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Ericksonian, Cognitive, Behavioral, Strategic, or All Four? Betty Alice Erickson Estimated reading time: 28 minutes, 8 seconds.

When I read about the different schools of psychotherapy or hear addresses by leaders in various methods of therapy, I often have difficulty sorting out what is Ericksonian and what is better named strategic or brief or cognitive or behavioral therapy. Sometimes, it all seems to be the same. And most of the time, it doesn’t matter what the method is called as long as the client receives the needed help. I do think, however, that understanding the basics of Ericksonian psychotherapy and seeing their connections to the multiplicity of current therapies gives modern therapists clarity to define their own stances and philosophical frameworks. We all want to give our clients what they need in ways that are most palatable and understandable to them. Picking and choosing conceptualizations, approaches, and interventions from the various schools, becoming truly eclectic, is one way to do that.

Before Milton H. Erickson, M.D., there were just a few somewhat rigid theories, sweeping generalizations, and only a few “right” ways to do therapy. Therapy, once began, often became part of a person’s life essentially forever. It was not uncommon for a patient to see a therapist multiple times a week for years and years.

The patient’s personal history and recollection of past events were deemed of paramount importance. They were examined in great detail for reasons and understanding. Insight was a requirement for change. Change without insight was considered superficial and not long lasting; it was not really change at all.

Symptoms were regarded as entities in themselves – a behavior that was “needed” or required for the level of functionality that the patient displayed. “Curing” or altering a symptom was foolhardy. It was thought that the symptom well might reappear in a different, and probably more harmful, manifestation.

Psychotherapy, necessarily, became limited to those people who had the time, money, and energy to spend years examining themselves and their remembered past, and coming to insightful understanding about their present lives. Obviously, great numbers of people who had troubles and who were struggling to make better lives could not get psychotherapeutic help.

Erickson played a very large part in revolutionizing this way of doing therapy. He built a bridge between that kind of psychotherapy, the psychotherapy of his time, and his own conceptualizations and ideas. These ideas, these bridges, have helped create many of the modern schools of therapy.

Erickson believed that theories were too restrictive for the infinite variety and variations of the human race and the infinite creativity of human thinking and behavior. So Ericksonian psychotherapy has remained atheoretical. That may be good for the client, but it is not so good for ease of understanding by students. There is simply no way to fit what is done in Ericksonian psychotherapy into a neat tidy theory.

Nothing in Erickson’s life altered his fundamental belief about the inadequacy of a single theory of human function and dysfunction. His work in prisons and mental hospitals, the psychiatric examination of thousands of military inductees during World War II, his work with the courts and the legal system, his private practice, and his work with students all emphasized that people are different. People live functional, productive, and happy lives in an infinite variety of ways, and they think and behave in infinitely creative ways. Creativity and problem-solving abilities are the frameworks of human behavior.

In 1990, at the second Evolution of Psychotherapy Conference, Ar­nold Lazarus, who is clearly identified as a noted cognitive-behavioral therapist, alluded to that thought when he advocated a “flexible personal therapeutic stance that tries to calibrate the goodness-of-fit of the treatment to the client’s basic style.” He continues with the quotation from Erickson that Jeffrey Zeig and Stephen Gilligan use to preface the front of their edited book, Brief Therapy. “Each person is a unique individual. Hence psychotherapy should be formulated to meet the uniqueness of the individual needs, rather than to tailor the person to fit the procrustean bed of a hypothetical theory of human behavior” (1990, p. 103). (Zeig, in a footnote to Lazarus’ comment, explains the history of that quotation. Erickson selected it when asked for a statement for the promotional literature for the first International Congress on Ericksonian Hypnosis and Psychotherapy held in 1980.)

Erickson believed insight was not always important. He focused on productive change, with or without understanding and insight. The future was truly “yet to be” and was rarely ordained by the past. A person’s past was just that – past, even though personal perceptions of that past were highly changeable.

