet military. It was the changes in Afghanistan that were most formative to me in 2006, with the obvious tension I saw that had replaced the peace I myself had known there. I was glad to discover that the Afghans I met in 2006 still welcomed me as they had in the 1970s, although I certainly noticed a greater amount of tension and reservation than I remember existed during my youth in Afghanistan.
Nursing as a career choice appealed to me since people-helping has always been an important value for me as a person. Penprase, Oakley, Ternes & Driscoll (2014) have found that men who enter nursing have stronger empathy traits in comparison to the population of males overall. “Strongly linked to caring (and sometimes used interchangeably), is empathy; nurses must be able to feel empathy towards other human beings” (Penprase et al., 2014). Entering the practice of nursing allowed me to apply my values of caring for others directly in my work and the longer I have practiced in nursing over the last 17 years, the more my career satisfaction has increased. In a survey of nurses conducted by the journal Mental Health Practice it was found that: “35 per cent said the main reason they chose nursing as a career was to ‘make a difference to people’s lives’” (Duffin, 2009, p. 20) and I would agree with this sentiment.
Juliff, Russell & Bulsara (2017) affirm that men consider nursing as a career when they have family members who are nurses, and this was certainly my experience as well. In my family there are nurses and in my family pursuit of people-helping professions such as nursing are honoured. This greatly influenced my own decision to pursue nursing as a career. Research by Chen, Fu, Li, Lou & Yu (2012) demonstrates that once qualified as a nurse, supportive relationships with others are an important part in the nursing career development of male nurses. Chen et al. (2012) affirm that, for men in nursing, positive social support is directly correlated to progression and development in their careers. Thus, nursing allows me the opportunity to engage in a people helping profession. The relationships in my life have had important influence in my decision to enter nursing and have direct influence upon the development of my nursing career.
Just before deploying to Afghanistan I had finished my speciality training as a mental health nurse. Working in military mental health inherently involves working with clients who have experienced trauma. To best accentuate my skill set in being able to assist with treatment of trauma, I purposefully engaged training in Cognitive-Processing Therapy (CPT) and have since gained Quality Provider Status in delivery of CPT, with the developers of CPT (Cognitive Processing Therapy, n.d.). To assist with research focused on determining how CPT best functions to treat PTSD, I further joined the CPT Implementation Study, which gave me the opportunity to both receive supervision in utilization of CPT and inclusion in a community of people sharing the same clinical focus. The positive experiences with others through involvement with CPT echoes the affirmation of Chen et al. (2012) that positive relationships with others accentuate the careers of men in nursing.
As a military nurse, I am professionally returning to the professional roots of my profession. Florence Nightingale began the professionalism of nursing with the care of soldiers during the Crimean War of the 1850s (Koffi & Fawcett, 2016). Florence Nightingale was especially famous in her advocacy for the professionalism of nursing and the importance of the skill set of the professional nurse in caring for patients (Selanders & Crane, 2012). Currently, there is a lack of understanding about the role and abilities of nurses who are trained as psychotherapists, as I am, and this has placed me in the role of advocate for both myself and other nursing professionals who have psychotherapy training. One of the challenging realities present for mental health nurses is the fact that other mental health specialists have been found to note that mental health nurses are “aiming too low or that their talents would be wasted in nursing” (McCrae, Askey-Jones & Laker, 2014, p. 770). Complicating the situation for mental health nurses is the stigma within the nursing profession itself that mental health nursing is one of the least desirable types of nursing to practice (Harrison, Hauck & Ashby, 2017).
Caring relationships are an important facet, and historical inherent trait, of nursing. One of the factors that I affirm with my fellow mental health nursing professionals is that they can accentuate their clinical skill base by building rapport through utilization of Bordin’s (1979) working alliance. I have become passionate about the great value of the voice and choice of the client in health care and have found that adopting the Socratic Method within the working alliance is of crucial importance. It is my belief that the Socratic Method is especially relevant for nursing professionals. Therefore, I have made education about the Socratic Method a particular focus for my career.
During the 2017 Canadian Federation of Mental Health Nurses (CFMHN) National Conference, I provided a lecture entitled Socratic Questioning Basic Training (Quinn, 2017). I was very happy to read the feedback given from my nursing peers as noted at Appendix B and more especially in regard how participants felt that they would use the Socratic Method directly in their clinical practice. The professional experiences which gave root to the knowledge of the efficacy of the Socratic Method began during my training in Solution-Focused Brief Therapy (SFBT) and were especially affirmed with my training in Cognitive-Behavioural Therapy (CBT). In 2015, I delivered a lecture at the 2015 CFMHN National Conference entitled An Effective Way to Operate Cognitive Behaviour Therapy (CBT) Groups in the CAF (Quinn, 2015) and received feedback from my nursing peers that the learning provided was relevant to their clinical practice, as noted in my resume, which is attached as Appendix A.
