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Milton Erickson’s Use of Implication By Steve Andreas

When children paint the sun, they often draw a circle with rays coming out. You’ve all seen that; you probably did it yourself when you were young. A year or so later, a child might paint the sun partly behind clouds. Several years later, they might paint rays coming out from the clouds, but the sun is not visible — what a friend of mine calls a “God sunset.” Even subtler is to paint only the scattered reflection of sunlight on water. An accomplished artist doesn’t paint the sun at all, but suggests where the sun is by painting a tree with a little more light on one side than the other, and a subtle shadow to indicate the sun’s location. I think that’s a good metaphor for implication: indicating something without ever explicitly stating it. One of my favorite quotes is: “The larger the island of knowledge, the longer the shoreline of wonder.” (Ralph W. Sockman) Knowledge and wonder are stated; the ocean of ignorance is implied.

On the first page of the first volume of Conversations with Milton H. Erickson, (in which the word “implication” appears about every third page) Jay Haley says, “I have a whole week, so I suspect I can learn all about psychotherapy in that time. I wouldn’t expect that anywhere else but here.” Erickson laughs and says, “Well, we can have our dreams.” That’s a polite way of implying, “You are wildly optimistic!”

When Erickson worked with an alcoholic, he would often say, “Bring a full, unopened bottle of alcohol with you to the next session.” The implication was, “Don’t drink,” and the deeper implication was that the client can control his drinking.

In working with couples, Erickson would often say to one of them, “I want to hear your side of the story. One implication is: “I also want to hear the other side of the story.” But, because of the word “story,” the further implication is a distinction between the “story” and real story. Virginia Satir made the same kind of distinction by saying to a family member, “I want you to tell me how you see the problem,” implying that there were other views.

Erickson would frequently say to a client, “I want you to withhold any information that you don’t want to share with me.” “Withhold” is not necessarily permanent; you can withhold for a while, and then you can yield. But the implication is: “Don’t pay attention to all the stuff you’re going to tell me; pay attention to the stuff you want to withhold.” So, clients would tell him many sensitive things, and most likely by the end of the session, would think, “Well, I told him all that other stuff, I may as well tell him this too.”

Erickson was in session with woman right before she was scheduled for risky surgery and she had doubts if she would be okay. He gradually led the discussion around to cooking, and asked about her favorite recipes. When she would mention something, he would say, “Oh, you know, I’ve always wanted a good recipe for that. Would you give it to me?” Of course, she couldn’t give it to him in that session because she was due to have surgery, so he’d say, “Oh, that’s all right, you can bring it in when we have our next session,” implying that the surgery would be successful.

I went to see Erickson in 1979, about a year before he died. In the middle of the day, seemingly out of nowhere, I heard him say, “Marry an ugly woman and she’ll always be grateful.” I thought to myself, ‘What an awful sexist thing to say!’ At the time, I was with a woman who I — and many others — thought was quite beautiful. The implied message is: “Marry a beautiful woman and she won’t always be grateful.” I didn’t understand that consciously until after the woman and I were married.

Erickson once worked with a woman he called, “Inhibited Ann.” Shortly before bedtime, she’d start gasping and choking, which interfered with her having sex with her husband. In order to be physical with him, the woman insisted that the lights be out, so that she could undress in the bathroom, put on a long robe, and then, covered head to toe, she’d come into the bedroom in the dark and get into bed with her husband. After finding out that Ann loved to dance, Erickson said, “You know, you could dance into the bedroom in the nude.” And then said, “We don’t want to give him heart failure,” implying, “We do want to give him something else.” Then, later in the session, Erickson said, “You really could dance into the bedroom in the nude. You’d be in the dark with all the lights out, so your husband can’t see anything, and he’d never know.” So Ann took his suggestion, danced in the nude in the dark, and then crawled into bed feeling like a school girl, giggling about doing something so daring. Giggling implied not gasping, and not gasping implied availability for sex.

On another occasion, Erickson worked with a professor of music who fainted whenever he tried to go onstage to give a piano performance. He told Erickson he was going to be fired from the university if he didn’t perform. So Erickson said, “Okay, ahead of time, put down towels of different colors all the way from the backstage up to the piano. Then, as you walk onstage, decide which one you’re going to faint on.” Involving the professor in a decision process implied that he would not be attending to whatever thoughts made him faint in the past. Since fainting is elicited unconsciously, the implication is he won’t faint at all. And since you have to faint where you are, not somewhere else, thinking about fainting there implies not fainting here.

