A few weeks ago I wrote about the three reasons motivation is the most important force in therapy.
Clients only take action if they are motivated.
Interventions only work if clients are engaged.
Most therapy problems are motivation problems.
This week I want to give a case study [1].
When I was in my doc program I started babysitting to make some extra money. One of the kids I was babysitting was a little girl who lived with her aunt. After I met with the aunt for the first time she asked me a question.

"I know you're in training to become a counselor," she said. "My niece is wetting the bed. Do you think you could help her? I've tried everything and still every night her bed is soaked."
I was excited. I’d just finished my hypnosis training with the great Douglas Flemons and had religiously read his book Of One Mind. In that training I'd learned that hypnosis was a great intervention for mind-body problems, and what was more mind-body than bed-wetting?
I said yes.
From the start I did all the things I was taught to do. I talked about body awareness. We drew pictures of her body. I had her imagine closing the "gate" to her pee at night.
I was in the dissertation phase of my Ph.D and didn't have any course work, so I saw this kid 3 times a week. After two weeks of all my interventions the girl was still peeing the bed every night.
I thought maybe the problem was the kid wasn't motivated. So I worked with the aunt and we gave the kid more responsibility, which she readily took. She started doing all her own laundry every morning before school. I thought this would help.
It didn’t. A few more weeks passed and she still peed the bed every night.
I couldn't understand it. The way they talked in all the books, bedwetting was one of the easiest things to treat with hypnosis. But I kept failing. I emailed Douglas Flemons, the trainer who did my hypnosis training, hoping he'd have advice.
His response to my email? "It's easier if we just talk. Would you like to do a call?"
Douglas Flemons, my therapy idol, was offering personalized case consultation FOR FREE.
I said yes.
“It seems to me you’re working more with her on how to be responsible. That's a very behavioral approach,” he said in our consultation. “Try working with her more on coordinating with her body and her unconscious.”
I believed him, but I also asked a question. “I already tried the play techniques you taught us in your training. It seems to me, the kid isn’t really in trance when we do the imagery work.”
“Well kids are always kind of in trance. So you don’t really have to do formal hypnosis. Imagery and play should work. Find what she likes and use that as a metaphor for her body.”
Find what she likes. She was into tennis, so I got some kids tennis rackets and we played with them for the next few afternoons, and afterwards we'd talk about how tennis pros like Serena Williams have amazing body control.

She kept peeing the bed. Every. Night.
At this point over two months had passed. Nothing I'd done had helped, so on a Thursday I sat down with the aunt and basically told her I was out of ideas.
I was pretty embarrassed. As I packed up to leave I asked, “is there anything else you’d like my help with?
“Well, she sleepwalks at night. Could you talk to her about that?”
WHAT!?

“Can you do something for me?” I asked.
“Sure.”
“The next time she’s sleepwalking, tell her to go to the bathroom.”
“Oh. Okay.” She said.
I called the aunt that following Monday.
“It didn’t work.” Aunt said.
“What do you mean? What happened?”
“Well, The other night she was sleepwalking and I told her to go to the bathroom and she did but she just stood there. And then in the morning she’d peed the bed.”
YES!
“I’m sorry. I should have been more clear. You told her to go to the bathroom and she did. Next time tell her to go to the bathroom and pee in the toilet. The wording is very important.”
On Tuesday I showed up for my normal babysitting hours.
“It worked!” aunt said. “She peed in the toilet.” Niece had had her first dry night in years!
That began this snowball of success with this kid. She had dry night after dry night and a few weeks later went on her first sleepover.
Most of the time trainers tell stories like this to show how powerful their approach is or to show how clever they are. Both hide the real underlying reason this worked out so magically.
First, clients only take action if they are motivated.
Looking back, I'm amazed the aunt followed my suggestions.
I mean, “talk to your niece when she’s sleepwalking”?
Really? Most would have said, “yeah sure,” and rolled their eyes as soon as I left.
It just sounds crazy.
Of course I could have explained it to her. I could have said, "you know sleepwalking is a naturally occuring hypnosis-like state. So suggestions to 'pee in the toilet' are more likely to work while your niece is sleepwalking."
That might have worked. Or it could have made her think I was even more of a crackpot.
As much as I'd like to claim that my intervention was a bit of brilliant puzzle solving, I think the truth is I got lucky.
That intervention worked because the aunt was motivated to try it.
Second, interventions only work if clients are engaged.
Therapy interventions, especially intrapsychic ones, work best when clients are willing to fully engage with them.
The kid was willing to engage with her aunt. And to the aunt's credit, she handled the situation really well. When the kid just stood in the bathroom the aunt could have gotten frustrated and snapped at the kid.
This could have started a cycle of rebellion where the kid would sleepwalk to the bathroom to pee on the floor as an unconscious rebellion against the aunt.
More likely, if aunt had snapped at her, kid could have experienced a lot of shame and shut down everytime the aunt told her to go to pee. This shutdown would have been akin to an unconscious free response, similar to women who are assaulted and "freeze." It's not a conscious response or something their bodies do on purpose, but rather just something the body does automatically.
But the aunt didn't get frustrated. She was very kind and patient with her niece, which allowed niece to fully engage.
The intervention worked because the kid was fully engaged.
Third, most therapy problems are motivation problems.
Most therapy problems have a motivational split. Part of the client wants to change and part of them doesn't.
This kid didn't have a motivational split. This kid wanted to stop peeing the bed, so much so that she was willing to do her own laundry. Once the suggestion was brought up the niece never fought it. The aunt showed the niece once how to load the washing machine. The niece would get herself up early, load the washing machine, pour in the detergent, and get ready for school. All aunt had to do was to push 'start' because the niece was too short to reach the button.
This problem was easily resolved because kid didn't have a motivational split.
Conclusion: It's important to remember that motivation is the most important force in therapy because...
I tell you this story for two reasons.
First, because I think it shows how motivation is the foundational force in therapy. I could spin this story as a testament to my brilliance. How I, with Sherlock Holmes like insight, cracked the case of the 7 year old bedwetter. Elementary.

But so much of what happened was built on top of both the niece’s and aunt's motivation.
Second, because I think it also makes clear that motivation isn’t the only force. The niece was not in a deep enough state, through play, for my suggestions to take root. And once she was in a deep trance state (via sleepwalking) the suggestions worked.
Our interventions matter. What you learn in your grad program matters. What you learn in your CE course matters. Of course they do.
They just rest on the foundation of client motivation.
Best,
Jordan (the counselor)
Note:
[1] This case report has had important details changed to protect identities and privacy where necessary.
Paul Peterson and Jordan Harris are co-founders of Private Practice Incubator, a consulting firm dedicated to:
Helping clinicians earn more money.
Helping clinicians help more clients.
If you'd like to learn more about launching your practice, visit us here.
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