My career as a nurse psychotherapist is best seen within the lens of social constructionism, as seen in SFBT and the Happenstance Learning Theory (HLT) of Krumboltz (2009). My career has been literally constructed by the influence of the relationships in my life. It has literally been socially constructed and is thus best seen through this career theory. SFBT has both benefited the clients whom I have consulted, and it has acted as a framework through which I engaged my career. Krumboltz (2009) notes that careers are best built when a person seizes the opportunities which present to them in life. “HLT posits that human behavior is the product of countless numbers of learning experiences made available by both planned and unplanned situations in which individuals find themselves” (Krumboltz, 2009, p. 135). At the start of my career, I greatly benefited from having SFBT taught to me as the baseline of my counseling skill set since it both enhanced my skill set and gave me tools by with which to construct my own career.
SFBT is an ideal means through which career development and construction can be seen (Bezanson, 2004; Burwell & Chen, 2006; McMahon, Adams, Lim, 2002). SFBT “claims that the individual’s notion of what is real – including his or her sense of the nature of problems, abilities and possible solutions is constructed in daily life in communication with others” (Bannink, 2006, p. 12). One of the most important texts which I believe has enhanced my skill set in SFBT and Socratic questioning is 1001 Solution-Focused Questions by Bannink (2006). Bannink notes in her book is: “the client’s capacity for change is related to his or her ability to begin to see things differently” (Bannink, 2006, p. 12). The sentiment of Bannink’s words is directly rooted in the statement of the Stoic Philosopher Epictetus, that: “men are disturbed, not by things, but by the principles and notions which they form concerning things” (Epictetus, 135, on-line). It is clear that: “modern psychotherapy, especially in the form of cognitive-behavioural therapy (CBT), the most “modern” of our contemporary schools, can also be viewed as part of an ancient therapeutic tradition derived from the informal philosophical circle surrounding Socrates (470-399 bc)” (Robertson, 2010, p. 18-19). Practicing psychotherapy is thus learning and applying ancient wisdom, while demonstrating modern efficacy in applied clinical practice.
I am not only of course a nurse psychotherapist. I have now for 17 years been a husband and for nearly 16 years a father. Being a military member has been a special source of responsibility in my life, since the Canadian Armed Forces expects military duties to supersede all other responsibilities in life (Canadian Armed Forces, 2014). Thus, as a military nurse psychotherapist, I have had to provide counseling to military clients experiencing challenges while balancing work and home life responsibilities. The appropriate balancing of these responsibilities is a work in progress. SFBT is shown by the work of McKenna & Mackey Jones (2004) to assist with development of exceptions noting what is helpful in making life more bearable when facing the challenges of balancing work and home responsibilities. Mulawarman-Munawaroh & Nugraheni (2016) further note findings that illustrate the SFBT assists with adaptations that are necessary in work, due to the challenges of work and changes that occur with work.
The HLT of Krumboltz (2009) notes that life is a happenstance of circumstances and the purposeful decisions that people decide to take during their life can have great beneficial effect for them. Mitchell, Levin & Krumboltz (1999) note that planning is an important aspect to happenstance that occurs, that people can beneficially gain from unexpected circumstance and also purposefully generate beneficial change. “Clients must plan to generate and be receptive to chance opportunities. A strong component of planned happenstance is facilitating the client’s actions of generating and anticipating possible opportunities” (Mitchell, Levin & Krumboltz, 1999, p. 117). Kim, Rhee, Ha, Yang & Lee (2016) found that that people who demonstrate the ability to utilize happenstance to their benefit are seen to have greater career related satisfaction and greater beliefs in their own abilities to influence and beneficially modulate their careers.
Early in my military career, I learned the classic maxim of Helmuth Karl Bernhard Graf von Moltke that reads “no plan survives contact with the enemy” (Wikipedia, 2017, on-line). Moltke’s maxim illustrates that change and challenge are not only possible but to be expected and mirrors the wisdom as seen within the HLT. SFBT is focused on assisting facilitating the development of goals and the action plan(s) that assist with attainment of the noted goals. (Bezanson, 2004). One of the ways that SFBT assists with development of goals which build a preferred future is by the exception focused questions, questions which ask when concerns present were lessened or improved, when the glimpses of the preferred future was seen (De Jong & Kim Berg, 2002). The process of the HLT facilitates actions which allow experiences of success to occur, which allow a person to accentuate their own abilities in attenuating their own career related concerns (Krumboltz, Foley & Cotter, 2012).