This same intervention saved Erickson’s life once. When he was working in a mental hospital, he walked into an elevator and per regulation, locked the door behind him before realizing that there was a murderous psychopath in the corner, who said, “I’m going to kill you.” As Erickson always did, he first paced what the psychopath said, and then replied, “Oh, okay, you’re going to kill me…” as he put the key in the elevator door to unlock it, “and the only question is, ‘Where do you think the best place would be for you to slaughter me?’” Erickson opened the elevator door, pointed down the hall and said, “Would over there be best?” The psychopath looked out into the hall as Erickson calmly walked out of the elevator, saying, “Or, maybe over there in that chair would be better. But then again, over there might be best.” Erickson continued walking down the hall toward the nurse’s station, and to safety. Since there is not where he can be slaughtered, he distracted the psychopath from killing him where he stood.

Learning about implication is similar to opening another set of eyes and ears; seeing and hearing in a whole new dimension. It’s spooky the things you can become sensitive to, particularly nonverbal implication. I believe that Erickson’s unparalleled ability to “read” people was largely due to his ability to notice and use implication.

In earlier issues of the Newsletter I have written more extensively about both verbal and nonverbal implication. (Vol. 23, No. 1; Vol. 24, No. 1; Vol. 24, No. 2)

* Edited from a dialogue between Jeff Zeig and Steve Andreas “Experien- tial Approaches: The Power of Impli- cation” at the 2014 Brief Therapy Conference. BT14-D02

Eye Movement Desensitization and Reprocessing Dr. Francine Shapiro’s Therapeutic Approach Summarized by Murriel Schulte, Ph. D., Dallas, TX

“From 0 to 10, with 10 being high, how would you rate your current level of distress?” With his rating, the client is asked to keep the most distressing picture of his presenting event or memory in mind; then, to identify where the feeling lodges in his body; and lastly, to identify his associated negative cognitions that go with the problem–such as “I’m help-less,” or “It’s my fault.” Continuing with his images, feelings, and thoughts, he is kept grounded in the present through the clinician’s interactions with him. The eye movement stimulation (or possibly an alternate form, auditory or tactile, of left-right lateral stimulation) is then introduced. He is intermittently asked for his rating of his distress on a scale of 0-10–the Subjective Unit of Disturbance Scale (SUDS) while he is processing the trauma, until the point when his memories have lost their disturbing power. This recursive procedure is maintained until he has desensitized his difficult memories and until positive self-cognitions have replaced his negative self-cognitions. When his negative images are dissipated, he is asked to rate the believability of his alternative positive cognitions on a scale of 1(completely untrue) to 7(completely true)–the Validity of Cognition Scale (VOC). From having spoken of his negative cognitions initially, he now speaks of what he would rather believe about himself, his positive cognitions.

In the EMDR process, something creative happens; with an almost surprising acceleration, images, memories, associations, thoughts, and emotions are often brought forth rapidly into a client’s mind. In reliving events, the client may emote in rage, grief, or fright. After EMDR therapy, he is not simply desensitized or less anxious; his thinking has changed. In the course of one or more sessions, the former memory has lost its power. The EMDR process posits that trauma teaches maladaptive lessons that can be unlearned. The speed of change and the lasting resolution with EMDR are reported to be the most appealing aspects to clinicians of this psychotherapy.

The founder of EMDR, Francine Shapiro, Ph.D., is the executive director of the EMDR Institute, Inc., and a Senior Research Fellow at the Mental Research Institute, Palo Alto, California. She was awarded the 1993 Distinguished Scientific Achievement in Psychology Award presented by the California Psychological Association. She is the author of three books: Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures (1995), EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma (1997), and the forthcoming EMDR and the Paradigm Prism (American Psychological Press). Training in the EMDR techniques through the EMDR Institute is mandatory for clinicians. According to Dr. Shapiro, it is a specialized approach and method that requires supervised training for full therapeutic effectiveness and client safety. To date, 30,000 clinicians have been trained throughout the world. Level I EMDR training centers on how to desensitize traumatic memories, anxieties, and phobias, and to install positive belief structures. EMDR has applications to natural disasters, family therapy, Post-traumatic stress disorder (PTSD), children and adult survivors of abuse, adult children of alcoholics and for the personal use for the therapist to process vicarious imagery overflow from traumatized patients. Level II Training has applications for Dissociative identity disorder, Axis II diagnoses and other major disorders.