Therapy could often be very brief. There is a story Erickson used to tell. When he was growing up, there was a young man in his small home town who was well known as a troublemaker. That young man’s life was changed completely by just one moment of meaningful interaction. He asked the prettiest girl in town if he could take her to a Friday night dance. According to Erickson, she looked the young man up and down and said, “If you’re a gentleman, you can.” And so he became a gentleman. He turned his dysfunctional behaviors into ways of productive living. Was that really therapy? I am not sure. But I am sure that, without insight, and without examining his past, this young man rebuilt his life in wholesome ways that earned him more pleasure and rewards.

Understanding the concepts of how and why the man was able to change and move forward with his life, as well as concepts of Ericksonian psychotherapy overall, is central to comprehending the wide variety of therapeutic approaches competing for our attention today, including Strategic, Brief, Cognitive, Solution-Focused, and Behavioral therapy, among others. Many of these concepts, Erickson helped to create. Some of these ideas provided a foundation for changes and the current proliferation of a broad range of different orientations. And more important, many of these changes have become standards of modern therapy.

There are all kinds of ways to do therapy, but they include very few “right,” rigidly structured methods. Theories mostly have taken second place to practicalities, and people are recognized for their individualism and differences. Therapy is “supposed” to be quick, brief, goal directed, future focused, and aimed at returning the clients to more productive, and happier lives. Much of the time it is not necessary to understand the reasons for behavior; change is what counts. And all of these ideas were pioneered by Erickson. With the pace of life becoming faster and faster, and the increasing emphasis on immediate gratification, psychotherapy is almost certain to continue to move, in fact, to gallop, in the direction of brief, strategic, practical, reality-based, and future- and goal-focused work. Insight and the understanding of patterns, systems, and theories will probably become less and less important, although they will still be relevant. Managed care certainly approves of this trend, and will do its best to continue and promote it.

Any number of people and events have taken part in the inventing and reinventing of psychotherapy. Any number of dedicated professionals have been working, studying, and experimenting with the human condition for countless years. There has always been available a community warehouse and wealth of knowledge about human psychology. Therapists, known and unknown, have played significant roles in the creation and promotion of very important advances in psychotherapy.

Erickson was fortunate in that his work was studied by some very bright hardworking students who were able to take some of what he taught them and teach it to others. I do not mean to imply that Erickson was the sole originator of some of the ideas and techniques for which he has become so famous. But this chapter is about understanding the underpinnings of Ericksonian psychotherapy. All good and effective therapies have commonalities. Respect for the individual, plans for a productive future, enjoyment of life, the overcoming of obstacles, the promotion of self-responsibility are all hallmarks of a wholesome and responsible life and are all parts of good therapy. Certainly Erickson did not invent this!

His methods of achieving these goals were often very different from other methods. He understood the unconscious to be a storehouse of resources and abilities, he relied on the strengths of the individual, and he used the client’s own world, own resistance, as a tool for change. That, and his careful observation of and attention to details and language, created a framework of therapy so flexible, and yet so individualistic, that it is timeless.

There are inherent limitations in attempting to encapsulate an entire psychotherapeutic theory in a sentence or two. This is certainly true for Erickson’s multi leveled and apparently simplistic, yet complex, work. It is just as unfair to pull a sentence or two from other schools of therapy, and through these sentences show a connection to Erickson’s work. Additionally, much good therapy overlaps. Should a particular approach be identified as Cognitive? Solution-Focused? Behavioral? Strategic? Narrative? The subtleties between the different names are virtually impossible to sort out.

Here is where the one of the real gifts of Erickson’s works lies. His framework for psychotherapy was so flexible that many of his ideas and methods have been incorporated into other schools. Understanding the versatility and applicability of his work as a source for some of these conceptualizations and methods broadens perspectives and allows each of us to become just a little more knowledgeable about psychotherapy. Familiarity with his work, and with the work of those who studied with him, heightens our ability to view other branches of psychotherapy more clearly.