The successes I have experienced in advocating for my own role as a nurse psychotherapist and for advocating for nurses practicing psychotherapy skills overall is well seen within the principles of SFBT and HLT. During my military duties, I was given the opportunity to become a military mental health nurse. When I qualified as a mental health nurse, I quickly learned of the great importance psychotherapy plays in the treatment plan of clients. In my career as a mental health nurse, I have actively striven to accentuate my skill base in psychotherapy, as reflected in my resume as listed at Appendix A. My career progression reflects the benefit of seizing career opportunities and creating beneficial change, as seen in the HLT of Krumboltz (2009). The spirit of SFBT has not only provided me the means to assist the clients I consult but has as well provided me framework and perspective through which I have built my own career. The assessment processes of the HLT and SFBT provides further description of how my career has developed.
Krumboltz (2009) affirms that with the HLT, career related assessments must serve to facilitate learning about career. Assessment within SFBT is a continuous process, questions literally functionally create SFBT in action (Bannink, 2006). The questions that I would ask a client such as myself would include “what is your level of satisfaction in having addressed the principle concern you have, with 10 being the highest level of satisfaction” and “what types of events have occurred in your career which have allowed you to realize that you are on the right track in addressing the challenges you have in your career.” The answers I have for these SFBT questions is that my level of satisfaction is 9/10, due to the successes I have had in learning and applying psychotherapy as noted in Appendix A. Events that are most encouraging to me include when I have seen the beneficial action of psychotherapy occur. The learning I gain from reflection upon these SFBT assessment questions is that there is benefit in advocating for my role as a nurse psychotherapist and that the application of the tools and resources of psychotherapy are of pivotal importance in counselling practice.
Theories can be helpful to illustrate my career experience. However, no theory can completely and exhaustively explain my career development. The HLT of Krumboltz (2009) describes the benefit of seizing upon opportunities that present by happenstance. However, it does not describe how I developed the motivation to accomplish such or the creativity of how to best modulate circumstance in the best manner possible. While SFBT has given me extraordinarily effective questions and perspective, it is my own creativity and application of the tools I have been given that has made SFBT processes effective for myself and my clients. I must give SFBT much credit in providing me with the wisdom found with adopting a non-judgemental and not-knowing perspective, as illustrated by De Jong & Kim Berg (2002). Perhaps the most significant benefit of possessing a non-judgemental and not-knowing perspective has been the broadening of my perspective.
Theory can be helpful in providing perspective but can also constrain perspective if diversity of the human experience is not appreciated. My career journey has exposed me to many different cultural experiences. As an example, Arthur & Collins (2010) note that to best integrate understanding of the impact of culture it is important to develop awareness of your own culture, the cultural experience of others and how these culture experiences relate to one another. The perspective of SFBT, in striving to place the client as the expert as noted by De Jong & Kim Berg (2002) may be an impairment in certain cultures. “A client may expect a practitioner to act authoritatively and present explicit advice, whereas the practitioner’s orientation may involve respecting client autonomy. The practitioner must balance both positions to create appropriate boundaries that facilitate a productive alliance” (Basseya & Melluis, 2013, p. 160).
In regards the HLT, my learning in Afghanistan illustrates a challenge with this model. In Afghanistan, it was my experience that there is cultural reliance on the concept of fate, or as Afghans will say ‘it is written.’ Basseya & Melluis (2013) note that eastern cultures can have a deterministic perspective and such a perspective may thus have difficulty incorporating the very idea of happenstance in a functional way. The very idea of possible career change can also have cultural dimensions, such as may be seen within cultures which possess systems of social structures such as caste systems. As an example, when my father was working in the middle-east, one of his engineering colleagues, who was from India, was surprised to learn that my father’s father was a mechanic and truck driver. The very aim and purpose of a person’s career pursuits often have cultural dynamics, such as for people from Eastern perspectives: “contributing to society and others’ development, and also leading a peaceful life is seen as an important life goal to realize” (Burde & Rao, 2011, p. 376). When I was in Afghanistan, I experienced the collectivist perspective directly. When bartering at the markets salespeople would often tell me that valued items gained through trade would be taken home for sharing with their families.
Arthur & Collins (2010) emphasize that cultural awareness is important and that it is important to also avoid over-emphasis on cultural aspects. In regards the concept of determinism, people who have deterministic viewpoints do have beliefs about how fate effects human existence. However, this does not preclude the fact that change happens or that people with deterministic perspective want change to occur for the benefit of themselves, their families and their communities. Krumboltz (2009) notes that the intent of the HLT is to facilitate career related circumstances that cause benefit, learning that facilitates beneficial change and both modulation of events that occur and creation of events that cause benefit. Thus, the HLT would be an ideal framework which can be adapted to the needs of people from different cultures, provided that it is adapted to the perspective of the culture of the person concerned. This brings us to the fact that Socrates was right, in that adopting a not knowing stance is of critical benefit to human thinking.
