Article by Terry Marks-Tarlow in The Neuropsychotherapist

Psychotherapy is serious business. Our patients frequently face life-and-death issues on the opposite end of the spectrum from fun and games. 

Psychotherapists harbor a tremendous amount of responsibility when encountering deep unhappiness, trauma, and at times, unthinkable horrors within their patients. Given such a somber state of affairs, what does play and creativity have to do with psychotherapy? 

From an evolutionary perspective, play became highlighted in the mammalian brain in service of open growth and flexible adaptation to ever-changing environmental conditions. Through play, young children learn the roles, rules, and relationships of culture, while expanding their window of tolerance for a wide range of emotions—areas that overlap tremendously with the domain of psychotherapy. Through play, children push to their very edges of what is tolerable and understandable as they wrestle, spin, twirl, hurl, and leap into novel states of mind. Certainly, novel experiences are necessary for change within psychotherapy. Apart from other mammals, children’s play is uniquely characterized by imagination— an important aspect of the psychotherapeutic process that has been historically overlooked and theoretically undervalued. When lost in the fun and pleasure of a moment in play, children explore novel forms of thought, speech, action, and social interaction. Meanwhile, novel response is the hallmark of full engagement and healthy adaptation within psychotherapy. 

Both developmentally and within psychotherapy, play that engages creative imagination represents a safe way to experiment with people, objects, concepts, and culture at the very edges of being and becoming. Carl Rogers (1954) was a pioneer of psychotherapy in the middle of the last century who recognized the need for open, flexible minds. In his pearl of an essay, “Toward a Theory of Creativity,” he asserts presciently: 

In a time when knowledge, constructive and destructive, is advancing by the most incredible leaps and bounds . . . genuinely creative adaptation seems to represent the only possibility that man can keep abreast of the kaleidoscopic change in his world. . . . Unless man can make new and original adaptations to his environment as rapidly as his science can change the environment, our culture will perish. Not only individual maladjustment and group tension, but international annihilation will be the price we pay for a lack of creativity. (p. 250) 

Rogers defined the creative process as “the emergence in action of a novel relational product, growing out of the uniqueness of the individual on the one hand, and the materials, events, people, or circumstances of his life on the other” (1954, p. 251). By not restricting creativity to some particular content, his definition includes ordinary activities like discovering new sauces in the kitchen, or finding a clever new technique to communicate in our offices or to students in the classroom. Scholars often distinguish between “Creativity” with a big “C” versus “creativity” with a little “c.” The big “C” variety is reserved for geniuses and savants who make major discoveries in science or who usher in new forms in art. The little “c” variety involves the creativity of everyday life, which includes micro-acts of novelty, spontaneity, humor, and improvisation that help each moment to sparkle and each day to stand out from the last. 

When patients enter psychotherapy for trauma, the therapeutic process frequently involves the reduction of negative symptoms, including crisis resolution. Psychotherapists privileged enough to extend treatment beyond the short term often enter more positive realms of deep connection and personal growth, which is where new unfoldings of personality become possible. Perhaps the most important little “c” type of creativity involves the creation of one’s self throughout the lifespan. Within psychotherapy, the task of self-creation and the co- construction of the self, become emergent relational processes. A playful attitude in therapists promotes an atmosphere of safety, support, and nonjudgment for patients and sets the foundation for novel response and creative shifts. Simultaneously, a playful attitude helps therapists to stay curious and engaged, which protects them from burnout and empathy fatigue. 

In so many ways, play and creativity speak to the heart and soul of what all psychotherapists engage in, or perhaps should engage in doing! 

In their classic text, Kluckholm and Murray (1953) assert that each person is simultaneously “like all others”, “like some others”, and “like no others”. We each resemble all others in how our mind/body/brains are wired and in facing the same laws of nature and basic existential conditions of life. We resemble some others by being inherently social creatures who participate in collective activities and social groups, as defined by culture, ethnicity, attachment style, sexual orientation, religious affiliation, etc. We resemble no others in how our many facets combine uniquely into precise developmental and family histories plus life trajectories. 

When Kluckholm and Murray’s formulation is applied to the enterprise of psychotherapy, being like all others leads researchers to conduct outcome studies in search of universal factors. Candidates include the quality of the therapeutic alliance (Geller & Greenberg, 2002; Messer & Wampold, 2002) and memory reconsolidation, by which newly updated associations replace outdated, traumatic, or dysfunctional memories (Lane, Ryan, Nadel, & Greenberg, 2015). These pan-theoretical factors cross-cut all schools, orientations, and modalities of psychotherapy. 

Within psychotherapy, our resemblance to some others highlights the issue of diversity. True empathy mandates psychotherapists to understand the social, cultural, and historical frames of reference of the people with whom we work. Meanwhile, symptom-focused approaches to treatments classify people into groups based on genetic factors and diagnostic categories. Whether people are grouped in terms of heritage, habits, or symptom clusters, no matter how sensitively this is done, psychotherapy necessarily proceeds according to generalizations, broad formulations, and/or prefabricated treatment techniques. 

It is Kluckholm and Murray’s assertion that each individual resembles no other that invokes the realm of clinical intuition. In order for therapists to attend to the unique dynamics of this person, in this moment, given this attachment history, in this era, we must operate on the micro-scale of Daniel Stern’s (2004) “now” moments. This is where the minute-to-minute expression of who we are determines the precise dynamics and interpersonal chemistry of the dyad. Only through clinical intuition can body-based perception tune into those tiny shifts in emotion, energy, posture, and information that fly back and forth across the room, often under the radar of conscious awareness. The purpose of this chapter is to explore the creativity and play of clinical intuition as it emerges in the realm of the unique. 

Tuning in Through Clinical Intuition 

I define clinical intuition as the capacity to register and respond to interpersonal patterns in healing and growth- facilitating contexts (Marks-Tarlow, 2012a, 2014). Clinical intuition requires attuned response though which psychotherapists become anchored enough in their own bodies and perception to fully open their eyes, ears, hearts, and even souls without preconception. This is how we operate with full presence and authenticity, from the inside out, grounded within our own sensibilities, emotional experiences, and unique perspective. 

Whereas clinical theory offers abstractions that exist outside experiential realms, clinical intuition operates spontaneously, as a fresh response to a lived moment. No matter how many books we may read, workshops we may attend, or supervisions we may absorb, in the heat and heart of the clinical moment, we must put all of this aside. We render each moment both sacred and new partly by learning to bracket off past learning while laying future agendas aside. In this way, the science of clinical practice blends with the art of its timing through an unpredictable and present-centered dance of leading and following. 

Implicit Knowing 

Within talk therapy, attunement relates less to the content of speech, or what we say, and more to the processes of speech, or how we say it—tone and rhythm of voice (prosody), posture, body movements, facial expression, and eye gaze. These paralinguistic vocal, visual, facial, and postural cues are all part of the implicit relational knowing (Lyons-Ruth, 1998; Seligman, 2012), the primary form of learning and memory a baby uses during the first two years of life, guided primarily by right-brain processes (Schore, 2010, 2011). 

Implicit knowledge involves emotional, relational, and body-based experiences that precede later-developing, explicit, cognitive, and verbal faculties. Implicit processes shape Bowlby’s internal working models, helping us to form social expectations that determine relational openness or defensiveness and color the emotional tone of ongoing experience. I speculate that implicit learning and memory also account for the quality and landscape of repetitive dreams throughout life (Marks-Tarlow, 2012a, 2014b). 

Whether psychotherapists work with children or adults, in order to pick up on these tiny, multimodal, implicit cues, context is everything. Both during early development and within psychotherapy, the full context is always too complex for any complete verbal description or future prediction. This is one reason why parental and clinical intuition take on such significance and how-to books pale by comparison. Only through nonverbal, intuitive channels can we register the full spectrum of interpersonal data, by drawing upon immediate sensory, emotional, and imaginal cues (Marks-Tarlow, 2012a, 2014a). 

Because clinical intuition responds to nuance implicitly and subcortically, this is a fully embodied mode of perceiving, relating, and responding. In contrast to explicit levels of processing (e.g., thinking, analyzing, deciding), implicit responses are fast-acting and effortless; they operate automatically, in context, beneath the level of conscious awareness (Claxton, 1997). Implicit relational knowing draws more upon the right brain’s deep connection to the stress and emotion-regulating aspects of the autonomic nervous system (Schore, 2010, 2011). The importance of implicit relational learning to psychotherapy also has been underscored by clinical theorists like Daniel Stern (1985, 2004), members of the Boston Change Process Study Group (2008), and infant researcher Beatrice Beebe (Beebe et al., 2010; Beebe, Lachmann, Markese, & Bahrick, 2012). Beebe documents how tiny contingent moments of discordance or synchrony between caretakers and infants affect future attachment status. 

Due to the primacy of this mode during psychotherapy, I assert that clinical intuition is what fills the gap between theory and practice (Marks-Tarlow, 2012a, 2014a, 2014b). Where theory is static, intuition is alive. Where theory exists outside of real time, intuition involves immersion within lived moments. When clinicians become immersed in this fashion, we often attain states of flow (Csíkszentmihályi, 1990, 1996) with our patients. When in a state of flow, therapists get caught up in the throes of implicit processes as intuitively guided. This is the realm of intersubjectivity, where self and other become physiologically and psychologically, if not spiritually, entwined (see Marks-Tarlow, 2008a). Here, there may be emotional challenge, yet often little sense of effort. As therapists and patients ride the waves of interrelatedness, it becomes easy to find smooth rhythms of exchange. Time flies by. Psychotherapy can take on an all-enveloping quality of wholeness. This sometimes feels like a dance where exquisitely coordinated movements are choreographed by no one and both people at once. Or, verbal flows may feel like poetry in motion or a song of syncopated call and response. When psychotherapists are lucky enough to spend long periods intuitively immersed, despite intense, often negative emotional involvement, they can nonetheless leave work feeling energized and refreshed. Amid deep intuitive engagement, the relationship itself becomes vitalizing, pulling each person along, ideally nudging both into spontaneous, unexpected places. 

Because of the effortless, non-conscious way that clinical intuition operates, it becomes all too easy to overlook its importance in graduate and postgraduate training programs. Yet, with the current emphasis on empirically validated methods, if clinical intuition proves to be the most authentic and healing form of contact, I wish to boldly assert that it may be unethical not to pay attention to intuition as a vital dimension of clinical education. The issue is of crucial significance because clinical intuition appears necessary to fully tune into the uniqueness of each person and moment. The topic has hitherto received little formal attention because of the invisibility of its workings, its association with unscientific processes, as well as the difficulty of measuring its action. 

Fortunately, all of these conditions are now shifting due to the burgeoning field of interpersonal neurobiology (e.g., Badenoch, 2008; Cozolino, 2002, 2006; Hill, 2015; Schore, 2003a, 2003b; Siegel, 1999). This field deepens understanding of how relational exchanges tune the bodies, minds, brains, and spirits of individuals. Exciting advances in brain imaging increase capacity to measure two mind/body/brains in real-time interaction with one another (Babiloni & Astolfi, 2012; Dumas, Lachat, Martinerie, Nadel, & George, 2011). Much like clinical theory has moved form a one-person to a two-person psychology, clinical neurology is currently enjoying a similar revolution in perspective (Schilbach et al., 2013). We rapidly approach the day when the holistic workings of clinical intuition can be measured in real-life contexts. 

Within the enterprise of psychotherapy, clinical intuition appears to be a necessary, though not sufficient, condition for change. Intuitively attuned response provides the safety to release defensive stances in service of emotional risk-taking and novel exploration. The change extends in both directions. As our patients heal and grow through connecting to and trusting their own intuitive foundations, we therapists grow and heal alongside them. The personal and interpersonal growth involved keeps us fresh over many years, arising as a natural byproduct of deep and meaning-filled connection with other human beings. 

Keywords; Play, creativity, psychotherapy, Implicit Knowing, Clinical Intuition

This article is an excerpt from Play and Creativity in Psychotherapy by Terry Marks-Tarlow. 

https://www.neuropsychotherapist.com/play-creativity-psychotherapy/