Casework done from an Ericksonian point of view blends with, and supports, other types of more “modern” psychotherapy. This is true even when at the surface the problem and the intervention are strictly Ericksonian. Hypnosis, for example, is inextricably linked with Erickson’s work. The underlying principles of much of the use of hypnosis, however, are the same principles that underlie other schools of therapy. Hypnosis is, after all, a technique for communication and for accessing the client’s own resources. In an article in the Milton H. Erickson Foundation Newsletter (vol. 16, no. 2), I described a client with whom I had worked who had been referred to me for hypnosis to help him learn to swallow pills. He had always found it difficult to take them, and, in childhood, his mother had accommodated him by crushing the pill and mixing it with applesauce. Later, he simply tried to avoid pills. And when he really needed to take one, he would grit his teeth and chew it no matter how bad the taste.

He now has a serious illness and must take up to 30 pills a day. Avoiding pills not only no longer is an option, but some of the tablets must be swallowed intact if they are to work effectively. He knew he was being illogical. He had no trouble eating, and realized that pieces of food he swallowed were often larger than tablets. He also could swallow gum. But he gagged if he tried to swallow pills.

I could have worked with this client about possibly unresolved issues with his mother. Perhaps he had a fear of self-responsible adulthood, and this was a symptom of deeper underlying issues. Perhaps his illness was so frightening that a part of him wanted to avoid medication, and this was one way to do it. Perhaps his habitual behavior precluded open and flexible thinking. I didn’t know, and I didn’t think it was important.

From an Ericksonian standpoint, the therapist works with the world of the client. This client’s world was simply that he wanted to learn to swallow pills – briefly, quickly, and without trying to know the unknowable reasons “why” he couldn’t.

Ericksonian therapists also have a penchant for dealing with the simplest symptoms first. Changing one small part of a person’s thought pattern or behavior often creates an unexpected number of other changes. Also, it is more respectful to the client to address issues from the “top down,” so to speak. Finding pathology from a particular symptom usually isn’t respectful or helpful.

My client wanted to be hypnotized into swallowing pills. I could have helped him achieve that goal by relying strictly on his definition. I could have used my authority as the hypnotist to command – or I could have given a posthypnotic suggestion.

I also could use his world to teach him about his unconscious and underutilized resources. When I teach hypnosis, I talk about how we all have such resources. Most of us do not consciously realize that we can manipulate blood-circulation patterns; he didn’t believe he could. I told him that if I were to say just a few words, he would know he could manipulate part of his circulatory pattern. He would blush. I waited a moment while he thought of the words I might say, and he blushed, just as I did when Erickson used that example with me when I was learning formal hypnosis.

I pointed out that I hadn’t even said those words. He had manipulated the circulatory pattern in his face all by himself, and simply by the power of his unconscious resources.

The next week, he told me had thought a great deal about how he could manipulate his blood flow. He had spent hours thinking about how he did it and blushing again and again until he could blush whenever he wanted. He demonstrated.

He had decided, he then said, that if he could do that seemingly impossible feat, controlling his gag reflex in order to swallow a few pills had to be simple. He had imagined the pills going down his throat smoothly, without triggering his gag reflex, until he could take his pills easily. He proudly demonstrated his newly recognized abilities.

Erickson said, in 1976, that if you really want to prove something to a client, let that proof come from within the client. Cognitive therapy points out that one of its goals is to help the client become his or her own therapist. Therapists do not need to confront or challenge the client’s beliefs head on to produce change. It seems to me that my client proved something to himself – that he became his own therapist (Meich­ enbaum, 1992).

Behavioral therapy, which has a great deal of empirical research substantiating it, recognizes that imagery is a powerful conditioning and reconditioning tool. Calmness of relaxation is often juxtaposed against anxiety as clients learn to overcome their stress with regard to a particular situation (Wolpe, 1997). As that young man imaged pills moving smoothly down his throat, I don’t know if he was in a self-hypnotic trance, or merely imaging comfort and relaxation. But I do know he changed, without having to receive any new information, and without my confronting and dealing with his illogical beliefs. He didn’t need insight or self-under­standing. Perhaps he “desensitized” himself by the imagery, perhaps he corrected his faulty thinking, perhaps he gained flexibility in thinking, perhaps … who knows? I don’t even know if I, an Ericksonian therapist, can declare this a therapeutic success, let alone put it in the column of Ericksonian psychotherapy.

Strategic therapy aims to be quick and dynamic therapy, finding ways to solve problems and recognizing that changing one part of a dynamic system necessarily affects the rest of the system. Erickson called this method of change “the snowball effect,” comparing it to a snowball rolling down a hill, gathering snow and bits of grass and leaves while changing its size and appearance.

In 1964, one of my friends saw Erickson for one lengthy session. She had a three-year-old daughter diagnosed as borderline microcephalic – the child’s brain was going to remain small and poorly developed. The little girl’s abilities and disabilities were oddly scattered. She had never uttered an intelligible sound, but she understood rather complex sentences and sequencing. She lacked certain abilities usually found in children her age, but she was able to perform beyond her years in other areas.

The mother had been advised to institutionalize her. The girl would take time from the family’s other children, she would not develop further mentally, and, as she got older, she would probably become rageful and difficult to control physically. The mother came to see Erickson, tearful and frightened. Afterwards, she told me only that Erickson had asked her questions that made her think. Over the ensuing years, we both moved several times and lost track of each other. When Erickson died, almost 15 years after her only visit with him, she called me. She said she wanted to tell me what had happened in that session. She said she had cried very hard as she told Erickson about her fears for the future and the dismal outcomes the other doctors had predicted. When her tears finally ceased, Erickson told her one thing that changed her life. “No one knows the future,” he said. “No one. But you can prepare for a future that may be possible.”

She said he then began asking questions. What did my friend really want for her child? How could she use her daughter’s attributes as a foundation for her life? By the time the session was over, my friend felt hopeful. She knew her daughter’s life would be difficult, but she knew she could prepare for a possible future. She had gone from “problem talk” to “solution talk” my friend said, using the language of Solution-Focused Therapy even though she knew nothing about that psychotherapeutic orientation (deShazer, 1988). My friend told me that her daughter, now a young woman, was happy and busily raising show rabbits that had won numerous prizes throughout the country. She even earned a modest income through the sale of her animals. The daughter needed help in keeping records, her mother acknowledged, but she did all the other work. “You don’t need words to communicate with rabbits,” my friend told me. “You don’t even need words to communicate to other rabbit fanciers – the animal speaks for itself.” I know Erickson didn’t plan this life for my friend’s daughter. After all, no one knows the future. But his statement opened new doors in her mother’s thinking.

The constructivist narrative perspective of Cognitive Therapy, as described by Don Meichenbaum (1997) at the third Evolution of Psychotherapy Conference, conceptualizes this dynamic way of working with patients. Patients are viewed as “meaning-making agents who proactively create their own personal realities” (p. 100). This type of therapy, he says, is both exploratory and discovery oriented, with the therapists helping the clients to see how their personal realities are created and the consequences, both good and bad, that are a result of those created realities. Sounds exactly like what Erickson did with my friend. Almost all formal definitions of psychotherapy include mention of some sort of client education. Cognitive therapist Aaron Beck (1997) defines it as “modification of dysfunctional thinking” (p. 56). Multimodal therapist Arnold Lazarus (1997) says education in therapy deals with missing information.

Erickson’s (1980) view of education fits well within his definition of therapy – that is, helping the “patient achieve a legitimate personal goal as advantageously as is possible” (p. 382). His way of teaching included two often overlooked, but vitally important, parts of Ericksonian psychotherapy – utilization and seeding.

Utilization is using whatever the client presents, whenever the opportunity presents itself, to reach the goal of therapy. “Whatever the patient presents to you … you really ought to use” (Erickson & Rossi, 1981, p. 16). Because the therapist is using what is brought by the client, the client’s world, it ensures that the therapy, the information, is given in ways meaningful to the client. Erickson would frequently use a necessary part of life to teach people to expand their lives, as well as to provide them with a way of thinking that would help them learn the enjoyment-seeking alternatives and options. In that way, the learner, be that learner a patient or a student or Erickson’s own child, would become more flexible and creative in the personal search for betterment. At the 1990 Evolution of Psychotherapy Conference, Albert Ellis (1992) talked about the importance of flexible, open-ended thinking. At that same event, Meichenbaum (1992) discussed schemata, the cognitive representations of past experiences that assist and influence the construction of current experiences and the organization of new information, or how people create data that confirm views. Sounds like what Erickson was doing.

Erickson used virtually everything as a teaching tool. He appreciated hard work; most of those associated with him learned to value work on many levels. When he assigned tasks to us children, which he never hesitated to do, he often used that work to help us learn to think creatively. I don’t think that mowing the lawn in Phoenix, Arizona, in the summer could ever be classified as real fun. However, even as we were complainingly lugging out the lawn mower, Erickson would ask, in an interested way, if we thought we could get the job done faster if we mowed in circles, or maybe in diagonal lines. Perhaps if we mowed a strip on the part close to the end and then “forgot to remember” that strip, the welcome, almost surprise, sight of that already mowed part would make it seem as though the job were moving faster. In other words, he was teaching us to approach life with creativeness and curiosity, to utilize what was in our life as a way of enhancing it. To this day, if I have a repetitive task, I figure out different ways to do it and how to do parts in the middle so I can have a pleasant “surprise” as I come upon a completed bit.

My brother, Lance, in the keynote panel address for the 1983 International Congress on Ericksonian Psychotherapy, talked about sweeping the basement when he was a youngster in the 1940s. Lance was interested in the Civil War, and Erickson discussed with him how the cracks and lines on the concrete floor could be seen as boundaries between countries. The dust and debris could be seen as armies. Then Erickson asked Lance if he thought that if the armies fought battles over and through the boundaries, the results would be the same each time. With that careful setup and the curious question, Erickson invited his young son to construct the reality of sweeping the basement floor in a more pleasurable way (Erickson, 1985).

The same framework for thinking was provided in many different ways. All of the Erickson children walked at least a mile to and from their various schools. We don’t remember those daily walks as drudgery. We remember some of the things we learned from what I now realize was Erickson’s carefully constructed paradigm. Did the flowers on the north side of the street bloom before those on the south side? How many short­ cuts could we find, and how much shorter were they really? Did some longer ways actually take less time because the environment was different? How much of our homework could we get done in our heads on the way home? Erickson obviously was not doing therapy on us. However, the concept is the same. He was helping us to create a flexible view of the realities of life that, in turn, would create a flexible way of constructing data for the rest of our lives. Our personal schemata of our tasks just as easily could have been created so that there was no creative pleasure or intellectual curiosity in the drudgery. But Erickson carefully structured and seeded a way of constructing reality, using natural curiosity and the inclination to find “easier” ways of doing work. He utilized what we brought in to seed more productive ways to achieve goals.

Erickson looked at this type of seeding as a farmer looks at seeding crops. If you sow enough seeds, some of them will take root and grow – especially if you are wise enough not to keep going back and pulling them up to see if they have sprouted. Even in the autographing of books, Erickson sought to seed information. My son, at age 10, was noted for his carefree, nonchalant attitude. Erickson’s inscription in one of his books to Michael referred to a time when Michael had thoughtfully planned for the future of his pet birds, which had to be left behind when our family moved back to the United States from overseas. My son cherished what was written; he quoted it many times during his growing up, usually when he was being chastised for some impulsive behavior. As an adult, he still credits Erickson for being the first to recognize his “foresight in planning for the future.”

I don’t know for certain that the inscription helped him mature. I do know he thinks it influenced him. His personal reality, his schema for life, began to incorporate planning for the future as a counterpoint to his inclination to impulsivity. Deliberately creating interventions that invited a client to provide his or her own meaning, to become his or her own therapist, was a strong point in Erickson’s methods and is a goal of Cognitive Behavioral Therapy (Meichenbaum, 1997). Resistance is side-stepped as the clients truly become the experts on themselves, and independence is fostered. I don’t have to go too far to find ways in which Erickson did that. He advised hundreds of people to climb Squaw Peak, but rarely told them what he expected them to get out of the hike. Because people could create their own meanings, the hike meant whatever the person needed it to mean. Sometimes he structured the event for a positive interpretation, knowing that this would help the client’s overall sense of self. He knew, as the late Viktor Frankl espoused so poignantly and meaningfully, that people always search for meaning. He believed that if a positive meaning is implied, people are likely to adopt that positive definition. I recently talked with a patient who had seen Erickson in the mid- 1950s. While working with him, she had learned Origami – the Japanese art of creating objects by folding paper in specific and careful ways. Right there, I could see the opportunity for a multiplicity of meanings. At her last session, she said, she gave Erickson a small Origami box she hand made. He examined it carefully and admiringly, then handed it back to her, and told her that she could keep it as a reverse Pandora’s box. “Bad­ness” would be safely locked in the closed box. She could continue to feel control and self-determination in life. She showed me the little blue-and-white paper box. She has kept it for more than 40 years, through countless moves and upheavals in her life. The box she had made so long ago has continued to be a symbol to her of empowerment in her life. The sole purpose of her visit to me was to show me how her cherished reverse Pandora’s box was still working for her. She was still managing her life well, she said. When I reflected that to her, she smiled. She already knew. She wanted to be sure that I, as Erick­son’s representative, knew it too. Erickson’s ability to incorporate a vision of the future in the present is one part of his framework that is difficult to quantify and teach. It does not seem to have yet become a regular component of other theoretical positions. The future was very real in a great deal of his therapeutic work, and even in casual conversation. People were given permission and the empowerment they felt they needed to do things in the present so that, in the future, they would be able to look back at their accomplishments. It might be hard work now, he would indicate, but it will be so fulfilling in the future to look back at it. In this chapter, I have barely addressed the use of hypnosis, which was an important and integral part of his work. I do not believe Erickson’s therapeutic methods can be well understood without a basic understanding of hypnosis. I have also barely addressed his use of metaphors and his storytelling, about which entire books have been written. This method of teaching, of providing options, of creating new and flexible thinking, is so strongly identified with Erickson that some think it constitutes the major part of his psychotherapeutic orientation. But Erickson knew that a story is just another way of helping a client to rely on internal resources and to learn how to think flexibly and creatively. It was a small part of his repertoire, but part of his lasting legacy. We all need to learn to tell stories – what a delightful way to evoke curiosity and concentration, to teach, to normalize, to give humor, and to promote independence. If Erickson were reading this, I know he would be shaking his head at me. I have not even mentioned two integral parts of his orientation that he emphasized to others over and over. One is observation. “Observe,observe, observe,” he would say. The therapist must learn to set aside personal perspectives and really see and hear from the client’s point of view. The other is the careful choice of words. Words have multiple meanings, not only to different individuals, but within the context of the moment. Pop psyche says it all – men are from Mars, women are from Venus. We are all unique with different experiences upon which we build meanings. But words are a primary pathway to thoughts, as well as to manipulating and changing personal thoughts and schemata. I almost always ask clients, at the end of therapy, to tell me what was most valuable to them. One, a young man I’ll call Tommy, answered immediately. “That’s easy,” he said. “You told me, ‘Be fearless, Tommy. Write it on your hand if you have to, but be fearless.’ So I did. Every time I had to do something that was scary, I’d take a deep breath, read the imaginary writing on my hand – be fearless – and go for it.” I told that story to a little girl named Beatrice. She listened intently and said she was going to do that too. But she was going to write ‘Be scaredless.” I smiled, thinking she was misusing a word, as children do. “No,” she explained. “You don’t understand. I am writing ‘Be scaredless’ because my name is Bea, and every time I do something hard, I will be scared less.” Bea reorganized her understanding of her world by using words to help create new internal experiences. She manipulated her thoughts by words. She created her own scheme for her future. She also re-reminded me of the importance of remembering that the meanings of words are created, in part, by the uniqueness of the individual’s perspective.

In this chapter, I have focused primarily on some of Erickson’s methods that have become part of the larger therapeutic world. Sometimes his ideas and thoughts have been incorporated into other therapies, sometimes they overlap the good therapeutic methods developed from different roots, and sometimes they have been altered to fit the culture of today. So where are we going now? What is the future of Ericksonian psychotherapeutic methodology? I don’t know for sure. No one knows the future. But I would bet that the foundation of Erickson’s work will still enrich and be part of therapy as it continues to develop. As therapists search for the best, most efficient, most respectful ways of doing therapy, the work that Erickson did and taught will remain a part of their base.

Perhaps refusing to define a theory was one of Erickson’s greatest gifts to modern therapies. As humans, we all are unique, and so individualistic that each of us should choose wisely from the vast buffet of psychotherapeutic methods available according to our tastes. To benefit the most, each of us should come to that plethora with an appetite to learn and an understanding of the ingredients of each offering.

Studying the original work of Erickson, along with the work of those who studied with him directly does that. It gives today’s therapists a deeper understanding of the ingredients, of the complexities and nuances, of many therapeutic stances. This, in turn, allows all of us to become even more effective. We can pick and choose among the ways of doing therapy or of giving information those that are best for a particular client on a particular day. We can help to create a possible future. And we fulfill the real goal of therapy – to help our clients achieve legitimate personal goals as advantageously as possible.

References

Beck, A. T. (1997). Cognitive therapy reflections. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference. New York: Norton .

De Shazer, S. (1988). Keys to solutions in brief therapy. New York: Norton. Erickson, L., et al. (1985). Keynote address: Special (family) panel on Milton Erick­son. In J. K. Zeig (Ed.), Ericksonian psychotherapy, Volume l • Structures. New York: Brunner/Maze!.

Erickson, M. H. (1980). The collected papers of Milton H Erickson on lrypnosis. Vol IV. E. L. Rossi, (Ed.) New York: Irvington.

Erickson, M. H., & Rossi, E. (1981). Experiencing lrypnosis. New York: Irvington. Erickson, M. H., Rossi, E. L., & Rossi, S. I. (1976). Hypnotic realities. New York: Irvington.

Lazarus, A. (1992). Clinical/therapeutic effectiveness. In J. K. Zeig (Ed.), The evolution of psychotherapy: The second conference. New York: Brunner/Maze!.

Lazarus, A. (1997). Can psychotherapy be brief, focused, solution-focused and yet comprehensive? In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference. New York: Brunner/Maze!.

Meichenbaum, D. (1992). Evolution of cognitive behavior therapy. In J. K. Zeig (Ed.), The evolution of psychotherapy: The second conference. New York: Brunner/ Maze!.

Meichenbaum, D. (1997). The evolution of a cognitive-behavior therapist. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference. New York: Brunner/Maze!.

Wolpe, J. (1997). From psychoanalytic to behavioral methods in anxiety disorders. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference. New York: Brunner/Maze!.

Zeig, J. K., & Gilligan, S. G. (Eds.). (1990). Brief therapy: Myths, methods, and meta­phors. New York: Brunner/Maze!.

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.