De Jong & Kim Berg (2002) emphasize the SFBT operates from a not-knowing, non-judgemental stance and thus follows in the heritage of the Socratic Method. My experience in delivery of psychotherapy as a nurse has shown me the benefit of embracing and utilizing a not-knowing and non-judgemental stance. It has become one of the missions in my career to illustrate to others the benefits of functionally using Socratic questioning, since we cannot know what we do not know unless we engage purposeful discovery using a not-knowing and non-judgemental perspective. Hatcher, Kipper-Smith, Waddell, Uhe & West (2012) note that counselors report learning how to be non-judgemental directly in their work with their clients and I have been given this gift in my counseling work. This brings us to one of my personal heroes, the physician researcher and passionate advocate for the use of appropriate scientific process Ben Goldacre. Goldacre (2011) notes that the weakest type of evidence we have is authority and that critical review of evidence is essential in effective application of health care. The experiential learnings I have gained in my career has affirmed for me that the processes of SFBT, HLT and the Socratic Method are beneficial in applied counseling practice.
Undertaking this review of my career has given me both an appreciation of the work I have done and the significant effect that the teachings of Socrates and SFBT have had on me. The HLT of Krumboltz (2009) has provided me a lens through which I see how I have caused beneficial circumstance to occur in my career from seizing the opportunities present in happenstance: both that have occurred and which I have created myself. The principle question remaining in my career is the unknown inherent to the future overall. The resources and wisdom of HLT, SFBT and the teaching of Socrates allow me to best embrace future circumstance as it occurs. These principles have become the guiding factors in my career journey.
Attending school one very average morning in Kabul Afghanistan, I did not know that by lunch time my parents would be rushing us out of the country due to the military incursion of the USSR. I further did not know during one very average morning on 11 September 2001 that attacks would occur which would result in my return to Afghanistan once again. When I engaged my training as a mental health nurse I did not realize that my certification would be finalized in Kandahar Afghanistan. I have learned directly that circumstances of life happen unexpectedly and that the choices you make in life can have an effect upon the course of your career.
Now I would like to explore how I would engage career counselling if I were the client in career counselling. First, I would apply SFBT type questions, utilizing a not-knowing and non-judgemental stance, as recommended by De Jong & Kim Berg (2002). I would specifically seek to explore what exceptions that have occurred in my career which I have found beneficial. As previously affirmed, learning and applying SFBT and the Socratic Method has been helpful to both my counseling practice and to my own lived perspective, as has embracing change caused by the happenstance of life as seen within the HLT of Krumboltz (2009). The recommendations I would thus make to myself as a client would be to continue embracing what has worked as noted. Additionally, I would affirm with myself the benefit inherent in embracing a not-knowing and non-judgemental stance as per the Socratic Method and SFBT.
The implications in regards counselling focused on work are directly related to the challenge present in my career. In becoming a mental health nurse, I both learned of the benefit of applied psychotherapy as well as the challenge that mental health nurses have with recognition of their profession and skill set. I purposefully have taken the challenge present in my career as a mental health nurse and have actively gained skills in psychotherapy. Additionally, I have taken as my mission the objective of teaching nurses the effective means of counseling such as seen in Socratic questioning. I have gained much from the example of advocacy via exemplars such as Florence Nightingale and Ben Goldacre. The process of applied practice is greatly accentuated when there are advocates who believe in what they do and insure that the tools and process of health care function to the benefit of clients.
Life occurs, and continuous change is inherent to life. The HLT as described by Krumboltz (2009) provides helpful perspective of the importance of adapting to circumstance as it occurs in life. The Socratic process and SFBT provide career counselors the ability to adopt a stance of genuine, not-knowing curiosity, which provides lucidity in critical thinking. I have learned that there is substantial benefit in developing expertise in not-knowing. Similarly, great benefit derives from the ability to ask critical questions which serve to illuminate the shadow cast by the illusion created by the authority of assumptions. I can come to know what I do not know, as long as I am aware that knowledge is forever to be gained, ad infinitum into the future. I have profound gratitude for the relationships in my life which have helped me build my life and my career. Overall, purposeful application of intention breathes life into the lived experience of career, especially in regards relationships with others during the happenstance of my life.
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My full paper, My Journey as a Nurse Psychotherapist, can be downloaded here: