The development of therapeutic intuition

Transcript of my workshop presentation at the APS conference in Darwin, October 2009

Psychotherapist? What for?
My other recent talk:
Paradox in therapy

   As a beginning therapist, I was an admirable example of doing things by the book:

   This can work very well. My second client was a lady with an eating obsession. Up to 5 times a day, she had vivid imaginings of eating 10 Mars bars in a row, or spooning down a litre of ice cream. Fortunately, she had an iron will, and so had a nice figure, but the obsession was a form of torture for her.

   In the first session, I got her to start an ABC diary, and worked on cognitive restructuring, in particular addressing feelings of guilt about being so faulty and greedy.

   In the following week, she'd had a food urge only 3 times. Since she was obsessive, I knew she'd conscientiously write down every instance, so I believed her. Keeping an ABC diary had magically reduced her obsession to tolerable levels.

   Then the Christmas period came, and she went right through the season of gluttony with minimal distress.


   Successes are all very well, but we learn more from failures. A young man we'll call Jock needed my help because he was terrified that he'd hurt his baby. He came from a small Scottish community, in which the parish priest was the central force. As a little boy, Jock was sexually abused by this man. This included anal penetration. Terribly upset, he told his older brother, who told him not to make up nasty stories about Father Angus.

   So, Jock didn't tell anyone else. He carried the secret around, and the abuse continued till he stowed away on a ship. He became a seaman, and ended up in Australia.

   Still as a teenager, he'd stepped in front of a car to kill himself. He survived, with some permanent damage. To cope with the pain, and the even more painful memories, he ended up on heroin.

   Then he met a girl, and in order to earn her love he cleaned up his act. He enrolled in a course of study, and did very well. They got married, and he held down a responsible job.

   Then a baby was born, and the troubles started. He refused to be left alone with the baby. This, and the resultant marital stresses, got him so depressed that he took extended sick leave from his job. He'd spend the day sitting on the couch, looking at the newspaper without turning a page for hours at a time.

   His wife arranged an appointment for him. It had to be a home visit, because he'd become reluctant to drive a car.

   We quickly bonded, and he told me about the childhood abuse. He said the reason he refused to drive was that on a couple of occasions, he'd found himself in a strange place, driving in heavy traffic without knowing how he'd got there. And he was adamant: his baby would be at risk if he was left alone with her.

   He suffered from several specific phobias, including to the smell of incense, and being anywhere near a church.

   I did my CBT thing, and decided that success with one problem would generalise, and chose the simplest. We started systematic desensitisation for the phobias.

   It didn't work. He visibly stopped trusting me.

   We had to discontinue after the third session, because his wife told him to go. She could no longer stand having two dependants and no support, and the constant misery in the house. Jock left the area, and I've never met him again.

   I failed him.

   If he came to me now, I'd LISTEN to him, and believe him. I would not impose my theoretical understanding, but accept HIS theory.

   When he'd told his brother about the abuse, he was not believed. His wife had joined the enemy by not believing that the child was at risk from him. And then I also joined the enemy by getting him to smell incense instead of believing that he could hurt his child.

   Given his history, and the reported lost times, now I'd ask him a question something like this: "Jock, I know you love your little girl and would never hurt her. But, is it the case that if you were left alone with her, someone else within you would hurt her?"

   And I think he'd reveal alters, some of whom are malevolent. I am sure now that he had multiple personalities. The clues were all there -- but needed to be accepted as real, treated with respect.

   If I could have explained the situation to his wife, she would probably have been more tolerant. And I think the three of us -- Jock, his wife and I -- would have conquered his problem.


   So, I am no longer the good little CBT therapist. Instead, I listen to the client. I ask the occasional question, reflect back to ensure I've heard right, and in the process may do a reframe, which often (not yet 100%) expresses what the client felt but couldn't or wouldn't put into words.

   Completely intuitively, I then engage the client in an activity that helps to ease the pain. This is always evidence-based: from the research literature, or what had worked for a previous client, or often, what had worked for me.

   This activity can range from

   Sadly, my hit rate is not yet perfect: each year, I get things wrong maybe 3 or 4 times. But the results of doing things this way please me: My work is never boring, always fresh. While I use the same tools with many people, it is always in a unique context. My clients like it. I haven't done formal outcome studies in recent years, but follow-up calls indicate that they maintain their gains, and many new clients come to me through personal recommendation.


   Fran is an example. She was diagnosed as schizophrenic by a colleague who then sent her to a psychiatrist who confirmed the diagnosis. Then my colleague said she was not competent to deal with schizophrenia, and referred Fran on to me.

   Fran was furious and indignant. She'd spent nearly $400 in gap fees, and had three hours of someone taking notes and doing nothing to benefit her. She refused to take the prescribed antipsychotics.

   My reaction was to believe her. Instead of joining the hugely numerous enemy like my colleague had, I joined her team, which then consisted of just the two of us.

   We were able to terminate therapy after 4 sessions, and at last follow-up she was doing well, her only complaint being that she couldn't lose any weight while living with mum's good cooking.

   In our first session, instead of bothering with DSM-based questions, I asked her to tell me why she needed to seek help at this point in her life. She said, wherever she went, people victimised her. This was because some enemy sent negative energy that induced them to do so. And this was why she was accused of being schizophrenic, which she rejected.

   I told her that if she were a Native American, or lived in Africa, her beliefs would be accepted as ordinary. Her problem was that she was going contrary to our culture, and she had a perfect right to do so. And within this first session, we decided that the way to fight negative energy is to send out positive energy.

   That was the end of the delusional disorder. In the second session, she told me that the negative energy had stopped, but she would continue to broadcast the positive energy.

   We spent three sessions on the actual behavioural interactions in her life. She had severe social phobia, and we dealt with that through coaching on how to use nonverbals to influence people (reframed in terms of how to send them positive energy), and through in vivo exposure she conscientiously carried out between sessions.

   She had enrolled in a course, and went along to the first session. However, 10 minutes into it, she made an excuse and left. The reason we terminated after the 4th session was that she had returned to the course, sent positive energy to everyone there, and realised that they were all on her side. Nobody victimised her.


   One of my favourite clients from recent years is an Aboriginal man, who has been more severely traumatised than any other person of my acquaintance. Like I suspect Jock did, he had multiple personalities. His way of 'drowning the voices' was to smoke marijuana. When he gave up for a few weeks, he invariably ended up either in jail or in a psych ward.

   Sean became a street kid at 8, and stayed alive because of superior intelligence, creativity and courage. But, at 36 years of age, whenever he perceived a situation as involving a threat, his 8 year old alter took over, and fought for survival. And a savage 8 year old in a superbly fit, strong 36 year old body is terrifying.

   I don't have the time to tell you all the many complicating details, or of our work together, just the one intervention that was the turning point for him. In hypnosis, I had him sit in a rowboat. He, adult, strong, wise Sean, was at the oars. 8 year old Sean was sitting in the back, holding a fishing rod, enjoying himself. He knew himself to be perfectly safe, because adult Sean was there, IN CHARGE.

   Thereafter, whenever circumstances triggered 8 year old Sean, he automatically remembered that the adult is in charge, and can keep the kid safe. Within the past 2 years, he has only been violent once. This was when a friend made a mock physical attack on him. Before he had a chance to think, he kicked out, breaking a rib in the friend's chest.

   So, again, by accepting the client's reality, I could induce a change of perception that the client could then implement. Because it is from within the client's reality, it is real, and usually permanent.


   Since we have the time, I'll mention one more client: Louise. She is 78, and was referred to me after her car slipped the handbrake and ran over her. We did chronic pain management, and dealt with phobic reactions, but after these issues were resolved, she kept coming. Nowadays, she makes an appointment every couple of months, and we both enjoy it.

   The point of mentioning her is that the centre of her life is the Catholic Church. Two sessions ago, she told me she'd given my card to a woman who was looking for a Christian counsellor.

   I had to be honest and tell her that I am not a Christian. I was born Jewish, but if you must put me into a box, it's Buddhist. But, we agreed, I have been Christian enough for her.