According to Bessel A. van der Kolk, M. D., “The speed at which change occurs during EMDR contradicts the traditional notion of time as essential for psychological healing. Shapiro has integrated elements from many different schools of psychotherapy into her protocols, making EMDR applicable to a variety of clinical populations and accessible to clinicians from different orientations.” Early inspiration for EMDR was in 1987, when, as a graduate student, Dr. Shapiro discovered the technique as she was walking in a park. She had been troubled by some old memories and disturbing thoughts. Her painful memories seemed to dissolve as she moved her eyes rapidly back and forth. She was amazed by her own discovery, gathered volunteers to experiment with this process, and then, organized formal research to test this discovery.

In 1988, she approached Joseph Wolpe, the originator of systematic desensitization, to teach him her method and to ask him to publish her paper in the journal he edited, The Journal of Behavior Therapy and Experimental Psychology. He experimented with EMDR, and published her article and one of his own case studies using EMDR in the journal. He stated that with EMDR treatment for PTSD “there is often a marked decrease in anxiety after one session, and practically no tendency to relapse.” In 1989, she published her research, “Eye movement desensitization: A new treatment for post-traumatic stress disorder,” which was then followed in adding ‘reprocess-ing’ in the 1991 article, “Eye movement desensitization and reprocessing procedure: From EMD to EMD/R: A new Treatment Model for Anxiety and Related Trauma.” From these original studies, a great deal of other research has followed, until, to date, there have been more controlled treatment outcome studies on EMDR than on any other method used in the treatment of PTSD.

One controlled study by Wilson, Becker, and Tinker (1995), evidenced the effects of three 90-minute EMDR treatment sessions on traumatic memories, working with 80 participants. These subjects revealed decreases in their presenting complaints, and in addition, reported increases in positive cognitions. The general functioning of these participants improved, with less depression, fewer somatic complaints, and improvement in self-esteem. These positive effects were maintained at a 90-day follow-up.

In 1998, a meta analysis of 61 studies compared the efficacy of several treatments of PTSD–drug therapies, behavior therapy, EMDR, relaxation training, hypnotherapy, and dynamic therapy–found that behavior therapy and EMDR were most effective. By self-report assessment, EMDR was the most effective treatment. Treatment effects were maintained at a 15-week follow-up. The meta analysis reviewed the theoretical bases for all treatments and summarized that EMDR maintains these treatment components: “imaginal exposure with concomitant lateralized movements, along with coping statements.” The provisions for how EMDR works is unclear. It is unknown as to “what changes occur in what part of the brain, how oscillatory movements are involved in those changes, how that leads to ‘reprocessing’ of the trauma, and how such reprocessing results in decreased PTSD symptoms. . . . Clarification of the mechanism by which symptoms change and the active ingredients in EMDR is now critical, given its apparent efficacy. Without such clarification, the acceptability of EMDR within the professional community is likely to remain controversial.”

Wilson, S. A., Becker, L. A., and Tinker, R. H. (1995). Eye move-ment desensitization and repro-cessing (EMDR) treatment for psychologically traumatized individuals. Journal of Consulting and ClinicalPsychology; 63, 928-937.

Van Etten, M. L., and Taylor, S. (1998). Comparative efficacy of treatments for Post-traumatic Stress Disorder: A meta analysis. Clinical Psychology and Psychotherapy; 5, 126-144.

Business as Usual by Carl Hammerschlag, M.D.

A middle-aged man came to see me under pressure from his wife. She had told him she would leave if he didn’t make some life changes. Both husband and wife expressed that their marriage was very important to them, but it was clear to us all that their marriage was near collapse. He told me he did not know what the problem was even though his wife had complained about his commitment to his work for many years. He acknowledged that he was highly committed to his work, but said it was important to them both and that he was very successful. He wasn’t completely aware, nor was he in agreement, that his business interfered on other levels of their lives.

His wife described the man’s work as his mistress and his only interest and hobby. He didn’t even take vacations without sleeping with his telephone by his side. At, and away from, home, where he wasn’t talking business he was reading financial magazines. He was not interested in his wife’s activities and was unwilling to converse about things of interest to her. They had virtually no social life as a couple.

When he arrived at my office the first time, his cell phone was clipped to his belt. He explained he was waiting for an important call. When it rang, he interrupted our session to talk at length on the phone. When I asked him if he thought the information that he was going to get from the phone was more important than what he might learn in my office, he replied without hesitation, that it was business and therefore very important.

I told him that if he couldn’t pay attention here in my office, it was clear to me he would not remain married. I asked him to turn the phone off. Reluctantly, he did so.

During the course of therapy, he agreed to follow my directions regarding an important intervention that I told them, could save their marriage. I prescribed what I knew would be an ordeal for him. He agreed to go on vacation with his wife to a place without a telephone or fax machine close by. He also agreed to let me provide all his reading material. I gave him a sealed package which I had already prepared.

His wife later reported that when they arrived at their destination, he opened the package and cursed, threw it against the wall and stormed out of the room. Inside the package was only one book. When he opened it, he discovered there were only blank pages and a pen. On the inside cover, I had written, “Dear John. Fill this book with whatever makes sense to you at the moment. You can choose to write in dialogue or in simple prose but you must write in this book every day. I ask that you to come to this task with openness and truth, and to tell the truth of your experiences at that moment.”

He cursed, threw the book against the wall and stormed out. His wife picked up the book and read my note. When he returned, and continued to rail on, she said, “Why not write this down?” She pointed out that writing about how angry he felt might be useful for him and would certainly provide a topic for later sessions. Her words struck a key with him.

Later in the vacation, he found an interesting stone that was covered with lichen. He knew lichen was an organism formed by a combination of fungus and algae growing as a unit on a solid surface. Picking up the stone, he inserted it into a hollow he created in the pages and began to write around it. “Everything grows connected to something other than itself.”

He began to describe himself as the lichen feeding from the impersonal rock of business. He recognized he wanted to find another way to thrive. This moment of insight became the beginning of productive therapeutic expansions and of rebuilding the marriage between two committed people.

I chose this somewhat ambiguous but potentially powerful intervention because of what I learned from Erickson and other medicine men I have known. They taught me that the most important knowledge is that derived from life experience not from theories or equations. If you can help people look again at their present experiences and at themselves with different perspectives, they can create new directions. The process of psychotherapy is to find creative ways through which you make the invisible visible.

Discussion by Ricky Pipkin, Ph.D.

Hammerschlag had a client typically considered difficult–a reluctant participant in therapy wanting a specific outcome without realizing that a generalized change must be made to reach that outcome. Additionally, this man was clearly successful in many areas of his life and accustomed to making fact-based business decisions. It often is easier to factor out emotional content and disregard the importance of feelings and, in business, it often is more efficient. However, this couple was highly motivated to keep their marriage which provided needed leverage.

The problem in the marriage was not a “business” one–it was that the wife felt discounted and unimportant. Hammerschlag’s problem was two­fold. First he had to capture the client’s attention; second, he had to make him understand that feelings and intangibles are important to a well-rounded life. As well as to relationships.

Directly confronting the inappropriate use of John’s cell phone during session and telling him that, what he learned in session could save the marriage was a business-like approach to a multi-level symptom. He used language that John was used to and could understand. John’s willingness to continue participating in therapy without using his phone created an implicit contract.

The sessions before the important intervention of the vacation were preparation for John to expand his own perceptions. Every act of insight, of expansion, is the result of the prepared mind and some serendipitous moment. Finding a rock with lichen, knowing what lichen was, provided John a metaphor of his own making. He recognized that even a lowly lichen is a union of different things, joined together to create a different and more complex organism. The needs of each part must be nurtured.

The simple moment of finding the lichen-covered rock and following, in his own way, Hammerschlag’s instructions, provided ways to understand himself differently. These changes were necessary in order for him to have what he really wanted-­the continuation of his marriage. This would not have occurred had not Hammerschlag first gotten John’s attention by using the techniques and language of business. Then, during the vacation, John was given only one concrete outlet for his thoughts and energies–self-examination in writing “the truth of his experiences of the moment.”

Erickson had a gift for creating and telling stories that patients could hear. He taught us all to look at our own blind spots and how to reach beyond them. Hammerschlag provided that for John by setting the stage for him to tell his own story about his own blind spots and to understand how to reach beyond them by the seemingly simple ambiguous and open assignment of writing on the blank pages , ”with openness and truth.”

Obviously, there was careful preparation so that John would be willing to go on vacation with no phone, fax or business reading materials. Hammerschlag’s success also demonstrates the value of using the client’s own language and world. The implicit contract between Hammerschlag and John insured that the directions would be followed even though, as business, John could implement them in his own way.

Good therapy often appears much simpler than it actually is.