Book review "Clinical Intuition in Psychotherapy: The Neurobiology of Embodied Response"

Clinical intuition is something that in formal learning terms is intangible, but in practice is earned and relied upon as a gift of experience. When I first received this book from the author Terry Marks-Tarlow, leafing through I thought the emphasis was on the neurobiology presaging a rather technical read. The references to brain structures, neocortex, brain waves ... seemed to suggest a reductive approach, remote from my conception of intuition in clinical practice. I need not have worried, the initial discussion on the brain and evolutionary development is not just a foundation for what follows but as the title suggests underpins and integrates the whole text. Despite the title and as the foreward advises you do not have to be a psychotherapist to read and appreciate this book. The stall is set from the outset in the introduction which explains that chapter one defines clinical intuition:

Clinical intuition is defined from a neurobiological perspective as a right-brain, fully embodied mode of perceiving, relating, and responding to the ongoing flows and changing dynamics of psychotherapy. (p.3)

The introductory material here is essential foundation reading for people starting a career in psychology and mental health related disciplines. The evolutionary development of the brain from reptile through to the mammalian brain is invaluable. Tying this to specific brain functions and circuits - care, fear, panic, play, lust, rage and seeking - helps integrate brain anatomy, perception, emotion, and behaviour. The advances in neurobiology to follow will no doubt demand that we all extend our understanding of this interdisciplinary fusion.

Clinical Intuition in Psychothreapy

The book itself (hardback edition) is very well produced, the type face easy to read and the book well structured and with a well balanced mix of illustrations and photographs. The reference listing at the end runs over thirteen pages and is well grounded historically and in having regard to ongoing research. The index is comprehensive (fourteen pages) and a resource itself providing a look-up approach. The book's use of case studies, thirteen in total informs the text and provides some continuity through the book. Dialogue between therapist and client is easy to follow and illustrations are provided with ample explanation in situ. The references also utilize web-based resources.

I recall intuition coming up as a thread on several occasions on the psychiatric-nursing list especially between 1998 and 2004. Intuition is a central quality for all personnel working in health and social care. We must also recognise intuition as a human trait as when non-health professionals exercise the judgement that: "Wait a minute, we need a clinical opinion here." Self-care is also discussed. I had a Pythonesque moment - "Is this the right room for an argument?" - considering psychotherapy as a therapeutic modality within therapies as a whole. Here in the UK (and no doubt elsewhere) self, brief and solution based therapies rule economically. Even though the shortage of psychological intervention is recognised in the UK through IAPT improving access to psychological therapies, we need to ask: how does psychotherapy fare in the current (austerity) climate? To what extent can clinicians exercise intuition? Therapy relies on caseness, relationships and narrative, but to what extent can these be acknowledged and delivered within the economical time frames that frequently operate? 

Although there's no specific chapter on training for clinical intuition, Marks-Tarlow provides a list of how researchers have characterized clinical intuition (more recently in the 1980-1990s); five characteristics are proposed:

• Sudden recognition;
• Immediate knowledge;
• Emergent awareness;
• Non-verbal insight; and 
• Holistic integrative sensibilities. (pp.42-43).

 Of the first two sudden recognition and immediate knowledge, I thought of the intuitive sense that is applied upon receiving a referral. That is the assumptions (not always helpful) that arise from the information provided (and missing) and where this leads you? But of course, is this clinical intuition? Intuition as the author makes clear (p.3 and) throughout the book is in psychotherapy. Intuition here (and for me) depends on interpersonal - therapeutic - interaction. What precedes is something else (data integration, hypothesizing, reasoning...?). I can however still see explanatory avenues in the above that can help us travel from the conceptual (reduced) to a holistic whole. I did wonder about the role of intuition in suicidal ideation and risk management, but this is also a question of referral criteria and caseness.

I would very much like to write myself about information and complexity and these themes recur in the text, especially the latter. Several 'spaces' are discussed too: social, physical and spatial schemas. The work of Buzsáki on the hippocampus, navigation and maps - landmark navigation - is fascinating in chapter 7 Navigating the Seas. I have likened Hodges' model to a cognitive periplus - an ancient maritime map. Over the next few months I'll post some quotes from the book.

This is an excellent book that I heartily recommend. The discussion of what is implicit in the brain and so in therapy, what is embodied and wisdom in mentoring invites re-reading. Finally but vitally there is much humour and humanity here too.

Many thanks to Terry Marks-Tarlow for the review copy.