Paradox in therapy

Talk delivered at the conference of the College of Counselling Psychologists, Victorian Section
August 2009

Psychotherapist? What for?
Pro bono email therapy
The development of therapeutic intuition

   All truth is paradox.

   You may know about the Dodo Bird phenomenon: a great many therapeutic approaches do as well as each other. Things as diverse as dynamic psychotherapy and CBT have very similar success rates. I know, I know, there are the common factors, but... but if I wave a crystal over my client's head while practicing the Rogerian virtues, my effectiveness and efficiency will be nowhere as good as if I use CBT tools while practicing the Rogerian virtues. So, the paradox is that the tools don't really matter... but they do.


   Second, there is that all-important therapeutic relationship. My friend Alfredo Zotti has said, "Any therapy is based on two hearts touching, and sharing their wisdom."

   And yet, from the first session on, my job as a therapist is to make myself unnecessary in the client's life. I've succeeded in therapy if the client feels strong, and confident of solving those life problems that made therapy necessary in the first place.

   One recent client is a 52-year-old Italian gentleman we'll call Vince. In the third session, he told me that throughout his day, I was constantly on his mind, and in effect gently steered him to deal better with his issues. He said he loved me like he loves his older brother. It was a beautiful experience for both of us when he said this.

   And yet, we had only two more sessions, a total of five. As we talked, it was clear to both of us that he no longer needed me. We agreed to terminate. As he walked out, he spontaneously gave me a big hug -- and I've never seen him again.

   I phoned a month later, and again three months later, to check if he had maintained his gains. Both times, we had a lovely five minute chat, then parted without any suggestion that he might want to meet me again.

   Is this not a paradox?


   Then there is PTSD. The central defining characteristic of this distressing condition is the constant battle to prevent flashbacks and nightmares. People invest a lot of energy in preventing flashbacks, and can be re-traumatised if this fails and the flashbacks come anyway.

   Sometimes, people can go through long periods without any re-experiencing, and are convinced that they're over the trauma. All the same, they may be low on energy and motivation, or be depressed, irritable, avoid people, their performance may be nowhere as good as before the traumatic event. It's as if they were carrying a huge inner load -- because they are. That load is the prevention of anything that may trigger a re-experiencing.

   How do you get rid of the problem? By re-experiencing. That is, you get the client to deliberately go against the central motivation since the trauma.

   One of my bushfire clients was Lorraine, who runs an animal shelter. She'd spent 18 hours a day for months, looking after burned animals, but then had constant flashbacks and nightmares, set off by many things including the smell of cooked meat.

   But also, since the bushfires, she had nightmares about two 20-year-old events: an attempted rape against her, and the witnessing of the death of one of her colleagues in a particularly gruesome accident. For 20 years, she thought she'd dealt with these, but we couldn't address the bushfire till we had done imaginal exposure on these old traumas. Incidentally, I prefer to do this using hypnosis.

   Having dealt with the sexual assault and friend's death, Lorraine then had recalls and flashbacks to previously forgotten events of parental abuse from her childhood. We had to deal with these too, and then finally with the bushfire.

   And each time, the tool was to deliberately invite the memories. In order to prevent future flashbacks of Black Saturday, she needed to find the courage to GO back there, BE back there, and re-experience. Because of the complexity of past traumas, we took 23 sessions, but by then she had processed the lot.


   The next paradox concerns ruminative thoughts. Many people suffer a lot of distress because they go over and over the same stuff. This can be guilt, resentment, self-pity, righteous anger, whatever. Not many things are as distressing as chewing over the same lament endlessly. The sufferer wants to stop -- but the resistance, the struggle, only adds power to the endlessly repeating internal dirge.

   Ruminative thoughts are at the base of much depression, anxiety, anger and even substance abuse ("I can only get a good night's sleep by getting pissed"). They lead to insomnia, which then causes a lot of secondary problems.

   Perhaps my most interesting example is Craig, a 42 year old current client. He is a sort of reverse Walter Mitty: he has repeating, vivid automatic scripts in which people stand around him: berating him, humiliating him, making him feel like crap. As far as he can remember, this repeating scene has never occurred in real life.

   We have tried various ways to deal with his repeating internal script. I tried Steve Hayes' "Radio Doom and Gloom," except that I made it a TV. Craig has often been in a room with the TV on, but paying no attention to the images on the screen, or the sounds coming from there. However, treating the internal horror show like this has not worked.

   I tried Edna Foa's method: setting aside a time, and then deliberately replaying the internal script over and over, inviting the negative emotions and fully experiencing them until they fade. Craig just couldn't do it.

   Then he invented his own method. He invited the script, but modified it: cowering on the ground as usual, he pulled a gun from his pocket and in imagination shot his torturers. This has worked for him.

   The paradox is that two techniques with a great deal of research support did not.


   My next case is a 12 year old girl we'll call Monique. When she was 3, her uncle sexually abused her for the first time. The abuse continued for years, until Monique's mother discovered it. The uncle was jailed, leading to a permanent split in the family.

   Monique is doing poorly in school, several years behind. She is very shy and withdrawn, and tends to go off into a dreamlike state in which her mind is a blank.

   In 2009, she was at a sleepover birthday party of a friend, when a man sneaked into the room where Monique and another girl slept. He sexually assaulted both girls. Fortunately, the other girl managed to scream.

   A few months later, a 15 year old boy living in the same street told Monique she had to come into his house with him. She didn't want to go, but went anyway. He then had sex with her, and again, she didn't know how to resist. Then he openly bragged about it at school, and spread the word that she is "a slut" and "asked for it."

   This little girl has an abhorrence of physical contact, even with her parents. She is terrified of many things and hypervigilant for danger. She is very childlike in her mental makeup. Although she is through puberty, she acts and looks like a shy 10 year old with bumps. She distrusts everyone except for her immediate family, and has a particular fear of males.

   The paradox is that, nevertheless, two predators had no trouble in getting her to comply with their demands.

   As you may imagine, therapy with her was hard work, but I am glad to say her PTSD symptoms have stopped, and she is now improving in her studies.


   I work a lot with people struggling with substance abuse. The 12-step model pioneered by AA has a very high success rate, though it doesn't suit everyone. The paradox is that the AA model is in complete opposition to something we routinely do in therapy: personal empowerment.

   AA is adamant that if you're an alcoholic, you cannot beat the addiction. Before you can start, you need to admit that by yourself you are helpless. You need the help of a Higher Power, and that of your friends in AA.

   And yet, if you want to describe psychological therapy in one word, it is empowerment. My job as a therapist is to engender hope, from the first session on.

   Sue came to me as a victim of crime. We had 20 sessions before terminating. She returned a year later under Medicare, and we had a further 18, although I think she kept spinning it out to maintain contact. By the end, she had kicked out her abusive husband who lived off her earnings as a taxi driver, made friends with her estranged kids, and was free of both alcohol and tobacco.

   These were remarkable achievements. She'd had her first drink of brandy at 4 years of age, and her first cigarette at 7. As a little child, she was taken away from her parents, and put in the care of the local policeman. This fellow sexually abused her for years.

   When she was returned to her parents, she freelanced after school as a child prostitute, doing fellatio on men in order to feed herself and her younger siblings, because the parents weren't doing so.

   When I met her, Sue was struggling with alcohol. Also, she smoked 70 cigarettes a day, although she is a very small person. She suffered emphysema, but found it impossible to cut down.

   I encouraged her to join AA. When we terminated for the first time, she was the secretary of one of the local groups, the treasurer of another, and was mentoring several people. During our second year of contact, she managed to stop smoking (after the 3rd serious attempt during this time), and last I checked, she was still off both poisons.

   So, at the same time, she admitted her helplessness and surrendered to her Higher Power, while gaining immense self-confidence and inner strength. She fought for months against police reluctance to prosecute a retired old policeman, and eventually got him to court and convicted. As I said, she also turned a miserable family situation around.

   You can see why she is one of my favourite clients of all time.

   While we're on addictions, let me tell you about an episode during my training as a nurse. We were shown a movie of how a hospital burned down, because a man smoked a cigarette and hid the butt (in the laundry chute). It was a deliberately traumatic story. The response of several of the girls? When it was over, they just had to go outside to have a smoke, in order to calm down!


   Since we have the time, I'll mention Gary, who saved his marriage by applying a paradox. He had a wife and two lovely little sons, a responsible job he was doing well -- and the DSM definition of depression could have been written for him.

   When he came home from work, all he wanted was to be alone. He was grumpy, and often the kids were scared of him. His wife threatened to kick him out unless he changed.

   We did many things together, but the intervention that started his recovery was my dictum: whatever depression tells you, do the opposite. During his lunchtime, he went to the library near his workplace and borrowed kid books, and toys from the associated toy library. When he arrived home, he spent 20 minutes in the car, doing mindfulness meditation, which I taught him. Then he went in with a big smile on his face. He read the book, and played with the toys. I told him this was simply a job he had to do. He had to consider himself to be a paid child entertainer.

   However sad and grumpy he may have felt inside, he had to do his work and make his kids enjoy the half-hour before dinner. And of course emotion eventually followed behaviour. In fact, he told me in our last session that he'd stopped the meditation in the car, because he was so keen to go in and play with his sons.


   I could keep going with further examples till the cows come home. But I hope you've got the idea: if you want to be an effective therapist, forget logic. Embrace the paradox.


   Not part of the talk, but more than relevant to it is something I have read in an unpublished Ph.D. thesis by Asanti Hart: "The desire to escape suffering [is] one of the greatest impediments to resolving suffering."